Addressing Pediatric Mental Health Using Telehealth During Coronavirus Disease-2019 and Beyond: A Narrative Review

Abstract

The pediatrician serves as a frontline provider addressing patients’ medical and mental health needs, yet coronavirus disease-2019 (COVID-19) is reshaping the way physicians deliver care. Pediatricians are increasingly faced with the challenge of delivering care, including mental health care, remotely. Given the rapidly evolving literature, we performed a narrative review of the use of telehealth for mental health care for pediatric populations during the COVID-19 pandemic. Areas of focus included 1) pediatric primary care settings, 2) special pediatric populations (eg, eating disorders, autism), 3) access and engagement in telehealth care, and 4) training opportunities available for mental health providers. Themes that emerged across studies included the importance of meeting patients’ needs (eg, access to technological resources) to optimize success in using telehealth tools and challenges around provider access to support tools for use during telehealth. Thus, we provided a summary of evidence-based tools (including COVID-19 specific resources) for improving the remote delivery of mental health care by pediatricians. We also reviewed future directions including trials currently underway to enhance understanding of future telehealth applications for pediatric mental health care.

What's New.

The evolving literature on telehealth for pediatric mental health care during the coronavirus disease-2019 pandemic is reviewed. Common themes, limitations, and future directions pertinent to pediatric care are provided. Evidence-based tools are also summarized to promote effective telehealth delivery.

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In the wake of coronavirus disease-2019 (COVID-19), the physician is increasingly tasked with using remote strategies to address patients’ medical and mental health needs. Telehealth is technology-facilitated communication between the patient (caregiver) and provider to allow individuals to function as if physically together.¹ Telehealth for mental health care (herein referred to as telehealth) can be used for both symptom assessment and intervention. Prior to the COVID-19 pandemic, telehealth was already used to manage chronic pain,² obesity,³ and sleep problems,⁴ all of which are common presenting complaints in pediatric primary care settings. The rapport between providers and patients in virtual settings was shown to be comparable to in-person treatment⁵ with increased patient disclosure.⁶ Prior to COVID-19, telehealth was only used by 15% of pediatricians⁷ and fewer than 50% of mental health providers.⁸ While billing and insurance coverage limitations previously affected use,⁷ there is now increasing reimbursement for telehealth services in response to the COVID-19 pandemic.⁹ As a result, remotely delivered care has increased and will only continue to evolve. Our goals of this narrative review were twofold: we reviewed emerging literature on the use of telehealth for pediatric mental health care during the COVID-19 pandemic. Second, we shared freely available evidence-based tools that clinicians may wish to use to enhance telehealth practice.

Review Methodology

We conducted a search for English-language articles on telehealth offered for mental health during the COVID-19 pandemic (January 2020 to March 2021). Articles in PubMed, Embase, PsychInfo, and LitCOVID were searched and filtered. Telehealth terms included, “telehealth” OR “telemedicine”; mental health language included, “mental health” OR “mental illness” OR “mental disorder” OR “anxiety” OR “depression” OR “ADHD” OR “distress” OR “worry” OR “behavior*” OR “autism.” The terms, “pediatric” OR “child*” OR “adolescent” OR “teen” were also searched.

The search revealed 876 articles, of which 73 seemed potentially appropriate following a title/abstract review, and 54 were deemed appropriate after a comprehensive review. Further, 1 article (identified by expert knowledge) was also included, totaling 55 original scientific papers in this review (Table 1 ).

Table 2.

