Rebooting Mental Health Care Delivery for the COVID-19 Pandemic (and Beyond): Guiding Cautions as Telehealth Enters the Clinical Mainstream

Predictors of homework engagement in internet-delivered Parent-Child Interaction Therapy for children with developmental delay: what about acculturation and enculturation?

Introduction

Families from racial/ethnic minoritized backgrounds and families of children with developmental delay (DD) often face more obstacles to engaging in psychosocial interventions compared to White families and families of typically developing children. Yet, research on engagement in behavioral parenting interventions has predominantly focused on typically developing children and White families from majority cultural groups. The present study offers the first examination of acculturation and enculturation as predictors of homework engagement among caregivers of children with DD from underrepresented racial/ethnic backgrounds participating in a telehealth behavioral parenting intervention.

Methods

Data were collected from 65 caregiver-child dyads participating in the Advancing Child Competencies by Extending Supported Services (ACCESS) Study evaluating Internet-delivered Parent-Child Interaction Therapy (iPCIT) for children with DD. Homework engagement was measured as the proportion of days caregivers practiced "special time" with their child. Acculturation and enculturation were assessed using the Abbreviated Multidimensional Acculturation Scale (AMAS). Linear regression analyses evaluated associations between these two cultural factors and subsequent homework engagement, controlling for caregiver nativity, language of preference, income-to-needs ratio (INR), and caregiver work status.

Results

While higher levels of acculturation (B = .110, p = .054) did not significantly predict homework engagement, enculturation (B = .140, p = .007) significantly predicted greater homework engagement throughout treatment with small and small-to-medium effect sizes (Cohen's f² = 0.029 and 0.104, respectively).

Discussion

These findings underscore the nuanced role of acculturation and enculturation in predicting homework engagement in telehealth behavioral interventions for children with DD. Although acculturation did not facilitate homework engagement, caregivers who retained a stronger connection to their cultural heritage demonstrated higher homework engagement within the context of iPCIT. The study highlights the need for incorporating cultural considerations into treatment planning and flexibility in adapting treatment protocols to optimize family engagement and improve outcomes in this population.

Clinical Trial Registration

ClinicalTrials.gov, identifier (NCT03260816).

Trends in mental health care and telehealth use across area deprivation: An analysis of electronic health records from 2016 to 2024

While telehealth may improve access to healthcare for some, it may also widen gaps in access across different economic groups. Using electronic health records for outpatient mental health care of patients with depression in a large US academic health system, we assessed changes in mental health care utilization from 2016 to 2024 (primary care: n = 42,640 patients, 270,754 visits; psychiatry: n = 12,846 patients, 336,918 visits) and odds of using telehealth relative to in-person care from 2020 to 2024, across national area deprivation index (ADI) percentiles. We found that over 3 years prepandemic (July 2016-June 2019), the volume of mental health care delivered to patients from low-deprivation areas (1st-25th national ADI percentile) was increasing at a steeper rate than for high-deprivation areas (76th-100th national ADI percentile). Visit volume changed rapidly at the onset of the COVID-19 pandemic, and by July 2021 it was increased relative to prepandemic levels. From July 2021 to June 2024, volume of care declined for all deprivation groups, but at a more rapid rate for the high-deprivation group than the low-deprivation group. Further, on average from July 2020 to June 2024, the odds of receiving telehealth relative to in-person care were significantly higher for patients living in low deprivation rather than high-deprivation areas in both primary care and psychiatry. We did not find evidence of telehealth improving access to care for patients in high-deprivation areas. Differences in telehealth use may contribute to sustained disparities in access to mental health care across economic groups.

Telehealth delivery of GenerationPMTO in the public mental health system: A pragmatic, noninferiority study

Telehealth is a promising means for expanding access to mental health treatment. Yet, more research is needed to ensure that telehealth service delivery is no less effective than in-person treatment in real-world service delivery contexts. In the current study, we compared telehealth delivery of the GenerationPMTO parenting intervention to in-person delivery in the context of the public mental health system. Using a noninferiority approach with a sample of n = 1452 caregivers, we found telehealth delivery to be noninferior to in-person delivery on all caregiver outcomes: parenting practices, parenting confidence, and caregiver depressive symptoms. We were unable to conclude that telehealth delivery was noninferior to in-person delivery for child behavior problems. Our findings add to the literature suggesting the utility of using telehealth to provide services to families-particularly for delivering evidence-based parenting interventions to enhance caregiver outcomes. Implications for couple and family therapy are discussed.

