Methodology for conducting the Children’s Attention-deficit Hyperactivity Disorder Telemental Health Treatment Study in multiple underserved communities

Abstract

Background Children who live in non-metropolitan communities are underserved by evidence-based mental health care and underrepresented in clinical trials of mental health services. Telemental Health (TMH), the use of videoteleconferencing (VTC) to provide care that is usually delivered in person, shows promise for helping to rectify these service disparities. Purpose The Children’s ADHD Telemental Health Treatment Study (CATTS) is a randomized controlled trial designed to test the effectiveness of TMH in providing treatment to children diagnosed with attention-deficit hyperactivity disorder (ADHD) who are living in underserved communities. In this paper we describe the methodologies we developed for the trial and lessons learned. Methods Children ages 5.5-12 years of age with ADHD were referred to CATTS by their primary care physicians (PCP’s). The test intervention group (Group A) received six telepsychiatry sessions followed by in-person caregiver behavioral training delivered by a local therapist who was trained and supervised remotely. A secure website was used to support decision-making by the telepsychiatrists, to facilitate real-time collaboration between the telepsychiatrists and community therapists, and communication with the PCP’s. The control group (Group B) received a single telepsychiatry consultation followed by treatment with their PCP’s who implemented the telepsychiatrists’ recommendations at their discretion. Caregivers completed five sets of questionnaires about children’s symptoms and functioning and their own levels of distress. Older children (aged 10-12 years) completed questionnaires about their symptoms and functioning. Teachers completed ADHD rating scales. Questionnaires were completed online through a secure portal from personal computers. Results Eighty-eight PCP’s in seven communities referred the 223 children who participated in the trial. Attrition was low (3%). Children in Group A completed an average of 5.3 of 6 scheduled sessions; 96% of children in Group B completed their telepsychiatry consultation. Parents in both groups completed an average of 4.8 of 5 assessments. Telepsychiatrists and therapists showed high adherence to treatment protocols. Lessons Learned TMH proved to be a viable means of providing evidence-based pharmacological services to children and of training local therapists in evidence-based caregiver behavioral management. Recruitment was enhanced by offering the control group a telepsychiatry consultation. To meet recruitment targets across multiple dispersed sites, we developed community-specific strategies. A dedicated scheduler was a critical staff role to coordinate the multiple sites, sessions, and clinicians. Trial implementation was easier with sites that shared an electronic medical record system with our research hub. Conclusions The CATTS study used methods and procedures to optimize inclusion of children living in multiple dispersed and underserved areas. These experiences should advance the development of technologies needed to recruit ...

The Children’s Attention-Deficit Hyperactivity Disorder Telemental Health Treatment Study: Caregiver Outcomes

“…Informed consent and assent were obtained from all caregivers and children who were included as participants in the study. The CATTS trial methods (Vander Stoep & Myers, 2013), interventions (McCarty, Vander Stoep, Violette, & Myers, 2015), and children’s outcomes (Myers, et al, 2015) have been described in detail elsewhere.…”

“…Between November 2009 and August 2012, we recruited children from the practices of 88 PCPs in seven communities in underserved areas of Washington and Oregon states (Myers et al, 2015; Vander Stoep & Myers, 2013). All study services were provided at community clinics that had high bandwidth, point-to-point videoconferencing connections (384 kbits/sec to 1.0 MB/sec).…”

“…Exclusion criteria included being in state custody, unavailability of the legal guardian, or having medical, developmental, or psychiatric disorders that required interventions beyond the scope of the study (Vander Stoep & Myers, 2013). …”

Rationale and Considerations for the Internet-Based Delivery of Parent–Child Interaction Therapy

“…Although most published work to date has relied on descriptive methods, emerging research investigations evaluating telemethods for the delivery of behavior therapy are using increasingly rigorous designs and finding positive outcomes. In one of the more prominent and rigorous research efforts underway, the Children’s Attention-Deficit Hyperactivity Disorder Telemental Health Treatment Study (CATTS) is using RCT methodology to examine a telemedicine model for delivering pharmacologic interventions with behavioral training for children with ADHD from multiple dispersed and underserved regions (Stoep & Myers, in press). …”

Teletherapy Delivery of Caregiver Behavior Training for Children with Attention-Deficit Hyperactivity Disorder

“…Children and caregivers described in the current study consisted of 37 of the 223 participants in the Children's ADHD Telemental Health Treatment Study (CATTS). The methodology [22][23][24] and outcomes 25 for the CATTS trial have been described elsewhere and are briefly summarized.…”