General and COVID-19 Specific Tools for Managing Mental Health in Primary Care

Resource	Description	Evidence	Grade†
Tools for providers
Behavioral Health Integration Compendium https://www.ama-assn.org/delivering-care/public-health/compendium-behavioral-health-integration-resources-physician	Compendium of resources for physicians to integrate behavioral health into practice	Multiple‡	1–5
National Child Traumatic Stress Network Resources https://www.nctsn.org/	Resources for understanding and coping with trauma in children	Multiple‡	1–5
American Academy of Pediatrics Mental Health Screening and Assessment Tools https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/MH_ScreeningChart.pdf	List of mental health screening tools used in primary care settings	Multiple‡	1–5
American Psychological Association's, “Telepsychology Best Practice 101 Series”⁎https://apa.content.online/catalog/product.xhtml?eid=15132&eid=1921	Course for practitioners on best practice of telehealth for psychological care	Multiple‡	1–5
COVID-19 Specific Tools
National Child Traumatic Stress Network COVID-19 Resources https://www.nctsn.org/resources/nctsn-resoures-related-to-covid-19	Compilation of COVID-19 specific resources for providers, children, and their families	Multiple‡	1–5
COVID-19 Exposure and Family Impact Survey https://www.healthcaretoolbox.org/tools-and-resources/covid-19-cefis.html	Measure of COVID-19 related family distress, available for parents, adolescents, and young adults	Kazak et al, 202165	3
Tools for patients
Anxiety
Anxiety Coach https://anxietycoach.mayoclinic.org	Anxiety/OCD program (5 modules) for children and their families	Whiteside, et al, 201966	4
MindShift (App)	Anxiety management tool using CBT	Weekly et al, 201867	5
Breathe, Think, Do (App)	Problem solving strategies for children	Weekly et al, 201867	5
Pain and somatic symptoms
Stepped Care for Pain https://steppedcare.research.cchmc.org/	Psychoeducation and relaxation for pain	Cunningham et al, 202168	2
WebMAP Mobile (App)	Pain coping program (8 modules)	Palermo et al, 202069	2
MyCalmBeat (App)	Guided diaphragmatic breathing	Weekly et al, 201867	5
Breathe2Relax (App)	Breathing and muscle relaxation exercises	Weekly et al, 201867	5

COVID-19 indicates coronavirus disease-2019; CBT, cognitive behavioral therapy; OCD, obsessive-compulsive disorder.

The above tools are suggestions for providers and their patients/families. Patient resources are geared toward children and adolescent populations.

^⁎Most are freely available at time of press with one exception.

^†Grades 1–5 were assigned to resources (with lower numbers indicating greater evidence: 1 = systemic review of randomized trials, 2 = randomized trial, 3 = nonrandomized, controlled study, 4 = case series or studies, 5 = mechanism-based reasoning) based on the OCEBM levels of evidence.⁷⁰

^‡Tool is comprised of several resources with varying levels of evidence.

Results

Primary Care

Several primary care clinics described the transition from in-person to virtual care as a result of COVID-19.10, 11, 12 Once telehealth was employed, the frequency of visits was comparable¹⁰ or increased¹¹ due to its use. There were also decreased no-show rates for those with pre-existing barriers to in-person care.¹³ Mental health concerns were among the most common presenting complaints during COVID-19 (28%–36%),¹¹ and integration of behavioral health treatment via telehealth was found to be feasible.¹³ A variety of mental health services, including eating disorder treatments and addiction treatments, were also successfully implemented.¹⁰

Telehealth use was more common for patients who engaged in preventive care in the prior year, younger children (ages 0–2 years), and those who identified as non-Hispanic white, suggesting barriers to access for minority populations.¹¹ In addition, several challenges (eg, patient privacy, inadequate infrastructure, limited mental health protocols) were reported following the rapid transition to telehealth.¹² Cumulatively, these studies suggest mental health concerns encompass a large portion of pediatric primary care visits and telehealth has the potential to increase access to care, though disparities in care and lack of provider resources remain barriers.

Special Populations

Multiple studies addressed specific pediatric populations including those diagnosed with eating disorders,14, 15, 16, 17, 18 attention deficit hyperactivity disorder (ADHD),¹⁹ autism,19, 20, 21, 22, 23 other severe mental health concerns,24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34 and chronic medical conditions including epilepsy.^{35 , 36}

