John Sargent, M.D., and Meredith Sargent, Ph.D.
The Menninger Clinic

Interactive video conferencing has been used in American medicine for over 40 years. There have been marked improvements in technology leading to enhanced resolution of the video image and real time visual and audio transmission. These have also led to greater ease of use and marked reduction in the cost of both technology and conference time. As systems have become more available and less expensive, many medical applications have developed, including telepsychiatry. Because psychiatric practice is based upon interaction and mutual understanding, use of interactive video allows for innovations in practice and makes available psychiatric resources in distant or underserved areas.

A wide range of video systems are used for telepsychiatry practice. They vary in cost of the system, the cost of use and in the degree of resolution of the video image. More expensive systems use personal computers, video cameras at both ends of the connection, computer based video monitors and ISDN cable wiring between sites. The video image is digitized and compressed and transmitted through cable. This is done by a codec (compression-decompression unit) which is present on both ends of the connection. The wider the band width of the cable the greater the amount of information that can be transmitted and thus the greater the resolution of the video image. Wider band width is more expensive to install and to use for transmission. ISDN transmission varies between 128 and 384 kbps with the highest band width providing excellent video representation. At lower band widths not only is the resolution less but movement is less smoothly presented, leading to a jerky and somewhat distorted image. Since telepsychiatry practice relies less upon evaluation of movement or precise image resolution, technology options can be chosen based upon cost and system availability.

Another system option has been utilized for some applications. This is known as the POTS (Plain Old Telephone) system. This system uses small video cameras at each end of the connection and attaches to cable ready television receivers and uses a regular (analog) telephone for the connection and transmission. These systems transmit at 25-40 kbps (much lower information) but are highly portable, very easy to use and inexpensive. Transmission costs for these units are the cost of long distance telephone calls. Resolution of these transmissions is more blurred and movement very jumpy, but the cost and portability often make this system cost effective when the degree of resolution does not limit psychiatric judgement and practice.

There are many applications of telepsychiatry in Child and Adolescent Psychiatry. Video conferencing can be used for psychiatric evaluations in mental health centers, juvenile justice facilities, in hospitals and in schools. Consultations can be provided for staff in these facilities and staff can get together to discuss challenging children. Psychopharmacology consultations and follow-up evaluations can be conducted. The technology provides unique opportunities for case consultation and case discussions. Video conferences can also provide specific instruction and staff development experiences as needed by the staff in the distant site. If limited resolution is adequate these services can be delivered within the staff's workplace, and the system can be moved among several locations by using the POTS system. Regular psychotherapy, with either children or families, can also be provided through telepsychiatry. An additional application is to conduct family therapy with therapists and children when the child is being treated in a distant inpatient or residential unit. These services are paid for by some insurance companies and require similar medical licensure, record keeping, consent forms and liability coverage as is customary in face-to-face care.

Determination of the appropriate system is based upon a consideration of the degree of resolution needed, the portability of the system most appropriate and the costs of installation and regular use. Telepsychiatry is most useful in underserved areas with limited access to child and adolescent psychiatrists, such as rural areas and inner cities. In each of these locations access and follow through with care are limited and utilizing technology to provide easy access greatly improves care and enhances the child's functioning. Because teleconferencing can provide opportunities for participation of several individuals involved with the child (including family, mental health professionals, school personnel and social service workers) the possibility of enhancing collaboration among those involved with the child and thus amplifying treatment and response is great. In carrying out telepsychiatry practice, it is essential to have a solid and trusting relationship with local professionals at the distant site who will be present at the video evaluations and maintain continuity of care between video appointments. In some instances this makes treatment much more effective at a significantly reduced cost of both time and money.

One such example is the program we have been involved in for the past two years. Our institution, the Menninger Clinic, has a contract with the School Districts of five counties in rural South Central Kansas. Dr. John Sargent performs Child Psychiatric evaluations together with Dr. Meredith Sargent who is a psychologist with special expertise in learning disabilities and in the education of children with psychiatric disorders and learning disabilities. We require that reports of education, behavior, special assistance and mental health treatment be provided to us prior to our planned video conference. We also require that parents, child, teachers, special educators and school administrators together attend the conference. In this way we are able to combine a child psychiatric evaluation, a learning assessment, a family assessment and an evaluation of the learning environment, the relationship between family and school and the adequacy of the school's learning plan. When appropriate, we have also included physicians and local mental health professionals involved with the child and family. We utilize the POTS system because it has been adequate technically while also being portable so that it can be used in the child's school and is affordable for these rural families and school districts. In this area the closest Child and Adolescent Psychiatrist is 100 miles away and the Learning Disabilities Center is over 200 miles away. We have found that children enjoy the telepsychiatry interactions and the school personnel and parents find the sessions helpful and satisfying. We provide follow-up sessions to review progress and revise the educational and therapeutic plans. We have been extremely pleased with the results of our interventions. Children with challenging emotional, behavioral and learning problems have been able to succeed in school and live at home with markedly reduced problems. In addition we have learned that this practice requires that we use significant sensitivity, thoughtfulness and skill to ensure trust, success and engagement in these interactions.

In a field such as Child and Adolescent Psychiatry which is significantly underserved and which is not readily available in many areas throughout our country, telepsychiatry offers access, enhanced services for children in need and the opportunity for highly effective clinical innovations.