TelePsychiatry: Seamless Integration into the Full Spectrum of Mental Health

Services

Felissa P. Goldstein, M.D.

Board Certified Adult, Child and Adolescent Psychiatrist

March 17th, 2011

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What are the Autism Spectrum Disorders (ASD)?

A series of neurodevelopmental disorders Have deficits in social impairment and verbal and

nonverbal communication. Includes repetitive behaviors, restricted interests

and rigidity. Lack basic skills in social relationships, play and

communication.

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Why Design a Telehealth Program for Children on the Autism Spectrum ?

“I think autism is a good illness in some respects to use telemedicine for. The kids actually interact well with technology and more naturally than they do if you’re in the room. They’re not good with social relationships and they may find it easier to find someone talking to them from a television than they do face-to-face, which might make them more anxious.” (Peter Yellowlees at UC Davis, in Terry 2009)

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Why Design a Telehealth Program for Children on the Autism Spectrum ?

Estimated 1 in 110 children in the United States have an ASD

ASDs occur across all racial, ethnic, and socioeconomic groups

4 to 5 times more likely to occur in boys If 4 million children are born in the United States

annually, approximately 36,500 children will be diagnosed with an ASD. 

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Why Design a Telehealth Program for Children on the Autism Spectrum ?

Increasing access to specialist care. Improving how quickly children can get care. Earlier identification and treatment of Autism

Spectrum Disorders Educating community doctors about developmental

disabilities.

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Marcus Autism Center

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Marcus Autism Center

Founded by Bernie & Billi Marcus in 1991

August 4, 2008, joined Children’s Healthcare of Atlanta

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The Evolution of a Telehealth Program

Collaboration with Ga. Partnership for Telehealth –Began in April 2009

In November 2010- Marcus Telemedicine Program becomes a part of the Children’s Healthcare of Atlanta Telemedicine Program

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Diagnoses Commonly Treated via Telemedicine at Marcus Autism Center

Autism Spectrum Disorders

Attention-deficit/hyperactivity disorder (ADHD)

Neurological and psychiatric sequelae of birth defects and brain malformations

Developmental delays Down syndrome Encephalitis Fetal alcohol syndrome Fragile X syndrome

Genetic disorders Intellectual disabilities Mitochondrial disorders Movement disorders Neurological disorders Psychiatric disorders Self-injurious behavior Sleep disorders

(nonrespiratory)

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The Process

1. Family contacts Georgia Partnership for Telehealth or Children’s Healthcare of Atlanta for Appointment

2. Appointment Scheduled

3. Marcus and CHOA verify benefits and register patient

4. Patient presents to Rural Site

5. Rural Site collects consents, demographics, and other miscellaneous paperwork

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The Process

6. Rural Site Representative obtains Vitals, brings patient to telemed room and turns on equipment

7. I connect with Rural Site and conduct evaluation and discuss treatment plan.

8. Rural Site calls GPT or CHOA to schedule follow up.

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Evaluation contents

History of Present Illness

Past Psychiatric History

Medical History Substance Abuse Social History School History Developmental

History

Mental Status Exam Formulation Axis I-V

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Benefits

Patient• Less travel• Less expensive• Opportunity to see

specialist• Less time spent in

car • Fewer missed work /

school hours• Easier for certain

patients to connect with clinician

Clinician • Less travel• Fewer incidental

expenses• Less time away from

family• Seamless transition

from one patient to next

• Ability to see patients throughout state

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Benefits

Patient Fast transmission

speed now makes it equal to in person communication

Clinician• Fast transmission

speed now makes it equal to in person communication

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Down Side

Patient• Harder to schedule

emergency appointments

• Longer time to receive prescriptions

• Some families miss in person connection

• Problems at rural sites with scheduling or equipment

Clinician• Insurance

reimbursement varies

• No shows• Harder to make

connection to children and families

• Sharing bad news over telemedicine is hard

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Down side

Patient Clinician • Increased paperwork

Mailing out or calling in prescriptions

Mailing out screening tools Receiving relevant

paperwork

• Lack of other specialists to refer patients to Speech and occupational

therapists Psychotherapists. Behavioral specialists

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The Future

Research• Quality of care / patient satisfaction• Accuracy of diagnosis by telemed vs. in office

Designing systems to evaluate children for developmental disorders

More specialties doing Telemedicine Streamlining process and simplifying logistics Behavior Treatment via Telemedicine Teaching Social skills via telemedicine or interactive

computer games

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Questions???

Felissa Goldstein, M.D.

The Marcus Autism Center

1920 Briarcliff Road

Atlanta, GA 30329

(404) 785-9405

Felissa.Goldstein@choa.org

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References

Autism Spectrum Disorders. National Institute of Mental Health., 41 pages with Jan. 2007 Addendum. http://www.nimh.nih.gov/health/publications/autism/complete-publication.shtml.

Cheng, Keith and Myers, Kathleen. Child and Adolescent Psychiatry The Essentials. Lippincott, Williams and Wilkins, 2005.

Facts for Families –American Academy of Child and Adolescent Psychiatry

Filipek, Pauline, Steinberg-Epstein, Robin, and Book, Teri. Interventions for Autistic Spectrum Disorders. NeuroRX, 3:207-216, 2006.

Hollander, Eric and Evdokia Anagnostou. Clinical Manual for the Treatment of Autism. American Psychiatric Publishing Inc., 2007.

http://www.cdc.gov/ncbddd/autism/data.html http://www.dana-farber.org/can/dictionary http://www.dsmivtr.org/index.cfm http://www.merck.com/mmhe/sec23/ch285/ch285a.html King, Bryan and Bostic, Jeff. An Update on Pharmacologic Treatments

for Autistic Spectrum Disorders. Child and Adolescent Psychiatric Clinics of North America. 15(1) 161-175, 2006.

Johnson, Chris Plauche and Scott M. Myers. The Identification and Evaluation of Children with Autism Spectrum Disorders. Pediatrics. 120 (5) .1183-1215, 2007

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References

Myers, Scott, and Johnson, Chris Plauche. The Management of Children with Autism Spectrum Disorders. Pediatrics, 120 (5)1162-1182, 2007.

Prevalence of Autism Spectrum Disorders --- Autism and Developmental Disabilities Monitoring Network, United States, 2006, MMWR, 12/18/2009, 58(SS10);1-20.

Terry, Mark, Telemedicine and Autism: Researchers and clinicians are just starting to consider Telemedicine Applications for the Diagnosis and Treatment of Autism, Telemedicine and e-Health, 416-419, 2009