RURAL AND REMOTE
POPULATIONS
Child and adolescent
telepsychiatry in New South
Wales: moving beyond clinical
consultation
Jean Starling, Robyn Rosina, Kenneth Nunn and David Dossetor
Objectives: Telepsychiatry has been demonstrated to be an effective and
acceptable way to deliver psychiatry services to remote and rural areas. This
paper describes the initial evaluation of the Child and Adolescent Psychological Telemedicine Outreach Service (CAPTOS) in New South Wales and
the changes made to the service after the initial evaluation.
Methods: The evaluation investigated patients’, rural clinicians’ and
CAPTOS psychiatrists’ satisfaction with the quality of the service and the
technology.
Results: There were 136 rural families, 20 rural clinicians and eight psychiatrists. Overall, satisfaction was high with the rural families and clinicians being the most satisfied (95–99% very or mostly satisfied). CAPTOS
psychiatrists felt that they were usually able to perform an adequate consultation (87%) but few (16%) felt the consultations were as satisfactory
as a face to face consultation. Because of the initial evaluation, and the
ongoing collaboration with rural clinicians, further services were developed
using the technology and the developing professional networks. These initiatives included telenursing, professional skills development, sabbaticals for
rural clinicians and a clinical skills workshop for rural clinicians.
Conclusions: This study confirms telepsychiatry as a useful service for
remote and rural children and families. The results also suggest some
reasons why urban clinicians show the least enthusiasm for the service.
Ways of addressing some of the limitations of the service are suggested, and
the expansion of CAPTOS to meet the needs of rural clinicians is discussed.
Key words: adolescent, child, mental health, telehealth.
BACKGROUND
Robyn Rosina
Nurse Manager, NSW Child & Adolescent Mental Health
Services Network, John Hunter Hospital, Newcastle, Australia
Kenneth Nunn
Director, NSW Child & Adolescent Mental Health Services
Network, John Hunter Hospital, Newcastle, Australia
David Dossetor
Chair of Division, Division of Psychological, Developmental
& Rehabilitation Medicine, The Children’s Hospital at
Westmead, Westmead, NSW, Australia
Correspondence: Dr Jean Starling, Child & Adolescent
Psychological Telemedicine Outreach Service (CAPTOS),
Department of Psychological Medicine, The Children’s Hospital
at Westmead, Locked Bag 4001, Westmead, NSW 2145,
Australia.
Email: jeans@chw.edu.au
T
he size of the problem: Rural and remote communities have high
levels of economic and social disadvantage. They also have poorer
health. Standardised death rates are higher in rural and remote
areas.1 Among other health indicators, infant mortality, road vehicle
accidents, and injuries both from accidents and interpersonal violence
are higher in remote areas.2 Suicide rates are higher and rural young men
have the highest rate of suicide in Australia.3 However, access to health
care is poor. There is inaccessibility to all forms of health care, including
general practitioners, medical specialists and non-medical health care
practitioners.2 This is particularly so for mental health practitioners,
despite the need for early intervention to prevent long-term disability.4
Rural and remote services: In NSW the services available to young people
with psychological problems vary, depending on the local teams that are
available. Young people and their families may be seen by mental health
nurses, psychologists, social workers, paediatricians, Aboriginal mental
Australasian Psychiatry • Vol 11 Supplement • 2003
Jean Starling
Head of Department, Department of Psychological Medicine,
The Children’s Hospital at Westmead, Westmead, NSW,
Australia
S117
health workers or other mental health professionals.
All of these professionals are referred to as rural
clinicians in this paper. Some are new graduates with
no clinical experience, while others have years of
experience but no formal training.
Models of service delivery in telepsychiatry:
Telepsychiatry has been used to deliver services since the mid
1990s. In the USA, Canada and Australia,5–9 services
were mainly provided to communities at least several
hours of travel time from the psychiatrist. In the UK10
and some North American services,11 telepsychiatry was
used over smaller distances, for populations that could
not easily access services. These included links to local
clinics that were geographically close but had no public
transport access, or putting small screens attached to
telephones into homes of patients who had difficulty
getting to clinics. Australian child and adolescent services have used telepsychiatry for clinical care, consultation, supervision, teaching and administration.6,12
THE DEVELOPMENT AND INITIAL
EVALUATION OF THE CAPTOS SERVICE
The Child and Adolescent Psychological Telemedicine Outreach Service (CAPTOS) started as a pilot
program to Dubbo and Burke from December 1996 to
July 1997.12 There were 72 video conferencing interviews and 54 patients were seen. Although only 24%
of families returned a satisfaction questionnaire, they
reported a high level of satisfaction with the service.
