From the beginning of April 2000 to the end of July 2003, 1,036 initial consultations were completed, with 230 follow-ups and 83 program consultations to residential and day-treatment programs. A special protocol on fire setting was also initiated. Thirty-two urgent consultations were requested. Thirteen per cent of the consultations were done in French and the rest, in English.

Part of the Telepsychiatry Program mandate has been to provide continuing education for the front-line staff at the participating sites. Based on a needs assessment, a seminar series was designed to cover the child mental health topics in highest demand. Seminars have emphasized practical, hands-on approaches and have been based on case discussion. The first series of seminars was well attended, with positive evaluations. Participants provided pages of detailed comments, frequently indicating how they thought they could use newly learned knowledge and skills in their daily work.

Educating psychiatry residents has also been a priority: a seminar on telepsychiatry is part of a core seminar series for all residents. To date, 138 residents and medical students have participated with division faculty in telepsychiatry consultations. Several residents have participated on multiple occasions, taking the lead in consultation. Two fellows have also provided unsupervised consultation.

Because this is a new area, there are few models for evaluating such a program (4,5,8,9). Tools more relevant than consumer satisfaction scales had to be developed. The evaluation program had to serve multiple interest groups, namely, the 14 community sites and regions; the Ministry of Community, Family and Children’s Services; the Division of Child Psychiatry of the University of Toronto; the consultants doing the consultation and The Hospital for Sick Children.

An evaluation protocol, to be conducted via video-conference, was developed for five focus groups selected to represent a range of large and small sites, First Nations and non-First Nations populations, languages spoken, urban and remote locations and length of time with the telepsychiatry program. In each focus group, a facilitator and a note taker took detailed notes of the proceedings. In addition, 12 caregivers, comprising most of the eligible families who had consultations during data collection, were interviewed via telephone. For each, the interviewer took detailed notes, and the conversation was audio recorded; the recording was used later to validate the notes and confirm quotes. A team of three researchers undertook the analysis. Each reviewed the material from the focus group videoconferences and caregiver interviews, identifying important themes and checking the results against one another.

Overall, participants indicated that their experiences with the telepsychiatry program were positive and that they found it to be a useful and helpful service. For families, the availability of the service in or near their communities meant reduced expenses associated with travel and less time missed at work and school. For mental health workers, local telepsychiatry services offered access to an expanded knowledge base, which increased their confidence and competence in assisting their clients. Participants in both focus groups and telephone interviews also suggested ways to improve the usability and effectiveness of the telepsychiatry program; these included more satellite sites, staff training, standardization of information forms and more follow-up.

First 500 Consultations

The first 500 initial consultations took place from the beginning of April 2000 to the end of August 2002. Data were obtained from referral questionnaires, checklists completed by the consultants and individual client files.

The 500 consultations took 645 service hours, or 1.29 hours on average per consultation, with a range of one- half hour to three hours. The consultations were provided by 38 consultants, all of whom have appointments with the University of Toronto’s Division of Child Psychiatry. All sites used the service—some considerably more than others—and three sites were major users.

Unlike most children’s mental health centres, wherein the ratio is two boys to every girl, we saw 297 boys and 203 girls. The boys were most often prepubertal and the girls postpubertal; the sex and age differential is statistically significant (P < 0.0001) (Figure 2).

Figure 2   Breakdown of age by sex   Male patients n = 297;            Female patients n = 203 Male patients < 12 years n = 199    Male patients > 12 years n = 98 Female patients < 12 years n = 84         Female patients > 12 years n = 119

Of the children, 73 per cent were not wards and resided with one or both parents. Accurate figures are not available, but it appears that many came from single-parent homes and were in the care of their mothers. Eleven per cent were temporary wards, and 10 per cent were crown wards living in foster homes.

Questions about treatment management (416) were asked first, followed by diagnosis (345) and medication (284). Questions about diagnosis were raised not only to inform clinical work but also as a way of obtaining extra help for the children in the schools. In Ontario, if a child has a formal diagnosis and a psychiatrist states that extra help would be useful, funds for extra in-school help can be applied for.

Because this is a consultee-centred service for front-line service providers, and also for medico-legal reasons, the responsible clinician had to be present during the consultation. Often, the child or patient was present (78 per cent of the time). Mothers attended 64 per cent of the time, fathers 34 per cent of the time and guardians 15 per cent of the time. Unlike urban sites, school personnel attended 17 per cent of the time and physicians 10 per cent of the time, even though they could not be reimbursed.

The consultants diagnosed most of the children (70 per cent) as moderately dysfunctional, with fewer than 10 per cent mildly dysfunctional and 10 per cent significantly impaired; 10 per cent were not coded. The full range of DSM-IV diagnoses were seen (Table 1), with most falling into the externalizing or internalizing group. A significant difference in sex distribution was seen: boys were more often diagnosed with externalizing and girls with internalizing disorders (P < 0.0001). Although few met the formal diagnostic criteria for posttraumatic stress disorder (six per cent), a chart review suggested that trauma was common, as were family dysfunction and out-of- home placements with lack of continuity of care. Girls were more often abused (both physically and sexually), which could explain the diagnostic differences as well as cultural expectations of behaviour. A new referral form that will systematically collect information on exposure to trauma was put into use in the spring of 2003.