Among individuals with eating disorders, worsening symptoms (eg, increased distress, binge eating) were reported during the COVID-19 pandemic, signaling the need for additional and/or sustained psychological care.^{14 , 15 , 17 , 18} However, patients reported a decreased willingness to attend in-person visits due to fears related to contracting COVID-19, which may be indicative of support for telehealth options.¹⁵ Importantly, strategies traditionally considered typical of in-person treatment for eating disorders (eg, group therapy, family involvement, and specialist consultation) were found to be readily adapted to telehealth, even in an inpatient treatment setting.¹⁶ In fact, virtual adaptions were planned to continue beyond the COVID-19 pandemic (eg, utilizing video platforms when patients, families, or staff are unavailable for in-person meetings).¹⁶ Patients generally reported an appreciation for the use of telehealth services to manage mental health,¹⁴ but engagement and treatment response may depend on eating disorder subtype, and further research is needed.¹⁸

Telehealth was also employed among youth with severe mental health issues receiving care in an inpatient unit.^{29 , 30 , 32 , 34} Units used telehealth to mitigate COVID-19 outbreaks²⁹ and to decrease hospitalization length (from approximately 26 days to 10 days) during the COVID-19 pandemic.³⁰ However, greater improvement correlated with longer in-person stays, suggesting that those with severe mental health issues may benefit more from in-person care.³⁰ Conversely, another study in an inpatient unit reported high satisfaction with telehealth among patients and families, though patients had difficulty returning to in-person care routines after a lockdown period.³² Further, several studies of youth with complex mental health needs reported that telehealth was feasible for providing care that was conventionally offered in-person.^{27 , 33 , 34}

Caregivers of youth with neurodevelopmental disorders reported that telehealth interventions were practical, helpful, and easy to implement.³¹ A small cohort of children with autism demonstrated symptom improvement while utilizing a virtual program led by providers and caregivers.²² However, other studies of children with autism reported several challenges (eg, decreased follow-up, potential worsening of symptoms) during telehealth.^{20 , 21} Other investigations of youth with complex disabilities reported increased mental health concerns among children and caregivers,²⁵ as well as mixed to low satisfaction with virtual care (eg, decreased access to care, perceived as a poor fit for their child).^{25 , 26} More than a quarter of caregivers reported inadequate support from those who addressed mental health challenges (eg, in schools or health care settings).²⁸ Parents of children with epilepsy similarly reported limited or inadequate access to resources for their children via telehealth.^{35 , 36} Given the mixed satisfaction and access to virtual care for complex mental health issues, telehealth alone may be inadequate to meet the needs of all children.

In addition to delivering care, telehealth posed challenges when used to conduct neuropsychological assessments virtually during the COVID-19 pandemic.^{37 , 38} One group noted that 63% of their patients needed further in-person evaluation.³⁹ However, other investigations reported leveraging digital technologies (eg, using live video and recordings) to enhance neuropsychological assessment for complex conditions such as autism and ADHD.^{19 , 23} One survey-based study revealed that several clinics were able to continue virtual assessment and even provided language interpreters for the majority of patients who needed such services.⁴⁰ Some reported they will continue to use virtual assessment strategies beyond the COVID-19 pandemic.⁴¹ While challenges should be considered, telehealth presents another avenue for pediatricians recommending patients to specialized treatment.

Access and Engagement

The COVID-19 pandemic adversely impacted patient mental health^{42 , 43} and increased the need for care (particularly in clinical populations) during the COVID-19 pandemic.^{10 , 11 , 44} However, less engagement in pediatric telehealth was noted specifically for psychotherapy, especially when compared to medication management.⁴⁵ Interestingly, in a community sample of high school youth, a sizable portion (one third) reported mental health concerns due to COVID-19, but only 40% intended to seek treatment. These findings mirror that of an intensive outpatient clinic providing mental health services, which reported increased rates of attendance via telehealth,⁴⁶ but an overall decline in service use.⁴⁷ Indeed, service use within settings may have varied throughout the pandemic. For example, while COVID-19 likely triggers increased distress in many children, a subset of youth (such as those with social anxiety) may experience diminished symptoms with virtual schooling or social distancing,¹³ and may discontinue treatment due to decreased anxiety.¹³ However, the return to in-person activities may increase anxiety for these youth and increase telehealth engagement. Indeed, this pattern has already been observed in some settings, with increased telehealth use at the onset of the pandemic, followed by decreased use during stay at home orders, and increased use again when some schools transitioned from virtual to in-person learning.⁴⁸

