"It works. It's the next best thing to being there." Dr. Tony Pignatiello is talking about the telepsychiatry program at the Hospital for Sick Children (SickKids) in Toronto. The program has grown over the past 10 years, wants to grow some more, and may well be part of a renewed focus on children's mental health across Canada.
The very first remote consultation in Ontario took place by teleconference in 1994 in Parry Sound. Jeffrey Hawkins, executive director of the Hands Children's Mental Health Centres in North Bay and Parry Sound, was there for the first call. "We did it over a phone line and got the money through an innovation grant. But it was very exciting and was the beginning of keeping at-risk northern children in their communities. It grew from there."
Telepsychiatry is a consultation program done by hospitals, conducted through high quality video teleconferencing, where the doctor is in one location and the patient is in another.
"The kids are comfortable with the technology, they rather like it," says Dr. Clive Chamberlain, a child and youth consultant at SickKids and at the Centre for Addiction and Mental Health. "It feels like I'm there in the room. After about two minutes you lose the sense there’s any technology. The cameras are good enough to pick up a blush or a tear."
"It makes a huge difference for people in remote areas to get access to an experienced child psychiatrist," says Chamberlain who used to fly into Big Trout Lake in northern Ontario twice a year to assist with difficult cases. "Now I can be available to help there in about 15 minutes."
These days he sits in a specially outfitted consultation room in Toronto every Thursday and advises on as many as five children who have severe behavioural problems. His expertise is kids in custody, particularly those who may harm themselves. Chamberlain uses his experience to guide local staff through difficult situations they may never have seen before.
"Not only am I working with the child, I am doing some in-service training with the workers. I think staff really benefit from being able to share with an older colleague. In the longer run this is probably more important than the clinical session."
Elizabeth Manson is the director of the telepsychiatry program at Sick Kids. She and Pignatiello have been instrumental in expanding telepsychiatry for children in Ontario.
"We have five consulting rooms here in Toronto and one portable unit," says Manson as she points out the huge flat screen monitors, the ease of the technology, and the padding on the blue walls to absorb sound so that every session is private. The appointment list on each door is much like a schedule at any doctor’s office.
Manson is particularly proud of a new initiative — one room has a cozy yellow couch and armchair. "We asked the children for feedback and they suggested we get out from behind the desks and be a little less formal. So we put in the couch on a trial basis and they say they love it."
Keith Zehr, the executive director of the William W. Creighton Youth Services in Thunder Bay with programs in Kenora, can't say enough good things about the program. He is with the youth justice division of the Ministry of Children and Youth Services and deals with girls between 12 and 18 years old at Creighton who are in secure custody for such crimes as murder and attempted murder.
"We always wished we had more on-the-ground child psychiatrists in Thunder Bay. The ones we have are fantastic but they are run off their feet. Telepsychiatry is way, way better than the long wait times, or pulling in personal favours to get a child’s needs met. We got the technology sorted out late last year. We have bone fide heavy-duty mental health issues and the children weren’t seeing psychiatrists. We are using the service a lot," says Zehr.
A young man in custody in a justice facility in Thunder Bay was unable to get a prescription that was vital to his therapy. There were no attending physicians or psychiatrists on staff, so the facility called for help.
A physician in Toronto did a consultation and within five days provided a recommendation for medication, which the youth received soon after.
He expressed his extreme gratitude toward the program and is now on the path to getting a long-term prescription to aid his therapy.
"I notice that even the hardest kids enjoy the technology, they understand it and the two-way interaction is very helpful. In fact, I think some of them prefer talking this way. We have some very difficult situations and I'm convinced that at least one child would be dead now without this program," says Zehr.
"The staff in Thunder Bay and Kenora feel very supported, and even that Dr. Chamberlain is their colleague.
"We like to think that the Ashley Smith case couldn’t happen here because, especially with the telepsychiatry program now in place, we are doing appropriate interventions and care," adds Zehr.
There was growth in 2007 when SickKids became part of a network with children's hospitals in Ottawa and London. The program is now in 24-25 communities in Ontario. This means such places as Great Trout Lake, Timmins, Parry Sound, and Orillia use teleconference centres to access children's mental health specialists in the larger centres.