Surprisingly, given the population, only two per cent were given the diagnosis of fetal alcohol syndrome–fetal alcohol effects–alcohol-related neurodevelopmental disorder (FAS–FAE–ARND). Three per cent were diagnosed with a pervasive developmental disorder, one per cent with psychosis and 15 per cent with mental retardation. Eleven per cent were diagnosed with a learning disorder, but this is likely an underestimation, given the lack of educational and psychological resources. Only 10 per cent were diagnosed with relationship problems. However, not all consultants or front-line workers have a family or systemic perspective; they may tend to focus only on the child, which may explain the dearth of this diagnosis.

Recommendations depended very much on the site, with some able to offer the full range of services and some having very limited capabilities. Across the North, there is an extreme shortage of long-term residential beds for children. Therefore, children with such needs end up in foster care or, sometimes, probation facilities, or they are sent out of the area to another province or to the United States. In our cohort, residential care was nevertheless recommended for 10 per cent of youths, the challenge being how to implement such recommendations. Individual counselling was recommended for 55 per cent of children, family therapy for 25 per cent, group therapy for six per cent, and parent counselling for 17 per cent. Developmental and educational concerns were common and significant: educational input was suggested for 20 per cent and psychological testing for 22 per cent. The consultants were for the most part impressed with the quality of care provided and supported the program in place, sometimes supplemented by additional recommendations (in 31 per cent of cases). Follow-up was suggested for 20 per cent. It was anticipated that questions about medication would be common. Although not part of the initial reason for referral, medication recommendations were made for 60 per cent. Predictably, stimulant medication was commonest for the boys and selective serotonin reuptake inhibitors (SSRIs) for the girls. Antidepressants other than SSRIs, mood stabilizers and antipsychotic medication were recommended for 15 per cent.

Issues and Concerns

Clearly, telepsychiatry standards and guidelines are needed. The document prepared by the University of Toronto’s Department of Psychiatry is a start, and other institutions, such as the Canadian Psychiatric Association, are grappling with the issues (7).

Well-designed studies comparing the reliability of teleconferencing with face-to-face interviewing are lacking (9,10). Early evaluations of our service are positive, but methodologies need to be developed. The real costs and savings of the service are not clear. It is also unclear whether the program supports children’s mental health providers and prevents staff burnout. Medico-legal issues have not been tested in court. Two provinces (Ontario and Quebec) have no category under the health scheme to pay participating professionals. Across Canada, the cost of the projects and services to date have been covered by federal and provincial government grants. Ongoing sources of revenue need to be found that are not provided on a year-to-year basis or to support pilot projects. Clearly, technology is being used more and more as a way of melting the miles in our vast country and countering the shortage of trained children’s mental health practitioners. The technologies are changing rapidly, and the issue of encryption will be solved to guarantee privacy, so that less costly technologies can be used.

Conclusion

Telepsychiatry is an efficient and user-acceptable way of providing child psychiatric consultation to distant and underserviced areas. Consultation to front-line workers seems to be the most efficacious model for service and program consultation. Front-line workers are highly dedicated but hungry for educational input, and they appreciate the service’s support.

More boys than girls were seen, with boys showing more externalizing disorders and girls more internalizing disorders. Most of the children showed at least moderate dysfunction. Questions about management strategies were the most common, followed by questions about diagnosis and medication. Sites with mixed mandates (that is, mental health and welfare) are usually farther away, serving smaller communities of largely First Nations people. The problems of children from these sites are significant and complicated, and the staff are generally less well trained, with fewer resources. How to help is a major challenge, but technological mechanisms can efficiently provide expert and timely care.

Key Words: pediatric telepsychiatry, videoconferencing, underserviced areas, child psychiatry

References

1. Whattie B. 1999. The mental health of Ontario’s children. Unpublished document prepared for Children’s Committee of the Canadian Mental Health Association. Located at: Canadian Mental Health Association, Toronto (ON).

2. Offord DR, Boyle MH, Szatmari P, Rae-Grant N, Links PS, Cadman DT, and others. Ontario Health Study II. Six month prevalence of disorder and rates of service utilization. Arch Gen Psychiatry 1987;44:832–6.

3. Parker Z, Steele M, Junek W, Morin L, Davidson S, Fleisher W, and others. Child psychiatry in Canada: physician resources. Position statement of the Canadian Academy of Child Psychiatry. Ottawa: 2002. Available : Canadian Psychiatric Association, Ottawa, ON.

4. Urness D. Telepsychiatry. Discussion Paper DP 2003–1. Ottawa: Canadian Psychiatric Association; 2003.

5. Baer L, Elford R, Cukor P. Telepsychiatry at forty; what have we learned. Harvard Rev Psychiatry 1997;5(1):7–12.

6. Caplan G. Theory and practice of mental health consultation. New York: Basic Books; 1970.

7. Telepsychiatry: guidelines and procedures for clinical activity. Toronto (ON): University of Toronto Outreach Program; 2002.

8. Boydell K, Volpe T, Brown N. 2001. An evaluation design for the telepsychiatry project. Unpublished report prepared for the Division of Child Psychiatry. Located at: Department of Psychiatry, University of Toronto, Toronto (ON).

9. Elford R. The Child Telepsychiatry Project: a randomized controlled trial [masters thesis]. St. John’s (NF): Memorial University; 1997.

10. Alessi N. Child and adolescent telepsychiatry; reliability studies needed. Cyberpsychology and Behaviour 2000;3:1009–15.

(CPA Bulletin 2004;36[3]:11-15)

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