Table 1:
After evaluation of the pilot program, the NSW
Health Department funded staff and equipment so
the CAPTOS Service could extend from the Children’s
Hospital at Westmead (CHW) to all of remote and
rural NSW (except for the Southern Area). This service
was evaluated between September 1999 and September 2000 inclusive.13 There were 136 telepsychiatry
clinical consultations between eight CHW psychiatrists and 20 rural clinicians. These consultations
consisted of new patient consultations with interview
(32%), repeat consultations with interview (13%),
consultations without interview (19%) and review
without interview (30%). Multiprofessional case conferences and other discussions made up the remaining 6% of consultations. The full evaluation included
questions on diagnosis, measures of functioning,14 a
family assessment measure15 and a child behaviour
checklist.16 The results of these measures have been
described in detail in a previous paper.13
The mean age of the young people seen was 11.9 years
(SD = 3.7, range = 4–23 years). Sixty-five per cent were
male, and 28% had safety or at risk issues. As shown
in Table 1, the most common diagnostic group was
the behaviour disorders (37%), followed by depression
(22%) and anxiety disorders (13%).
Table 2 shows that both rural clinicians and rural
families had high levels of satisfaction with the
services, as measured by a service satisfaction questionnaire.13 Ninety-six per cent of families and 99% of
Diagnoses made at telepsychiatry consultation
Australasian Psychiatry • Vol 11 Supplement • 2003
Diagnosis made at consultation
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Behaviour disorders (Conduct, Oppositional Defiant, ADHD)
Depression
Anxiety Disorders (Generalised, Separation, OCD, PTSD)
Developmental Disorder (Aspergers, Autism, Learning Disorders)
Psychotic Disorders (Schizophrenia, Bipolar Disorder, Psychosis NOS)
Eating Disorders
Other disorders (Adjustment Disorders, V Codes)
Totals
Table 2:
Number
Percentage
50
30
18
9
6
5
6
134
37%
22%
13%
7%
4%
4%
12%
100%
Results of the service satisfaction questionnaire (rural families and clinicians)
SSQ question
Quality of service good or excellent
Received the service they wanted
Very or mostly satisfied with the service received
Would be inconvenient or very inconvenient to attend a face to face consultation
Family
Rural clinician
96% (78/81)
96% (80/83)
96% (80/83)
80% (66/82)
99% (102/103)
99% (102/103)
99% (102/103)
89% (85/96)
rural clinicians rated the quality of service as good or
excellent, were very or mostly satisfied with the
services, and felt that the service received was what
was wanted.
As shown in Table 3 there was disagreement between
rural families and CHW clinicians about their satisfaction with technology, as measured by a Technology Evaluation Questionnaire (TEQ).13 Rural families
found that the equipment was easy to use (97%) and
interfered little with the consultation (97%). Less
than half of the CHW clinicians (48%) found the
equipment easy to use, although 87% felt that it
didn’t interfere with the consultation. Rural families
felt that the sound (91%), picture (95%) and overall
quality (96%) were good or excellent. In contrast,
CHW clinicians were less happy with the technology.
Overall, only 26% were happy with the sound, 14%
with the picture, and 18% with the overall quality of
the link-up. Finally, 91% of rural families felt that
telepsychiatry was as good or almost as good as a face
to face consultation, compared with 16% of the CHW
clinicians.
There were several conclusions drawn from the pilot
study and initial evaluation of the CAPTOS service.
Rural clinicians and families were highly satisfied with
the telepsychiatry service. They were extremely positive
about the quality of the service and adapted easily to the
technology. In contrast, CHW clinicians, while positive
about their ability to conduct an adequate service over
the telescreen, had concerns about the technical quality
of the link-up. They also felt that telepsychiatry was not
as good as a face to face consultation.
However, as the telepsychiatry service developed it
became clear that there were other limitations to the
mental health services provided to rural families. For
the telepsychiatry service to work, rural clinicians
were expected to prepare case summaries, sit in on
consultations and implement treatment recommendations. At times, this proved difficult. Rural clinicians had various levels of clinical skills. They did not
always have the experience needed to implement
specific treatment programs. Some were new graduates, and needed high levels of supervision, often not
The CAPTOS service also came to realise that there
were many other health professionals who filled the
gaps in child and adolescent mental health services.
General practitioners frequently waited weeks for
mental health back up, so often managed complex
cases alone. The rural hospital paediatric and general
wards were the main resource used to manage in a
crisis.
The CAPTOS service also found that rural clinicians
were isolated from each other by distance, and had
difficulty learning from each other or developing
professional networks. Telepsychiatry developed
links between CHW and rural clinicians, but did not
develop networks across remote and rural areas.
Because of these concerns about the limitations of a
service providing only telepsychiatry, the CAPTOS
service was expanded to provide other services. The
services that were developed are detailed in the
following section of this paper.
