therapy, art therapy, and other expressive modalities; thus, thoughtful adaptation is needed if these will be provided remotely. Similarly, parents often receive interventions, such as parent training, which will need to be adapted as well. Establishing a therapeutic space is an important aspect of therapy with children. In telemental health, the clinician needs to establish a balance with items needed for assessment or therapy, such as toys, drawing materials, and activities, versus the need for a nondistracting visual space. Telemental health services for children and adolescents have some of the same direct applications as services for adults (Hilty et al., 2016). Clinicians can conduct assessments, offer consultations, and provide direct services. These may be short- or long-term services depending on the needs of the client. With children, assessments and clinical services follow similar guidelines as those for face-to-face services. Practitioners need to conduct developmental observations, mental status examinations, and behavioral interactions using the video capabilities of the telemental health system. Similar to telemental health sessions with adults, the direct-service approach must take into account the needs of the client within the capabilities of video technology (Hilty et al., 2016). With young children, a clinician may use play therapy to engage them in treatment. The clinician using video technology may need a staff member at the originating site to help guide the child directly. In this way, the clinician at the distant site works collaboratively with the physical assistance of someone who is in the room with the child. A practitioner may want the assistance of someone in the room if the child has impulsivity, hyperactivity, or other behavioral issues. Mobile applications may be particularly suited for adolescents (Batastini, 2016; Kobak et al., 2015). For example, text messages can be used as reminders to check in about homework or mood and to offer reminders about particular aspects of self-monitoring. Practitioners can use mobile technology to offer online education information, tutorials, and materials for youth to review in private on their own time. There are many mobile eHealth apps that can be used with youth. The following are examples of mobile apps for issues related to mental health. ● Breathe2Relax: This is an application for stress management that guides users through breathing applications to stabilize mood and control anger. ● Talkspace: This application connects individuals with a therapist to contact via messaging. Users can send texts to receive immediate support. This application is not
intended to replace face-to-face therapy but is used as an additional support. ● Veteran Affairs has a number of mental health–related smartphone applications. Some are meant to be used with a mental health provider’s involvement (like CPT Coach for Cognitive Processing Therapy), while others can be used as self-help tools (like Mindfulness Coach). https://mobile.va.gov/appstore/mental-health ● There are also many mobile applications specifically designed for children. Some examples include Headspace for Kids; Breathe, Think, Do with Sesame; and Smiling Mind. Clinical work with children and adolescents often involves their family members. When using telemental health with children and their families, clinicians will need to help each member understand and feel comfortable with the use of video technology (Hilty et al., 2016). Telemental health services can be used in the delivery of family therapy, parent training, and home-based treatment. Telemental health services with children and youth can also be offered in schools. Adolescents may prefer to have sessions in school rather than suffer potential stigmatization if seen entering a mental health clinic (Hilty et al., 2016). Teachers can also participate in treatment by offering feedback about the child’s academic performance and social interactions at school. In addition, school psychologists can conduct assessments using telemental health technology. Practitioners can use telemental health services to provide treatment to juvenile offenders in correctional facilities (Batastini, 2016). Many juvenile offenders have difficulty accessing mental healthcare while detained because many facilities do not have on-site professionals. Youth offenders who receive early intervention via telemental health services may have better outcomes compared with those who receive treatment later. However, service provision utilizing videoconferencing capabilities is outrunning the research base that evaluates it. More research is needed to carefully evaluate the effectiveness of telemental health services with children and youth. Experts recommend more controlled evaluations rather than the single case studies that have permeated the recent literature. They recommend studies of specific mental health outcomes with telemental health as compared with traditional treatment. Large-scale studies may require substantial funding, but this may be necessary to build an adequate research base about telemental health with children and adolescents (Comer & Myers, 2016; Lau et al., 2021).
CLINICAL CONSIDERATIONS
Much of the research on telemental health describes positive outcomes and benefits for clients. Advocates of telemental health cite convenience, cost savings, and access to services for underserved populations and rural geographical areas as being among the most favorable effects of technology-driven services. However, practitioners should make informed decisions about when to offer services face to face or via telemental health. Developers offer an increasing number of telemental health technologies and applications, but their effectiveness should not be assumed without empirical efficacy studies (Daniel & Sulmasy, 2015). Procedures for some assessments may not lend themselves to remote administration without a physical presence. For example, the Wechsler Adult Intelligence Scale (Wechsler, 2008) involves hands-on interaction, such as administration of the Block Design, Matrix Reasoning, and Visual Puzzles subtests from the Perceptual Reasoning Index, which
would be inappropriate and impractical to administer via telemental health (Luxton et al., 2014). In some instances, assessments, such as cognitive functioning tests, may be administered through telemental health technologies with an on-site staff person. The staff member can administer the assessment and then share the results with a remote clinician who scores and interprets them. Practitioners who use remote technologies must consider clients’ cultures, backgrounds, and experiences. Such factors as age, familiarity with technology, and culture- specific norms can determine whether telemental health services are effective (Comer & Myers, 2016; Luxton et al., 2014). For example, the remote physical presence inherent in telemental health may create barriers that inhibit clients’ engagement and therapeutic rapport with the therapist. Individuals from some cultures, such as those that emphasize interpersonal connectedness, may have difficulties using telemental health technologies.
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