Telemedicine Effective for ADHD

Fran Lowry

March 23, 2015

Children with attention-deficit/hyperactivity disorder (ADHD) who live in underserviced areas can be effectively treated using telehealth technology, new research suggests.

Telehealth technology is a way of delivering healthcare that connects doctors in major centers with patients in remote locations to enable them to interact in real time as though they were in the same room.

By eliminating the need to travel to obtain healthcare, telehealth services can improve access to care for patients who live in rural or underserved areas. This is particularly important now, when the shortage of healthcare services and, in particular, mental health services is a growing concern, lead author Kathleen Myers, MD, MPH, associate professor of psychiatry and behavioral sciences, University of Washington School of Medicine, and director of Telemental Health Services at Seattle Children's Hospital, told Medscape Medical News.

"Telehealth services bring new resources to treat major psychiatric disorders, such as ADHD in children. It improves collaboration with primary care physicians, and, importantly, it is a way to redistribute the specialty mental health work force," Dr Myers said.

"There are not enough people now to treat children with mental health disorders, and it is projected that there will not be enough in the future, so we need new models of care," she said.

The study was published in the April issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

Telepsychiatry Consult

Telehealth programs have been used increasingly for 15 years, but scant outcomes data exist, especially for programs that are used to treat children.

"I have been directing a tele–mental health service since 2000, and could see that we were having pretty good outcomes, but we didn't have objective data. So we decided to go for it and see if it was, in fact, true that it was effective," Dr Myers said.

The investigators conducted the Children's ADHD Telemental Health Treatment Study (CATTS), which was a randomized controlled trial with 223 children who were referred by 88 primary care providers in seven remote communities.

The children who were randomly assigned to the experimental telehealth service model received six sessions of combined pharmacotherapy during a 22-week period. The sessions were delivered by child psychiatrists through videoconferencing. Caregiver behavior training was provided in person by community therapists, who were supervised remotely.

The children who were assigned to the control service delivery model received treatment with their primary care providers that was augmented with a telepsychiatry consultation.

The main outcome measures were the diagnostic criteria for ADHD and oppositional defiant disorder (ODD); role performance on the Vanderbilt ADHD Rating Scale (VADRS), completed by caregivers (VADRS-Caregivers) and teachers (VADRS-Teachers); and impairment on the Columbia Impairment Scale–Parent Version (CIS-P).

The values were obtained at five assessments during a 25-week period.

Children in both groups improved; however, those who were assigned to the experimental telehealth service model improved significantly more than those in the augmented primary care arm for the following outcomes:

  • VADRS-Caregiver criteria for inattention (P < .001)

  • VADRS-Caregiver criteria for hyperactivity (P = .02)

  • VADRS-Caregiver criteria for combined ADHD (P = .005)

  • ODD (P = .04)

  • VADRS-Caregiver role performance (P = .01)

  • CIS-P impairment (P < .001)

  • VADRS-Teacher criteria for hyperactivity (P = .02)

  • VADRS-Teacher criteria for combined ADHD (P = .045)

A Hit With Families

The study was a hit with the families, Dr Myers said. "They were grateful, because most of these children who came into the study had been through multiple trials of medication and sometimes therapy and still were not getting better. So families were appreciative of being in the control arm of the study, even though they wanted to be randomized to the active intervention. We had very positive feedback from families."

The telehealth service used high-definition, large, flat-screen TVs with point-to-point connectivity.

"This was the technology in 2008, when we started this study. But in that short amount of time since we did the study, the technology has changed. If we were to do this again and go to the sites that are most underserved, we would probably switch to desktop video conferencing. It's not as good a connection, it doesn't have all the bells and whistles to scan the room and zoom in, but it's pretty good, and it will reach to very remote areas. This would open access to many more families."

New Standard of Practice

In an accompanying editorial, Donald M. Hilty, MD, University of Southern California (USC) Medical Center and the Keck School of Medicine of USC, in Los Angeles, and Peter M. Yellowlees, MD, from the University of California–Davis Health System, note that this study "has very significant implications for the practice of psychiatry in general, child psychiatry, rural and primary mental health service delivery, and all of us in this era of increasingly integrated care."

The editorialists state that mental health services using multiple technologies "with a plethora of hybrid approaches to care being available is not only the new way to practice psychiatry but also is likely to lead in many instances to a new standard of practice; all this shows that telemedicine is versatile and puts specialized treatments where and when the patients need them."

They add that most mental health care takes place in primary care settings worldwide and that most patients with psychiatric disorders never see a psychiatrist.

"Versatile telehealth models such as CATTS help remedy this problem.... We propose that the Myers model of combined interventions should become the new standard of practice in child psychiatry for treating children who have ADHD combined with other psychiatric disorders, whether the children live in rural or metropolitan areas," they write.

Dr Myers, Dr Hilty, and Dr Yellowlees report no relevant financial relationships.

J Am Acad Child Adoles Psychiatry. 2015;54:263-274, 245-246. Abstract, Editorial

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