How Telehealth Can Help Bridge Pediatric Mental Healthcare Gaps

The burgeoning mental health epidemic in America is widespread across age groups, but the youth have faced a particularly challenging time amid the COVID-19 pandemic. As the youth mental health crisis reaches new heights, providers are increasingly turning to telehealth to help expand access to behavioral healthcare.

In December, Surgeon General Vivek Murthy, MD, issued an advisory calling for a coordinated response to combat the crisis.

"Mental health challenges in children, adolescents, and young adults are real and widespread. Even before the pandemic, an alarming number of young people struggled with feelings of helplessness, depression, and thoughts of suicide — and rates have increased over the past decade," said Murthy in a press release. "The COVID-19 pandemic further altered their experiences at home, school, and in the community, and the effect on their mental health has been devastating."

A 2020 survey of 1,000 parents around the country revealed that a majority (71 percent) believed the pandemic had negatively affected their child's mental health. Further, data from the Centers for Disease Control and Prevention shows that between March and October 2020, the proportion of mental health-related emergency department visits increased by 24 percent among kids aged 5 to 11 and 31 percent among adolescents aged 12 to 17 compared with 2019.

The tragedy of the recent school shooting in Uvalde, Texas, further highlights a need for expanded pediatric mental health services alongside gun safety measures. The recently passed bipartisan gun safety act includes provisions for expanding pediatric access to behavioral health, including through telehealth.

TELEHEALTH STRATEGIES TO CLOSE CARE GAPS

The first and perhaps most important way telehealth can help expand pediatric mental healthcare access is by bolstering the behavioral health workforce.

"There just aren't enough mental health providers to meet the need, and I think it runs the gamut from providers in all levels of mental health work," said Melissa DeFilippis, MD, director of the Child and Adolescent Psychiatry Division at the University of Texas Medical Branch (UTMB) Health, in a phone interview. "So down to social workers, counselors, up through psychiatrists."

The shortage is particularly acute in child psychiatry. As of April 2019, there were 8,300 practicing child and adolescent psychiatrists in the US, and more than 15 million kids and teens were in need of one, according to the American Academy of Child & Adolescent Psychiatry.

"And I know at least in psychiatry, we're an aging specialty, so we have a lot more people who are retiring than we have people coming in, and so that's a problem," DeFilippis said.

Further, as the demand for child psychiatrists grew during the pandemic, the stigma surrounding treatment for mental health issues reduced — though did not disappear — exacerbating the widening gap between demand and supply, she added.

But this is where telehealth can help.

"Telehealth has been a really good tool," DeFilippis said. "It's wonderful, especially for states like where I practice, here in Texas, that have a huge area to cover and a lot of rural areas."   

UTMB has been offering telepsychiatry for over a decade, initially partnering with community mental health clinics in rural counties that didn't have child psychiatrists, then expanding the service to school districts.

State funding that followed the Santa Fe High School shooting in Texas in 2018 has supported telehealth partnerships with school districts. The state legislature created the Texas Child Mental Healthcare Consortium to leverage the expertise of health-related higher education institutions in addressing pediatric mental health challenges. One of the consortium's initiatives — in which UTMB participates — is TCHATT.

TCHATT, or the Texas Child Health Access Through Telemedicine, involves school staff members identifying children who may need mental health support and contacting their parents to refer them to a psychiatrist, according to DeFilippis. The child is connected to the psychiatrist via a telehealth visit conducted at the school. After an evaluation, the psychiatrist recommends therapy or medication, depending on the child's needs.

"And then, once they've been somewhat stabilized with that initial treatment, we have social workers within the program who then work to get them connected with someone in the community who can continue their treatment," DeFilippis said.  

Currently, the program serves 24 independent school districts, but the goal is to extend it to every school in the state.