Services were even paused for some clinics, as a survey of pediatric/adult mental health clinic directors reported 23.7% of their facilities closed for a period of time,⁴⁹ and of those that remained open, 86% provided telehealth. A large survey of US mental health clinics (n = 8860) found only 45.2% of clinics treating children offered telehealth during the COVID-19 pandemic.⁵⁰ Staff deployment to care for COVID-19 patients also limited access to care,⁵¹ and systematic issues (eg, lack of platform, complex administrative processes, low rates of reimbursement for telehealth) were identified as challenges.⁵² Unsurprisingly, health care systems with the most successful transition to telehealth already had existing infrastructure and resources prior to the COVID-19 pandemic.^{53 , 54}

Limited use of telehealth occurred in clinics that did not accept Medicaid and were in metropolitan areas, as well as areas with more COVID-19 cases and shelter-in-place orders.⁵⁰ In inner-city mental health clinics, immigrant/refugee youth faced several challenges of remotely delivered care (eg, increased distress among children and their families, internet access difficulties, lack of technological devices, lack of a secure/private space).^{55 , 56} In line with such research, gaps in mental health care were exacerbated for minority individuals during the COVID-19 pandemic.^{11 , 24} For families with lower socioeconomic status, phone versus video platforms enhanced engagement,⁵³ and youth reported they were more likely to use telehealth if it was secure and available in instant messaging or video format.⁵⁷ Some families of youth with ADHD expressed appreciation for text messages helping them manage their child's symptoms.⁵⁸

Patient telehealth use during the COVID-19 pandemic posed challenges^{51 , 59 , 60} (eg, technological issues, privacy concerns, scheduling conflicts, and engaging patients physically/emotionally), with such reasons also being endorsed for missed appointments.⁵⁹ On the other hand, clinicians effectively transitioning to telehealth care reported supervisor support and ability to adjust to technological challenges as factors contributing to their success.⁶⁰ Among community mental health providers (n = 93) the adaption to telehealth delivery was generally viewed positively; however, providers noted risks to confidentiality, limits to delivering certain types of interventions (eg, access to tangible behavioral reinforcers), and other challenges specific to pediatric populations (eg, distractions, lack of parental support).⁶¹

Training

In the wake of COVID-19, provider training was enhanced to effectively use telehealth for addressing mental health concerns in children. One study described implementing a virtual training platform for mental health providers in a low-income country (Nepal) with a population of over 29 million (40–50% are children), yet only 1 full-time pediatric outpatient psychiatric clinic.⁶² Impressively, this program launched during the COVID-19 pandemic and increased access to mental health care throughout the country. Successes were also achieved in disseminating psychological first aid and other provider training resources (Table 2 ), and adapting a standard in-person, empirically supported treatment for child behavioral concerns (Parent-Child Interaction Therapy) for use in a telehealth platform following the COVID-19 pandemic.⁶³

Table 1.