State of the Science in Behavior Therapy: Taking Stock and Looking Forward

The scope and burdens of mental health challenges in today's world are staggering. Among the available psychological treatment approaches, cognitive and behavioral therapies, and their combinations, have garnered the strongest evidence base. That said, progress has not always been linear and most of the work is still ahead of us. Against this backdrop, Behavior Therapy has launched its State of the Science series-an exciting new journal feature offering a curated set of authoritative reviews of research in major areas of relevance to applied cognitive-behavioral science, written by distinguished scientists in each area and peer-reviewed. The vision for the Behavior Therapy State of the Science series is to launch with an initial set of articles that make up this special journal issue, with continued publication of additional State of the Science articles in future journal issues. The current article launches the State of the Science series, providing a brief summary of progress in cognitive and behavioral practice and related areas, as well as various missteps and harmful legacies that remind us that the state of the science for research focused on mental health and the alleviation of human suffering is always in flux and evolving. The 16 inaugural reviews in this special issue are then introduced one by one. Collectively, these State of the Science reviews take stock of what has been learned across key areas in the field, highlight critical knowledge gaps in need of research, and provide expert guidance for improving the effectiveness and reach of care, particularly for marginalized and underserved populations.

New Therapy for a New Normal: Comparing Telehealth and in-Person Time-Limited Parent-Child Interaction Therapy

Telehealth treatment for child disruptive behavior has the potential to overcome multiple barriers to access (e.g., transportation, therapist availability). Traditional Parent-Child Interaction Therapy (PCIT) has demonstrated efficacy via telehealth in randomized controlled trials. The current study extends this research by examining community-based effectiveness of time-limited (i.e., 18 week) telehealth PCIT, comparing intake and posttreatment child behavior and caregiver skills for both telehealth and in-person PCIT. Participants included predominantly racially, ethnically, linguistically, and socioeconomically diverse children aged 2 to 8 years, and their caregivers. Dyads (N = 380) received either telehealth (IPCIT) or in-person PCIT.Propensity score analyses were conducted to address potential selection bias due to the nonrandomized sample. Regression analyses revealed no difference between IPCIT and in-person treatment for child disruptive behaviors or compliance outcomes. However, caregivers who received IPCIT demonstrated fewer positive statements and greater corrective/directive statements at posttreatment than caregivers who received in-person treatment.This research demonstrated that time-limited IPCIT can effectively improve child disruptive behavior among a socioeconomically, linguistically, and culturally diverse population, and represents the largest sample to date demonstrating the effectiveness of PCIT via telehealth. Future research is warranted to document intervention sustainability on a more system-wide level, and balance prioritizing caregiver skill acquisition over family-derived treatment goals.

Preliminary perceived intervention changes and engagement in an evidence-based program targeted at behavioral inhibition during early childhood, delivered in-person and online

Introduction

Behavioral inhibition during early childhood is one of the strongest risk factors for the development of later anxiety disorders. Recently developed in-person interventions that target both young children who are highly inhibited and their parents (e.g., the Turtle Program), have decreased children's anxiety and have increased social participation in the peer group. However, researchers have yet to examine the effects of intervention mode of delivery. In the present study, we compared the pre-to post-intervention changes in child and parenting functioning of families participating in the Turtle Program, delivered in-person and online with those changes made in families allocated to a waiting-list condition; compared session attendance, homework completion and satisfaction with the intervention outcomes of families involved in the Turtle Program, delivered in-person and online; and explored the predictive role of parenting and child factors in session attendance, homework completion and satisfaction with the outcomes of families involved in the Turtle Program, depending on the mode of delivery (in-person vs. online).

Method

Fifty-seven parents of highly inhibited preschoolers (3-5 years), with no diagnosis of selective mutism or developmental disorders, who were randomly allocated to waiting-list (n = 20), Turtle Program delivered in-person (n = 17) and online (n = 20) conditions completed the Portuguese versions of the Behavioral Inhibition Questionnaire, the Preschool Anxiety Scale, the Social Behavior and Competence Scale, the Modified Child-Rearing Practices Questionnaire at pre- and post-intervention assessment. Parents also completed the Preschool Shyness Study Satisfaction Survey at post-intervention assessment.

Results

Independent of intervention mode of delivery, generalized equation estimates revealed a reduction in children's total anxiety symptoms and an improvement in parental nurturing behaviors. Child anxiety and social competence at pre-assessment were the most prominent predictors of session attendance and satisfaction with post-intervention child and parenting outcomes.