NEW SERVICE DEVELOPMENTS
IN CAPTOS
Telenursing
This service started in late 2001 and has been
described by Rosina et al.17 The Clinical Nurse Consultancy service (CNC) serves a network of 27 rural
wards throughout NSW, with eight hospitals yet to be
included at the time of writing. At times, all of these
wards care for children or young people with mental
health problems. The nurses on these wards rarely
have specialised training in child and adolescent
mental health. These nurses are concerned that they
are being asked to perform tasks beyond their level of
education and experience.18 The CAPTOS telenursing
initiative aims to enhance the skills of rural nurses
using the Caplan model.19 The focus of the CNC
consultation can be clinical supervision, patient management issues, or problem solving for a specific
situation. The CAPTOS CNC also offers rural site
visits as well as the telemedicine consultations.
Rural families’ and Children’s Hospital clinicians’ satisfaction with technology
Technology Satisfaction Question
Rural family
CHW clinician
Good or excellent ease of using equipment
The equipment interfered with the consultation slightly or not at all
The sound quality was good or excellent
The visual quality was good or excellent
The overall quality of the videolink was good or excellent
Telepsychiatry is almost as good or as good as a face to face consultation
97% (77/79)
97% (77/79)
97% (77/79)
95% (75/79)
96% (76/79)
97% (77/79)
48% (65/136)
87% (118/136)
26% (36/136)
14% (19/136)
18% (25/136)
16% (22/136)
Australasian Psychiatry • Vol 11 Supplement • 2003
Table 3:
available close to their workplace. The high staff
turnover exacerbated these problems.
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Sabbaticals for rural clinicians
that urban services show towards telemedicine,20,21
and talk about clinicians’ fear of technology and
inability to change.11 Our study suggests other possible reasons for this reluctance. The most enthusiastic group in this study, rural families, must travel
long distances to see a child psychiatrist. For those
in remote NSW, this could entail two full days of
travelling to attend a single appointment. This is not
only expensive, but also disruptive to school and
work commitments. If rural clinicians organise an
opinion this way, they receive minimal feedback and
are not able to be present at the consultation. This
means that telepsychiatry is embraced with enthusiasm because of the absence of practical alternatives.
However, urban clinicians use a different yardstick
for comparison. Their benchmark is the face to face
consultation, where a whole family is in their office,
and they can pick up multiple cues from all family
members. When a family is seen via telescreen, there
are fewer cues, with particular difficulty interpreting
non-verbal cues. This may help explain why urban
clinicians rate telepsychiatry less favourably.
Rural clinicians often have limited access to evidencebased information and training. Because of this,
CAPTOS has been offering sabbaticals of a week to
rural clinicians. The rural clinicians negotiate learning goals for their visit with their Child and Adolescent Mental Health Area Director, and are supported
by a CHW clinician on their visit. The goals can vary
from learning a clinical skill, researching a specific
topic, or even writing a policy document. The visit
not only helps achieve learning goals, but also allows
the rural clinician to feel part of a wider CAPTOS
network.
Telepsychiatry by itself is a service with substantial
limitations. It meets the rural clinician’s needs for
psychiatry review and a second opinion. However,
further services are needed to build the skills of rural
clinicians and support rural networks. This paper has
also presented some ways in which the CAPTOS
service has attempted to meet these additional needs,
both by using the telescreens and the other resources
of the CAPTOS network. Evaluation of these additional services continues, and we hope that the
CAPTOS service can continue to evolve to better
support rural and remote clinicians.
The clinical skills workshop
REFERENCES
Professional skills training
Australasian Psychiatry • Vol 11 Supplement • 2003
Child and Adolescent Psychological Telemedicine
Outreach Service started piloting training programs
when it became clear that some rural clinicians
lacked the skills to implement treatment recommendations. Family therapy was the most requested clinical skill. Since 2001, three rural teams have been
involved in family therapy training. A rural area
forms a training group of clinicians, and a CHW
clinician skilled in family therapy becomes the supervisor. Preliminary theoretical reading is sent out, and
the group meets once face to face to plan the course,
which lasts 12 months. The group then meets via
telescreen for tutorials and case discussions. At the
end of the 12-month period the group has acquired
basic family therapy assessment and treatment skills.
A similar model is being piloted for individual work
with children and adolescents. A CHW psychotherapist participates in theoretical and case discussions
with a group of rural clinicians via the telescreen.
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The CAPTOS service has coordinated two workshops
for 40–50 rural clinicians with the goals of developing a collegiate network across rural areas, and developing clinical skills. The training included workshops
on assessing preschoolers, primary aged children and
adolescents, as well as training groups on various
types of therapy. One of the highlights was the
opportunity for rural clinicians to network with each
other, and compare their solutions for rural problems. The evaluation of the workshop was positive,
with the practical and interactive sessions receiving
the best feedback.
CONCLUSIONS
Telepsychiatry has been demonstrated to be an effective way of augmenting child and adolescent mental
health care to rural and remote areas. The evaluation
of the CAPTOS service confirmed this conclusion.
Surprisingly, we found telepsychiatry was more popular with rural clinicians and families than with
urban clinicians. This is not an isolated finding.
Other studies have lamented the lack of enthusiasm
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