Pignatiello points out that the telepsychiatry program at SickKids is more than a video link. The full program includes working clinically with children and families at risk, building skills of local doctors and mental health workers in areas outside of Toronto through a range of programs, consultations, continued professional development which includes medical school trainees, developing guidelines for telepsychiatry and qualitative research.
The buzz phrase is "building capacity" which means expanding and sharing knowledge at the local level. Pignatiello says this is crucial because there will never be enough child psychiatrists, especially in remote areas, and it is key to continue to train front-line workers through teleconferencing.
"This is not about Toronto for us," says Hawkins, "it's about Parry Sound and how the experience in Toronto supports the kids, and the care providers here."
Hawkins tells of a case where his team was stuck but after a teleconference consultation they did a reassessment of the child and came up with a new diagnosis. "The parents were so relieved as it made sense and took a big rock off their backs. And it was all done locally. The child was not sent somewhere to a big hospital."
Most Common Diagnoses
An estimated 20 per cent of children have mental health issues and five per cent of these have a mental health illness. In 10 years the Ontario telepsychiatry program has done 7,056 consultations. The most common diagnoses are:
- oppositional defiant disorder.
- anxiety disorder.
- learning disability.
- relationship problem
- problems related to abuse/neglect.
- mood disorder.
- attachment disorder.
- conduct disorder.
Source: Telepsychiatry and Telemental Health, Jan. 2011
While SickKids is a leader in telepsychiatry, Alberta has had a program for a number of years and other provinces, such as British Columbia and Quebec have considered adopting it. Nunavut, Newfoundland and Labrador and the North West Territories are currently studying the program. Newfoundland is looking at an adult program for off-shore workers.
"Many programs aren’t sustainable because the funding isn’t secure," says Pignatiello. "We have put multiple routes of funding in place and I think that is why we have been going strong for more than 10 years. And we continue to look at ways to respond to the needs of the communities out there."
A recent expansion provides specific services to individual hospitals. SickKids can give urgent consultation within a 72-hour period to kids and youth who have been admitted to acute pediatric mental health beds in hospitals in Timmins, Thunder Bay and North Bay. In most of these cases, the children are being detained against their will for the purpose of assessment.
"We also provide referral services to all primary care physicians for children in Ontario. This happened in December 2010," says Pignatiella. In fact, thanks to telepsychiatry, a referral outside of Toronto to a child psychiatrist can happen in a couple of weeks, while in Toronto it can take several months.
Another client, Debbie Grasser, director of services at Family and Child Services of Timmins and District, says telepsychiatry is instrumental in providing insight into potential mental health diagnoses that may otherwise go undetected.
A small community referred a young man who set a dangerous fire that caused significant damage. There was concern in the community that the boy was psychotic and hearing voices.
However, a consultation via telepsychiatry determined his behaviour was due to a number of issues in his personal life, much of it stemming from underperformance in school.
The boy was tested and identified as having a learning disability. His school then made adjustments to help him and as a result, his quality of life increased. His therapy has continued.
Mary Jo Haddad, the head of the Hospital for Sick Children, says there is a renewed focus on children's health and wellbeing. "We will be a big voice in the future of children's mental health and what it looks like in Ontario."
She says there is a real momentum now to take on children's mental health. "You can feel a crescendo here, built on 'we need to do something.'"
She feels that the telepsychiatry program is a natural for even greater expansion because it has been evaluated and found to be a highly effective way of getting help into communities.
Haddad would like to see a national strategy for children’s mental health that includes less fragmentation and more co-ordination among government ministries that are focused on children and youth.
"We may always have mental health issues just like we have physical health issues, but we can improve on the number of people with mental health problems. One of the keys is to help the children so we can decrease the profound consequences of unaddressed mental health issues," says Haddad. She wants to pay special attention to educating health care workers and removing the stigma of mental health.
Hawkins is passionate about the role telepsychiatry can play in improving children's mental health. One of its strongest advantages, he says, is keeping at-risk children in their communities with their families and local support.
"We all seem to know that one in five children have mental health issues. I do feel the whole environment is changing as people understand the importance of helping children so they can be successful and strong members of society."