Articles Pertaining to Telehealth for Pediatric Mental Health During COVID-19

Target	Study	Sample	Study Findings
Primary care	Barney et al, 2020	Adolescents and young adults in an urban academic medical center	TH visits increased 0–97%; Maintained pre-COVID visit rates; Successful for most txs but not for health supervision
	Schweiberger et al, 2020	45 pediatric primary care clinics	MH consults were the most common TH visit; TH use varied based on child's demographics and preventive care use; Practices with higher TH use had fewer in-person visits but more visits overall
	Satti and Ojubele, 2020	13 general pediatric clinicians; 1 pediatric behavioral health clinician at a rural medical center	TH visits increased 0–82%; Addressing patient privacy, resources, and creating standard protocols crucial for success
	Perrin et al, 2020	Pediatric and adult psychologists/doctoral trainees	Fewer referrals and some parents opted to pause child's tx; TH increased access to care and rate of visit attendance
Special populations	Termorschuizen et al, 2020	~1000 adolescents and adults with eating disorders in the United States and the Netherlands	Participants reported increases in distress, maladaptive behaviors, anxiety, and fear of relapse during COVID-19. Appreciated TH tx, but some had limited access
	Davis et al, 2020	Children and adolescents with eating disorders in Singapore	TH mediated patient health-related anxiety and fear of infection; Financial support and parent encouragement integral for success
	Datta et al, 2020	Children, adolescents, and young adults with eating disorders in inpatient care	TH effective for inpatient care; Clinic will continue TH for family engagement and bedridden patients post-COVID
	Grael et al, 2020	Children and adolescents with eating disorders	73.1% of visits were via TH and 26.9% in-person; 41.9% of patients had reactivation of sx
	Fernandez-Aranda et al, 2020	Adolescents and adults with eating disorders attending tx centers across Spain	TH effective for patients with anorexia nervosa and obesity but not bulimia nervosa; Those with anorexia nervosa dissatisfied with TH compared to in-person tx; Some patients experienced worsening sx
	Reddy and Brumpton, 2021	Children and adolescents seeking assessment for ASD or ADHD	TH most successful if all other processes are electronic; Videos can be used for behavioral assessments, but physical assessments are better done in-person
	degil Espinosa et al, 2020	Children with ASD and their parents in Italy	Standard tx not supported by TH due to increased caregiver distress/involvement and lack of structure/resources; Protocols successful when tailored to family's needs
	White et al, 2021	Children and adults with ASD and their caregivers	COVID created a disruption in care; Few families had access to TH; TH reported as minimally beneficial; Sx and family distress worsened
	Pollard et al, 2021	Children with ASD	Technician- and caregiver- led TH had comparable tx doses to in-person care; Correct independent responding was maintained or improved with TH
	Wagner et al, 2020	Providers evaluating children for ASD	TH increased access to care; Beneficial to assess child in their natural environment; TH acceptable for assessments, but tech issues often warranted further in-person assessment
	Yang et al, 2020	Children and adults seeking mental health care at a large health center	Non-MH visits declined -38.2%, MH visits increased 11.7%; MH visits via TH rose from 5% to 83.5%; MH visits for minoritized groups decreased
	Masi et al, 2021	Children with neurodevelopmental disorders	68.8% report using TH for child's sx; 54.8% of respondents were dissatisfied with tx; 30% reported TH works well for their child; COVID impacted 76.1% of caregivers’ wellbeing
	Murphy et al, 2020	Children with cognitive/physical disabilities	72% of respondents indicated having access to care via TH; 44% had low satisfaction with care, TH accessibility main predictor of satisfaction
	Dursun et al, 2020	Children with mental special needs and their caregivers	Developed tiered intervention app for caregivers to consult specialists on child's sx; Reported high satisfaction with system; 63.3% reported sx improvement
	Faccioli et al, 2021	Children and adolescents with cognitive/physical disabilities	Most had access to remote psychological support; 26.8% of caregivers and 13.2% of adolescents wished they had greater support
	Emans et al, 2020	Adolescents and young adults in mental health clinics in the United States	COVID outbreak in psychiatric unit despite restrictions; TH should be used to lower exposure risk; Coverage of TH critical
	Ozbaran et al, 2020	Youth with psychiatric disorders in inpatient care in Turkey	TH offered as alternative to inpatient tx to mitigate infection risk; Hospital stays decreased from 26 to 10 days after COVID
	Summers et al, 2021	Children with neurodevelopmental disorders and their caregivers	TH intervention managing child's sx was easy to use; Tx received from TH viewed as practical, implementable, and helpful
	Buono et al, 2021	Children and adults with intellectual disabilities in an inpatient facility	TH acceptable by patients and families; Patients using tech-regulated activities had difficulty returning to normal routine after lockdown
	Provenzi et al, 2020	Children with neurological and psychological disabilities	92% of caregivers reported improvement in child's sx after using TH; 40% rated TH more effective than in-person care; Barriers included following provider instructions and internet access
	Taddei and Bulgheroni, 2020	Children presenting to an inpatient/outpatient neuropsychology center	93% of families willing to use TH; TH had high satisfaction and viewed as comparable to in-person tx; Barriers were socioeconomic or language-related
	Trivisano et al, 2020	Children and adolescents with epilepsy	25.1% of patients had TH with 93.9% being satisfied and 67.2% felt TH was advantageous; 59.6% of those seeking MH tx specifically felt TH was inadequate
	Brambilla et al, 2020	Children with Dravet Syndrome	Few had access to MH care via TH, and half of those who did were unsatisfied; Most who did not have access wished they did
	Pritchard et al, 2020	Pediatric psychologists and neuropsychologists	Tiered system of TH effective and will be used post-COVID; TH not suitable for all types of assessments