Discussion

Overall, this study showed that parents in both intervention conditions perceived comparable positive changes in child functioning from pre- to post-intervention assessment and similar levels of session attendance, homework completion, and satisfaction. Significantly, however, perceived satisfaction with post-intervention child and parenting outcomes was higher, when children were reported to display higher SEL skills at baseline, independent of the intervention mode of delivery.

Engagement over telehealth: comparing attendance between dialectical behaviour therapy delivered face-to-face and via telehealth for programs in Australia and New Zealand during the Covid-19 pandemic

BACKGROUND

While the COVID-19 crisis has had numerous global negative impacts, it has also presented an imperative for mental health care systems to make digital mental health interventions a part of routine care. Accordingly, through necessity, many Dialectical Behaviour Therapy (DBT) programs transitioned to telehealth, despite little information on clinical outcomes compared with face-to-face treatment delivery. This study examined differences in client engagement (i.e. attendance) of DBT: delivered face-to-face prior to the first COVID-19 lockdown in Australia and New Zealand; delivered via telehealth during the lockdown; and delivered post-lockdown. Our primary outcomes were to compare: [1] client attendance rates of DBT individual therapy delivered face-to-face with delivery via telehealth, and [2] client attendance rates of DBT skills training delivered face-to-face compared with delivery via telehealth.

METHODS

DBT programs across Australia and New Zealand provided de-identified data for a total of 143 individuals who received DBT treatment provided via telehealth or face-to-face over a six-month period in 2020. Data included attendance rates of DBT individual therapy sessions; attendance rates of DBT skills training sessions as well as drop-out rates and First Nations status of clients.

RESULTS

A mixed effects logistic regression model revealed no significant differences between attendance rates for clients attending face-to-face sessions or telehealth sessions for either group therapy or individual therapy. This result was found for clients who identified as First Nations persons and those who didn't identify as First Nations persons.

CONCLUSIONS

Clients were as likely to attend their DBT sessions over telehealth as they were face-to-face during the first year of the Covid-19 pandemic. These findings provide preliminary evidence that providing DBT over telehealth may be a viable option to increase access for clients, particularly in areas where face-to-face treatment is not available. Further, based on the data collected in this study, we can be less concerned that offering telehealth treatment will compromise attendance rates compared to face-to-face treatment. Further research is needed comparing clinical outcomes between treatments delivered face-to-face compared delivery via telehealth.

To Proceed Via Telehealth or Not? Considerations for Pediatric Anxiety and Related Disorders Beyond COVID-19

The COVID-19 pandemic accelerated a widespread shift to telehealth among mental health professionals to prioritize both providers' and clients' safety. Telehealth is likely here to stay; however, there is limited practical guidance for clinicians about how to make decisions regarding who should proceed with care via telehealth versus in-person. There also is virtually no data on the effectiveness of hybrid approaches to care; yet this can be an attractive option with potential clinical benefit. This paper provides practice-informed guidance to support shared clinical decision-making between clinicians and families to decide whether to engage in therapy services in-person or via telehealth. We specifically focus on decision-making guidance relevant for youth with anxiety or related disorders, given the unique implications of telehealth for these youth. Guided by the three-legged stool of evidence-based practice, we discuss how clinicians can use principles of shared decision-making to inform clinical recommendations about treatment modality.

Fostering telecompetence: A descriptive evaluation of clinical psychology predoctoral internship and postdoctoral fellowship implementation of telehealth education

PURPOSE

Telehealth education within clinical psychology predoctoral internships and postdoctoral fellowships has become a frequent recommendation designed to prepare future providers with evidence-informed telehealth skills that can be applied to rural populations. Unfortunately, the availability of telehealth training among internships and fellowships, as well as areas for growth, remains unclear. Thus, the current study evaluated graduate clinical psychology internship and fellowship integration of telehealth training components before and after the onset of COVID-19.

METHODS

Individuals representing 74 internships and 29 fellowships completed author-created REDCap-hosted demographic and telehealth training surveys.

FINDINGS

Before COVID-19, 2 internships and 4 fellowships reported implementing telehealth education, with a majority of materials for both types of programs being optional educational targets and generally encompassing 0-15 hours of student education. After the onset of COVID-19, 72 internships and 27 fellowships indicated implementing telehealth education, with a majority indicating materials as mandatory and encompassing between 0 and 50+ hours. Despite increases, 73.6% of internship programs and 62.1% of fellowship programs noted a desire for their students to receive additional telehealth education in the future. Integrated educational foci are discussed.