Outside of school-based telehealth partnerships, UTMB also partners with community-based mental health clinics in sparsely populated counties. Children are already coming to these clinics for services like therapy or case management, but there is no psychiatrist nearby to prescribe medications, DeFilippis said. This is where UTMB psychiatrists step in and provide medication management close to home.

Anthony Sossong, MD, chief medical director of behavioral health at Amwell, echoed DeFilippis, stating that bolstering the meager supply of child psychiatrists is the primary way telehealth can help expand access to pediatric mental healthcare.

Not only can telehealth help widen direct care access for patients, but it can also enable psychiatrists to collaborate with pediatricians.

"There can be professional-to-professional support, like formal or informal consultation, clinical supervision, or peer education," he said.

The collaboration between mental healthcare professionals, pediatricians, and adolescent medicine practitioners is vital for the early detection and diagnosis of behavioral health conditions in children that parents may be unable to catch.

Further, telehealth can help ensure family involvement, especially in families where all the adults work, making it hard for them to attend in-person visits with their children. When adult caregivers cannot take their children to psychiatrists due to work, it further extends the time for pediatric patients to get much-needed help.

"The time it takes to get to treatment is really unacceptable across the United States," Sossong said. "The average delay between the onset of mental illness and treatment is 11 years."

In addition, Sossong believes that self-guided programs that leverage virtual care capabilities can help expand pediatric mental health access. These programs, like Amwell's Comprehensive Behavioral Health program, can include asynchronous and synchronous coaching and virtual therapy. They can aid in symptom management and early detection of mental health conditions.

"We're actively working to show the clinical validity of internet-based cognitive behavioral therapy, which forms the basis of a lot of the treatments in children and teens," he said.

KEY CONSIDERATIONS WHEN EXPANDING TELEHEALTH ACCESS

Though virtual care options can increase access to care in many ways, they can sometimes be hard to access. Factors like technology and broadband access can keep patients from experiencing the benefits of telehealth.

"The last thing we want to do by expanding access is to create increased disparity between people with poor socioeconomic status and those who have more access to technology," Sossong said.

One strategy to avoid inadvertently creating care gaps is to keep telehealth services as device-agnostic as possible. This means creating services that are accessible through various devices —from computers to smartphones to tablets, he said.

Further, in areas with particularly poor internet connectivity, providers of pediatric mental health can establish centralized kiosks from which patients can participate in virtual visits.

"Again, that's not a great long-term solution in that it doesn't allow for the direct access to patients at home, and there may be some travel required," Sossong said. "But sometimes it can get care closer to the home than it would've otherwise been able to be accessed."

Schools can help boost access to broadband during vacation months, in addition to providing children with direct access to virtual care when school is in session.

"The summer months may be difficult for some kids if they don't have really good Wi-Fi at home or any Wi-Fi at home," DeFilippis said. "And so, I do believe a lot of the schools, at least I know here locally…they will set up Wi-Fi hotspots where parents can actually drive to the school and sit in the parking lot and use Wi-Fi."

The potential rollback of pandemic-related telehealth flexibilities could also hamper the expansion of pediatric mental health resources. If regulations that were lifted during the pandemic — like geographic restrictions on originating sites and in-person visit requirements before telemental health appointments — are reinstated, telehealth providers will have to re-focus expansion efforts by state.

"I think one of the things that we're all waiting to see is [whether] some of the exemptions that have come through the public health emergency will very quickly go away afterward," Sossong said. "[Pre-pandemic regulations] have posed barriers in the past to fully integrating digital health and virtual visits into a hybrid or a full-spectrum paradigm for care."

But, regardless of the uncertainty surrounding telehealth use in the future, Sossong believes it is a vital tool for expanding much-needed access to pediatric mental healthcare.

"We're talking about not only a crisis of providers, and a lack of providers, and misdistribution, but a worsening of symptoms, and people not knowing where to go, so that they end up going to the ED," he said. "And this is something that we definitely have to address, and I think telemedicine and digital health, in general, is a great way to do that."