	Koterba et al, 2020	Inpatient pediatric neuropsychologists	Some inpatient care can be done via TH, but in-person tx still required; Neuropsychological assessments via TH not feasible
	Ramson et al, 2020	Children, adolescents, and young adults with complex medical issues	Demographics did not affect TH use; Laptops/desktops better for test administration than phone/tablet; 63% needed further in-person evaluation
	Wallis et al, 2020	35 developmental behavior pediatric clinics	Most clinics used TH to conduct evaluations and all used TH for follow-ups; >88% of clinics used TH for med management; >90% could provide interpreters and incorporate other team members for visits
	Hammers et al, 2020	Pediatric neuropsychology providers	Survey-based study found providers used TH for interviews, testing, feedback, and intervention; Most said they would use TH post-COVID
Access and engagement	Revet et al, 2021	Heads of European child/adolescent psych services	COVID viewed to have a medium to strong impact on patients’ MH; 95% of centers now offered TH despite only 20% using TH before COVID; 80% of centers had restricted or closed services; Referral rates decreased
	FAIR Health, 2021	Children and young adults (0–22 years) filing a health care claim	All medical claims decreased during 2020, but MH claims increased. TH consultation for MH skyrocketed in 2020
	Crocket et al, 2020	Children attending inpatient/outpatient behavioral psych clinics	Appointment volume increased 30% compared to pre-COVID and was 40% higher than the same time frame in 2019
	Hoffnung et al, 2021	Children and adults attending community mental health clinics	Children did not use TH as much as adults and were quicker to return to in-person tx; Children less likely to use psychotherapy services compared to other services
	Childs et al, 2020	Adolescents and adults with severe psychiatric disorders presenting to intensive outpatient	Rate of appointment attendance increased from 59.6–67.95%; Group-based TH sessions increased, overall visits declined
	Childs et al, 2020	Adolescents with severe psychiatric disorders in intensive outpatient	Number of visits declined after TH employed; Group therapy can be done through TH but not sustainable
	Renjan and Fung, 2020	Children and adolescents referred to a community mental health program	TH initially had logistical issues but increased access to care; Referrals increased with onset of COVID, decreased during stay-at-home orders, and increased again when schools resumed in-person learning
	Hames et al, 2020	Directors/representatives of psychology training clinics for all ages	23.7% of training clinics closed; 86% of open clinics offered TH; 80% suspended some services (eg, assessments)
	Cantor et al, 2021	>8000 outpatient mental health facilities	Of clinics offering pediatric services, 45.2% offered TH; Clinics less likely to have TH if they did not accept Medicaid, were in metropolitan areas, had shelter-in-place orders, or more COVID cases
	Mulay et al, 2021	Children presenting to a developmental/behavioral health unit in Singapore	Visits proportionately decreased when staff were deployed to help with COVID; TH viewed positively by patients; Barriers included lack of resources for staff/patients, communication across unit, and lack of emotional connection
	Sharma et al, 2020	Children and adolescents attending a psychiatry department	Slower transition to TH; Barriers included lack of sustainable platform and complex administrative processes; Documentation and time effort for TH comparable to in-person tx, but revenue was lower
	Ramtekkar et al, 2020	Children attending a large pediatric behavioral health unit	TH used prior for medication management but rapidly expanded with COVID; Evaluations (except physical assessments) could be done via TH; Easier to engage lower SES families via phone
	Lim et al, 2020	Adolescents with diabetes in a health/psychoeducation program	TH was paramount for COVID-related distress screening; 80% of patients/families rated TH comparable to in-person tx, 20% preferred TH; No adverse outcomes arose
	Endale et al, 2020	Refugee children and families presenting to a community mental health center	Initial resource barriers for underserved populations; CBT via TH became comparable to in-person services over time
	Falicov et al, 2020	Immigrant families presenting to a community mental health center	TH can pose barriers for those with limited resources; Flexibility from providers/teams critical for TH to be successful
	Li and Leung, 2020	High school students in China	One third of respondents had COVID-related distress; 40% of respondents said they would use TH; More likely to seek out TH if it was secure, in instant messaging or video platform, and had positive experiences with prior MH tx
	Shah et al, 2021	Children with ADHD	Texting intervention created to help caregivers manage their child's sx; 55.2% of caregivers found it helpful but wished for more sx- and age-specific interventions
	Sezgin et al, 2020	Children, adolescents, and young adults attending a behavioral health clinic	36% of TH cancellations/reschedules due to tech issues, 25% due to emotional/physical engagement, 24% due to scheduling issues
	Simms et al, 2021	Children and their families seeking family-based therapy	TH most successful when care team committed to delivering tx via TH over other methods, adhered to practices with minor adjustments for technology, and had regular check-ins with supervisors to review tx delivery
	Sklar et al, 2020	Pediatric mental health providers in community-based programs	TH viewed positively with patient/provider relationships rated better than usual; Some interventions were hard to employ; Child engagement was lower than in-person tx
Training	Dhonju et al, 2021	Children and adolescents referred to a community mental health program in Nepal	Tiered TH approach to address COVID-related distress successful; Barriers included reaching those with lack of resources, stigma against MH, and scheduling conflicts
	Gurwitch et al, 2020	Pediatric mental health providers	Psychological first aid via TH successful in managing urgent needs; Insurance coverage and training resources critical for success
	Batchelor et al, 2020	Pediatric psychologists, students, and volunteers	Remotely provided CBT training rated positively and increased knowledge

