The Telepsychiatry Advantage: Episode 4
How to make Telepsychiatry Work with Younger Patients
Hello everyone, and welcome back to the Telepsychiatry Advantage. I’m your host, Doctor Edward Kafterian. I’m the chairman and CEO of Orbit Health Telepsychiatry. And this is the longest running Telepsychiatry company in the world.
The Pediatric Puzzle: Unique Challenges in Telepsych
I’m a psychiatrist, and I’m accustomed to seeing children and adolescents as well in my practice. And I can tell you that children and adolescents pose unique challenges to the psychiatrist, as many of you know.Some of these challenges involve the fact that their symptoms and signs of mental illness are different than in adults, oftentimes.
For example, depression and anxiety often look different. They can manifest as stomachaches, headaches, irritability, or explosive tantrums. And so you have to translate those behaviors and those presentations into the clinical symptoms for the mental health disorders that you’re trying to diagnose and treat.
Another challenge of seeing patients that are younger is that the child is rarely the primary historian. Usually you have to gather information from parents, teachers, school counselors, and pediatricians, and these reports may actually conflict. So you have to put it all together like a puzzle.
Another challenge is that they’re moving targets. As children grow, they change. And so you have to constantly weigh the symptoms against the developmental milestones and changes in their lives. And so what’s completely normal and appropriate behavior for a four year old could be highly pathological in a 12 year old. And so that changes over time and then you’re dealing now with a moving target.
Another challenge is that the family dynamics are a big factor. And the child is really tied to their environment and their family and so you can’t effectively treat a pediatric patient in a vacuum. You have to understand and assess their family life and the family dynamics in order to get an accurate assessment and an appropriate treatment.
Another challenge of seeing patients that are children is the ability to sustain engagement. So whether it’s with telepsychiatry or in person, it’s often hard to engage the patient. They can be very distracted.
And then lastly confidentiality and consent can be very different with children because children may not be able to provide informed consent and you need to get a consent from the parents. So these are all issues that we deal with whether we are seeing a child via telepsychiatry or in person.
The Digital Playroom: Engaging Younger Children
Now, when I first started seeing children and adolescents via telepsychiatry, I was sort of thrown into the fire there and it was pretty challenging. For example, children were very distracted by their own environment. They were more interested in playing in their homes than talking to me, of course. And I don’t blame them, they’re children. And so it was my job to engage them on camera. And I saw that there was a variety of reactions to seeing their doctor on camera. Some of them seemed completely disengaged. Others thought it was odd and it was somewhat intriguing and it was definitely very difficult to get their attention. And so I learned various techniques to do this, to get their attention via telepsychiatry.
So I remember one of the first patients that I saw via telepsychiatry, I didn’t know how to get their attention. So I thought about it and then I realized, well, okay, maybe they have a favorite action hero. And so this boy that I was speaking with, he was into Marvel. And so as soon as I knew this, I asked him, okay, which character do you like? And he said, Iron Man. So then I quickly and sort of quietly googled Iron Man and got pictures of him and said, oh, look at this, this is a cool picture of Iron Man.
And then that began the conversation. And when he would tell me about a certain movie or other situation that Iron Man was in, I would try to find it. And I did this with other children as well. I showed them videos just to get their attention, and then interacted with them based on what they were interested in. So if they’re interested in Pokemon, maybe a short Pokemon video or a picture of their favorite Pokemon character, and that sort of got them committed to speaking with me and interested in speaking with me.
But then I learned other techniques as well. I learned how to leverage the home court advantage of having the children be in their own safe space. I call it the home court advantage because they are in their home court. And so you can have them introduce their pet to you, and that’s always a great one. You know, having pets introduced on camera that can be really effective in developing trust or rapport. I often would show my pets to them and that would get their attention. You know, there’s nothing like a dog or a cat or a turtle or any pet that you might have that instantly captures the children’s attention and makes them want to talk to you.
So you can also use interactive tools. I found out that you don’t just talk at the child, you can work with the child like the whiteboard feature on your platform. For example, you can do a quick game of Tic-Tac-Toe, Pictionary or squiggle game where you take turns adding to a drawing can be very effective in establishing trust or rapport and getting them to speak with you.
So another thing that I realized was that it’s foolish to get a very young child to try to sit there in their chair during the whole appointment. Expecting a child like a seven year old with ADHD to sit perfectly still in front of the webcam, tt’s a losing battle. And if they’re hyperactive, let them move. Let them move around. Talk to the parents while they’re moving around, and then you can talk with the kids even as they’re playing and walking around the room. You can even use it clinically to see what they’re walking is like, what they’re paying attention to in their environment. You can ask them, how high can you jump or can you balance on one foot for me. So you can get some good information about their physical status as well when they’re walking around. So don’t just try to keep them fixed to their chair because they’re not going to enjoy the appointment, you’re going to have a tough time trying to get them to do that, and it’s just going to be a challenge for everybody.