CONCLUSIONS

The current study demonstrated positive trends in the development of telehealth education among internships and fellowships. Nevertheless, some programs can likely benefit from additional integration of telehealth components, as well as more formal programming built around field-supported competencies and models. While work is required to further clarify field offerings, the current study provided a preliminary evaluation of internship and fellowship telehealth educational offerings.

Adapting CBT for youth anxiety: Flexibility, within fidelity, in different settings

Anxiety disorders are common in youth, associated with impairments in daily functioning, and often persist into adulthood when untreated. Cognitive behavioral therapy (CBT) for youth anxiety is a well-established intervention and has been modified to fit several treatment settings. Despite decades of results supporting the efficacy of CBT, there is a large gap in access to this treatment and a need to consider how it can best be administered flexibly to increase uptake and personalization. We first discuss the core components of treatment for CBT through the lens of the Coping Cat treatment. Next, we review the empirical findings regarding adjustments made for CBT for youth anxiety delivered (a) in schools, (b) in community settings, (c) through telehealth, (d) through online computer programs, and (e) by caregivers at home. In each setting, we provide specific suggestions for how to implement CBT with flexibility while maintaining fidelity.

Telehealth Treatment of Behavior Problems in Young Children With Developmental Delay: A Randomized Clinical Trial

Importance

Early behavior problems in children with developmental delay (DD) are prevalent and impairing, but service barriers persist. Controlled studies examining telehealth approaches are limited, particularly for children with DD.

Objective

To evaluate the efficacy of a telehealth parenting intervention for behavior problems in young children with DD.

Design, Setting, and Participants

A randomized clinical trial was conducted from March 17, 2016, to December 15, 2020, in which children with DD and externalizing behavior problems were recruited from early intervention and randomly assigned to a telehealth parenting intervention or control group and evaluated through a 12-month follow-up. Most children were from ethnic or racial minoritized backgrounds. Over one-half of children were in extreme poverty or low income-need ratio categories.

Interventions

Internet-delivered parent-child interaction therapy (iPCIT), which leverages videoconferencing to provide live coaching of home-based caregiver-child interactions. Families received 20 weeks of iPCIT (provided in English or in Spanish) or referrals as usual (RAU).

Main Outcomes and Measures

Observational and caregiver-report measures of child and caregiver behaviors and caregiving stress were examined at preintervention, midtreatment, and postintervention and at 6- and 12-month follow-ups.

Results

The sample included a total of 150 children (mean [SD] age, 36.2 [1.0] months; 111 male children [74%]) and their caregivers with 75 each randomly assigned to iPCIT or RAU groups. Children receiving iPCIT relative to RAU displayed significantly lower levels of externalizing problems (postintervention Cohen d = 0.48; 6-month Cohen d = 0.49; 12-month Cohen d = 0.50) and significantly higher levels of compliance to caregiver direction after treatment. Of those children with data at postintervention, greater clinically significant change was observed at postintervention for children in the iPCIT group (50 [74%]) than for those in the RAU group (30 [42%]), which was maintained at the 6-month but not the 12-month follow-up. iPCIT did not outperform RAU in reducing caregiving stress, but caregivers receiving iPCIT, relative to RAU, showed steeper increases in proportion of observed positive parenting skills (postintervention odds ratio [OR], 1.10; 95% CI, 0.53-2.21; 6-month OR, 1.31; 95% CI, 0.61-2.55; 12-month OR, 1.64; 95% CI, 0.70-3.07) and sharper decreases in proportion of observed controlling/critical behaviors (postintervention OR, 1.40; 95% CI, 0.61-1.52; 6-month OR, 1.72; 95% CI, 0.58-1.46; 12-month OR, 2.23; 95% CI, 0.53-1.37). After treatment, iPCIT caregivers also self-reported steeper decreases in harsh and inconsistent discipline than did than RAU caregivers (postintervention Cohen d = 0.24; 6-month Cohen d = 0.26; 12-month Cohen d = 0.27).

Conclusions and Relevance

Results of this randomized clinical trial provide evidence that a telehealth-delivered parenting intervention with real-time therapist coaching led to significant and maintained improvements for young children with DD and their caregivers. Findings underscore the promise of telehealth formats for expanding scope and reach of care for underserved families.