COVID-19 indicates coronavirus disease-2019; TH, telehealth; tx, treatment; MH, mental health; sx, symptoms; ASD, autism spectrum disorder; ADHD, attention deficit hyperactivity disorder; and CBT, cognitive behavioral therapy.

Another paper described a 1-day pediatric cognitive behavioral therapy training program that was delivered virtually as a result of the pandemic.⁶⁴ Even with this virtual adaptation, providers reported a statistically significant increase in knowledge of key concepts and positive feedback on the experience after undergoing the training. Across these investigations, virtual trainings enhanced provider knowledge and increased patients' access to care. It would be useful to compare in-person versus virtually delivered training modalities in future research to assess the effectiveness of training.

What Have We Learned?

The use of telehealth across a variety of patient settings/populations can inform primary care providers. Across settings, the rapid adoption of telehealth services was made possible due to a multitude of factors, such as health insurance companies agreeing to cover such services, relaxed regulations across technological platforms, and access to resources. Impressively, telehealth integration allowed for widespread access to mental health care in some instances. Benefits of telehealth included continuity of care and increased access to care for patients with barriers to in-person treatment. In some cases, telehealth was effectively used in instances where it was previously thought that in-person care would be preferable (eg, inpatient treatment). However, some aspects of care (eg, comprehensive assessment, treatment for those with severe psychopathology) may not always be appropriate in a telehealth platform. Other issues raised included safety/privacy concerns, limited access to internet/technological support tools, and limited provider access to protocols. Variable patterns of telehealth use have emerged as well. While telehealth allows for continuity of care in some instances, the barriers noted above necessitate that disparities in care are better studied to increase access to telehealth services particularly for minoritized groups.

Provider Recommendations and Evidence-Based Resources

Given multiple investigations noted limited access to knowledge and resources,^{12 , 20 , 29 , 51 , 52 , 61 , 62} we curated freely available, evidence-based resources (Table 2). Included is the American Medical Association's Behavioral Health Integration Compendium, a detailed guide for providers to implement mental health care (including telehealth) into current practice. A training program by the American Psychological Association for delivering telehealth for mental health care is also provided. Additional resources are offered for managing common issues such as COVID-specific distress, anxiety, and pain.