The other thing that I learned is that you can gamify the assessment. So you can turn your clinical questions into a game. You can do, for example, a thumbs up and thumbs down lightning round for symptom checks. And then if they complete a tough part of the interview, give them a reward, like having them pick their next whiteboard game, or sharing a funny meme on the screen. And this doesn’t have to take a lot of time either. You can do these things quickly and go back and forth asking questions, playing games, and you can get a whole ton of information doing that.
Another trick that I learned was mastering the micro break. So a 45 to 60 minute session is an eternity for a young child, especially if they have to pay attention to the camera.So you can plan a structured and frequent micro breaks and say, okay, I’m going to talk to mom for five minutes, and your job is to go run a lap around the couch and come back. This is a way for them to stay fresh with their attention.
Another tip that I want to share with you is that sometimes kids get distracted by their own picture, their own image in the self view of the camera. And I would recommend that you have the mother turn off the self view, because what happens is they get focused on their own face and they don’t focus on you. And that can actually work both ways. Sometimes us psychiatrists and psychiatric practitioners, we sometimes get distracted by our own image as well. I admit that. So sometimes I have to turn off my own self view. But kids are extra vulnerable to that, so you want to make sure that you have turned off their self view. Once you have sort of established the video visit.
Sometimes when you’re on camera speaking to a child, you have to be a little bit more animated than you would be in person. Now you want to make sure to watch the volume, because you don’t want to sound like you’re screaming at the camera, but at the same time, you want to enunciate clearly and talk in a volume that can be heard. This is very important for children in particular, and you should smile and sometimes I have to challenge myself to smile some more, nod more empathetically, and use dynamic vocal pacing to keep things interesting. Because if you have a monotone on camera, that can be a challenge. And I’ve faced that in my career as well, trying to make my voice more dynamic. So that’s a skill that you have to teach yourself and it’s really important in helping engage children on camera.
Now the parent is a very important part of this. Don’t just let the parent sit passively off screen. You want to give them the job to make sure that the camera is positioned correctly, that you want to have the parent physically handing them a piece of paper. If you want the child to draw something for you. And then, of course, the parents that you’re speaking with will be a great source of collateral information. They can tell you what the environment is like and maybe establish, okay, which room are we in right now? What’s outside of those walls? Are we in an apartment? In a house? What’s outside? Just the general environment of where the kids are living.
Beyond the Screen: Clinical Insights from the Home Environment
So one of the tools that we have with telepsychiatry that we don’t have when the patient visits our office, is that we can see what their environment looks like, and that tells us a lot about their mental life, their emotional life. So now I’m going to go over a few of of the things that this tells us.
The bedroom baseline, that’s what I call it. It’s the state of the child’s room, which is a direct window into their executive functioning and mood. A severely cluttered, trash filled room can be a stark indicator of depression, ADHD, or maybe even neglect by the parents. And on the other hand, a very obsessively sterile or perfectly arranged room might hint at OCD traits in a highly rigid or controlling family atmosphere. So when you look at their environment, you see how organized it is or how messy it is and that gives you an idea of maybe the patient’s personality or their environment that they’re living in.
Also paying attention to the lighting is important. So is the child always sitting in a very dark room with the curtains drawn, or is there plenty of natural light? And so if you are seeing that their home is a very dark and depressing kind of atmosphere, then it might suggest a factor that may be interfering with the child’s ability to be happy and can be important in your diagnosis.
Another thing that I would like you to do is to be a detective. Looking at the posters, the toys, maybe the art that’s scattered around the room and that gives you clues about the patient’s passions, their development, what kinds of things they’re into, and that can help you not only establish rapport with the patient to say, hey, I see you have a poster of Pokemon over there. What’s your favorite character? So you can establish rapport, but it can also tell you a little bit about what kind of environment they’re in, if it’s an uplifting environment or it’s a depressing environment. You also want to look at the background chaos that might be there. For example, are people walking in and out of the frame? Are there constant interruptions? Is there yelling or noise in the background or siblings fighting in the room? So this might tell you what the patient needs to deal with on a daily basis, and that that may affect their anxiety, that may make them more distracted, dysregulated. And so that’s a huge advantage for us to see that via telepsychiatry. And that’s not something that you’re going to see necessarily when the patient visits your physical office.
Another thing that you can tell from seeing the patient’s environment is if there are any red flags with regard to safety. So do you see like drug paraphernalia, alcohol bottles, anything inappropriate that is within reach of the children, anything dangerous, for example. Are there medications around? Is there anything in their environment that you think may not be appropriate for the child to access? And another thing that you can tell from the environment is where is the appointment happening? Are they calling from the bathroom or are they calling from the closet because there’s like no other place that they can get privacy or confidentiality? Is the Wi-Fi strong? You know, these are some of the things that we can tell you what kind of situation the patient has on their end.
The Confidentiality Tightrope: Navigating Adolescents
We’ve talked a lot about children, and some of these points that we’ve made apply to adolescents. But now let’s turn our attention to exclusively adolescents. So what are some of the challenges that you have when you’re seeing adolescents on camera?