Trial Registration

ClinicalTrials.gov Identifier: NCT03260816.

When a Straight Line Is Not the Most Direct Method: an Evaluation of Straight Line Versus True Distance Metrics for Patients in Rural Settings

Telehealth has been hypothesized as a solution for rural barriers precluding access to healthcare, of which distance remains one of the most significant. Providers, institutions, and policymakers may use distance as a metric to determine whether to keep, or to end, telehealth services. Although commonly used, straight line distance (SLD) may not reflect the true burden of distance (TD) for rural patients. A retrospective record review was conducted to determine the difference between SLD and TD for patients seeking behavioral health care at a large outpatient center. The discrepancy between SLD and TD ranged from 0.5 to 83.4 miles of additional actual travel distance (mean =  - 17.6). The mean percentage that SLD underestimated TD was 31.9%. Findings highlight that when considering distance as a determining factor for telehealth services, SLD is an inaccurate representation of the travel burden on this sample of rural patients, suggesting the utility of TD as an alternative.

Virtual Care for Behavioral Health Conditions

The COVID-19 pandemic has highlighted the urgent need for behavioral health care services. A substantial portion of mental health care transitioned to virtual care during the COVID-19 pandemic, remains virtual today, and will continue that way in the future. Mental health needs continue to grow, and there has been growing evidence showing the efficacy of virtual health for behavioral health conditions at the system, provider, and patient level. There is also a growing understanding of the barriers and challenges to virtual behavioral health care.

Overcoming Clinician Technophobia: What We Learned from Our Mass Exposure to Telehealth During the COVID-19 Pandemic

Mental health clinicians have migrated to telehealth during the COVID-19 pandemic and have reported their use of telehealth may be permanent. Understanding how stakeholders overcame hesitancy regarding the use of telehealth can potentially reveal how stakeholders can adopt future clinical technologies. The exposure therapy conceptual framework provides one explanation of how mental health clinicians can face their concerns about technologies that promise to improve clinical outcomes and worker well-being. We review available literature published since the start of the pandemic on the extent to which clinicians migrated to telehealth and their reactions to their transitions. In particular, we review available literature that describes negative attitudes and worries by clinicians as one of many barriers of telehealth implementation. We introduce the perspective that the necessary transition to telehealth at the start of the pandemic functioned as an exposure exercise that changed many clinicians' cognitive and emotional reactions to the use of telehealth technologies. Next, we provide guidance on how clinicians can continue taking an exposure approach to learning emerging technologies that are safe and can benefit all stakeholders. Clinicians can now reflect on how they overcame hesitancy regarding telehealth during the pandemic and identify how to build on that new learning by applying strategies used in exposure therapy. The future of clinical work will increasingly require mental health clinicians to better serve their patient populations and enhance their own well-being by overcoming technophobia, a broad term for any level of hesitancy, reluctance, skepticism, worry, anxiety, or fear of implementing technology.

Educating for the Future: a Preliminary Investigation of Doctoral-Level Clinical Psychology Training Program's Implementation of Telehealth Education

Literature has reinforced the importance of telehealth-focused education to foster provider competence and optimal patient care. As clinical psychology evolves to meet field needs, many have suggested graduate school as an optimal time to offer comprehensive telehealth education. Despite the rapid expansion of telehealth post-COVID-19, the extent of telehealth-specific doctoral-level programming, as well as the foci of available trainings, has remained unclear. To address this gap and inform future work, the current study evaluated doctoral-level clinical psychology training programs throughout the USA. Fourteen doctoral-level training programs completed author-created REDCap-hosted demographic and telehealth training surveys. Pre-COVID-19, three of fourteen programs reported implementing some form of telehealth-focused education, with a majority of the information being viewed as optional targets for instructors. Contrastingly, thirteen programs indicated implementing telehealth-focused education post-COVID-19, with a majority of the information being indicated as mandatory educational targets. Despite increases in educational activities, a large number of programs endorsed a desire for additional telehealth-focused education for students as they transition into future roles. Educational foci, methods of training, and instructor preparation are discussed. While participation was limited, the current study demonstrated positive trends in the development of telehealth-focused education. Nevertheless, there remains an ongoing need for both specialized coursework and a wider range of educational topics. Ultimately, the current study is believed to have provided a preliminary evaluation of the types and foci of telehealth-focused education among doctoral-level clinical psychology training programs.