Future Directions

COVID-19 increased the adaptation of telehealth into clinical practice, yet little is known about the safety and effectiveness of these strategies in controlled trials. It will be important to investigate the effects of telehealth in treating specific mental health conditions. Further, it is important to better understand and address barriers to accessing telehealth. While many tools have allowed for mental health self-management outside clinics and may increase access in principle (by reducing the need for staff), additional work is needed to confirm the effectiveness of self-management versus therapist guided strategies. A comparison of the effects of different telehealth methods (eg, video, phone, text messaging) may also be beneficial.

Several clinical trials are currently underway that investigate telehealth interventions for children (see Table 3 for examples). These trials report examining the feasibility and/or effectiveness of such interventions in a range of samples, including healthy adolescents and those with chronic illnesses. Current work is testing text-based apps (NCT04700137), mobile apps (NCT04524598, NCT04672486, NCT04697966), self-management web tools (NCT04634903, NCT04607902), and virtual live interventions (NCT04666493, NCT04548544, NCT04678843, NCT04020484, NCT04591912), including one to improve psychological distress in youth as a result of COVID-19 (NCT04408027). Two trials (NCT04020484, NCT04678843) formally investigate the implementation process for remotely delivered interventions respectively addressing the mental health needs of those with epilepsy and eating disorders. The findings from these trials may have significant implications for telehealth postpandemic.

Table 3.

Registered Trials Investigating Virtual Mental Health Interventions for Children

NCT Number*	Sample	Description
NCT04700137	Patients (children and adults), providers, and staff attending a large US Health Care system	Investigating how COVID-19 impacted MH and comparing the effect of 2 forms of a minimally burdensome virtual intervention for loneliness due to COVID-19
NCT04524598	Adolescents and young adults with depressive symptoms	Testing the effectiveness of a mobile app targeting depression with mindfulness strategies, compared against publicly available information on depression
NCT04672486	Adolescents seeking psychological care for stress management	Examining the feasibility and effectiveness of a mobile app teaching problem-solving skills for stress management compared against treatment as usual
NCT04697966	Adolescents with rumination	Investigating the effect of the Headspace app on rumination, attentional control, and brain functional connectivity as compared to a control
NCT04634903, NCT04607902	Adolescents with elevated depressive symptoms	Comparing two online, self-administered, single-session interventions for depression against a control intervention; long-term effects investigated
NCT04666493	Children with autism spectrum disorder and comorbid anxiety	Investigating the effectiveness of a virtual adaptation of a group CBT intervention to treat anxiety
NCT04548544	Healthy adolescents	Testing the feasibility of virtually delivering a mindfulness-based intervention for anxiety and depression symptoms as compared to a control
NCT04678843	Children/adolescents with anorexia nervosa and their families	Examining the implementation process and effectiveness of a virtual adaptation of a family-based therapy for children with eating disorders
NCT04020484	Children with epilepsy and their parents	Investigating the implementation, feasibility, and effectiveness of an online, mindfulness-based, group therapy for children with epilepsy as compared to a waitlist-control
NCT04591912	Adolescents attending high school	Assessing the impact of a remotely delivered program targeting mental health and wellbeing for high school students
NCT04408027	Children with anxiety disorders	Testing the feasibility, barriers to, and acceptability of a virtual CBT program targeting MH issues related to COVID

COVID-19 indicates coronavirus disease-2019; MH, mental health; and CBT, cognitive behavioral therapy.

^⁎Trial registered on ClinicalTrials.gov. Search criteria included trials for pediatric mental health treatments and were registered since the onset of C0VID-19 (January 2020-March 2021).

Conclusions

Now more than ever, appropriate mental health care can be provided to pediatric patients in the context of primary care via telehealth. We provided a review of the literature pertaining to use of telehealth for mental health treatment in pediatric patients, synthesized shared themes across these investigations, proposed future directions, and offered relevant evidence-informed resources. With knowledge of effective tools, strategies, and resources, the physician can continue to effectively screen for, assess, and treat mental health concerns virtually.