Well, first of all, adolescents are not always willing participants for the session. Sometimes they’re forced to see a psychiatrist by their parents, and their heart is not really in it. And so you need to overcome an extra challenge of a patient who really does not want to see you.
Another challenge of seeing adolescents that can occur in both telepsychiatry and standard psychiatry is that there’s a confidentiality tightrope that you need to walk where you need to protect the adolescents confidentiality to some degree, but parents also have rights too. And so you have to balance that and some of that can be dependent on what the local rules are as far as how much parents can know about the session. So that’s a challenge that you face as a psychiatrist. How much can be discussed without the parent and how much the parent needs to know. And your adolescent patient is going to be reluctant to share a lot of information if they know that this information is going to make its way to the parent. So this is a challenge that you need to face.
Another challenge is that since adolescents are digital natives and they’re used to technology, although that can be a good thing, it can also be a challenge because they may seem engaged with your interview, but they may be secretly texting somebody else or distracted by something else, but their eyes maintain somewhat of a focus on the camera, which is really difficult sometimes to gauge.
Another challenge of seeing adolescents is that as digital natives, they’re used to screen time, and they may be able to fool you and make you believe that they’re paying attention to you, but meanwhile, they’re texting on their phone or maybe they’re scrolling the internet, and sometimes it’s hard to tell if they are paying attention to you. So one way that you can ensure that they are focused on you is to make sure that they are looking at your picture, and you want to ask them to put your picture close to the camera so that it looks like they have eye contact with you and they’re not looking down. Now, this is still very challenging, so it’s sometimes helpful to ask the parent to come in and see. Is the adolescent paying attention to you or are they doing something else? And so that’s something that can be a challenge. But with a little bit of attention and care, you can find a way to make sure that they pay attention to you.
Another challenge of seeing adolescents is that it can be a high risk and high stakes assessment, because, of course, we want to make sure that the adolescent is doing well in their life. And if they’re not doing well and they have conditions like bipolar disorder, major depression or early stage psychosis, it’s very important that we diagnose that quickly and accurately so that we can get ahead of it. And in order to do that on camera, you have to be particularly paying attention to the visual cues that the patient is giving them. Their affect. And you also want to get collateral information to reinforce what you’re seeing on camera.
High-Stakes Tech: Tactics for Teen Engagement
So what are some of the things that you can do to help engage an adolescent on camera and make an accurate diagnosis?
Well, first you have to acknowledge the fact that a lot of them are not really interested in having the appointment to begin with. So you could say something like, I know your mom made this appointment, and you probably rather be doing literally anything else right now. So I’m sorry that, you know, you have to do that, but we’re going to make the most out of this, and we’re going to try to do this in a way that’s fun and helpful for you. So it’s not a cure all, but at least acknowledging that the patient doesn’t want to be there can lower their amount of annoyance and their defensive shields.
Another tip that you can use is use the chat function. So, for example, if a patient doesn’t want to do a whole lot of talking, maybe they want to chat with you over chat function with text. And so that can kind of help open up the communication. You’ll still be able to visualize them on camera, but they’ll be texting you. And this will also ensure that they’re not texting somebody else. So lean into the chat box and tell them, look, you don’t have to say it out loud. Just type the answer. Sometimes the patient doesn’t want to say something out loud because they feel like somebody in the other room is going to hear them. Sometimes leaning into the chat box will help them open up and make them more likely to give you sensitive information, knowing that nobody but you and the patient can see that chat box.
Another tip that I want to give you to engage adolescence is if you have a standard screening tool that you use. For example, the Q9 or the Gad seven, instead of asking the questions, you can have them fill it out together with you so you can look at a shared document, and that shifts the interaction from very one sided kind of dull interaction to the patient is helping you fill out the form and this is a dynamic discussion rather than the doctor interrogating the patient, you’re working on this together.
One of the most important things with seeing patients that are adolescents is establishing rapport. And just as we discuss with children, you want to find something either in their environment or ask them what they’re interested in and find something that you can talk about, whether it’s a show that they like or a comic book character, really anything that that they find interesting, you use that to establish rapport. And the advantage of telepsychiatry is that you can show them pictures and videos and you can discuss it together, maybe laugh at a funny clip together and just sort of enjoy their company and so that it is not a boring, oppressive psychiatry appointment, but rather just a fun discussion where you learn a lot about them and they are more trusting of you.
The Telepsychiatry Edge: Why Virtual Can Be Superior
So I hope that these tips and tricks have helped you learn how to establish rapport with the patient, diagnose conditions in children and adolescents on camera. And really, the bottom line is, the most important thing here is establishing rapport and having them share information with you on camera. And as you can see, telepsychiatry not only is NOT inferior to in-person care, but also it has advantages. So it’s not inferior, but it has advantages over in-person care sometimes. And so I hope that this gives you more confidence to embrace telepsychiatry appointments for children and adolescents over video.
Thank you very much for joining us for this episode of The Telepsychiatry Advantage. And until next time, keep raising the standard.
