The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declared a national emergency in children’s mental health in a statement released on Oct. 19, 2021.
According to the statement, childhood rates of depression, anxiety, trauma, loneliness, and suicidality have risen over the past decade, and by 2018 suicide was the second leading cause of death among 10-to-24-year-olds. The COVID-19 pandemic has led to further increases in mental health emergencies including suspected suicide attempts.
The statement made several recommendations regarding how mental health care might be improved, including continued availability of telemedicine for mental health care (Nelson, 2017; Olson, 2018). The statement also advocated accelerated adoption of effective and financially sustainable models of integrated mental health care in primary care pediatrics.
As a demonstration of effective integration of mental health care in a primary care setting, this blog provides a brief description of the outcomes of a pediatric hypnosis and counseling telehealth service in a Syracuse, New York pediatric primary care group practice for the 6 years since 2015. The pediatrician (author of this article) who provided the mental health therapy is based in La Jolla, California. The pediatrician has active medical licenses in both California and New York, which allowed him to practice medicine in both states.
At the Syracuse practice, an examination room was set aside for patients to be seen in private using a laptop computer. A “Do Not Disturb” sign was hung on the outside of the door. VSeeTM, a HIPAA compliant video platform, was used for the encounters. During the pandemic, to reduce infection risk, patients also have been seen through video encounters in their homes. Eighty percent of the patients seen were referred by the primary care group practice, while the other patients were self-referred or referred by other pediatricians in Central New York. Waiting time for a new patient appointment never exceeded 6 weeks.
The patients or their guardians signed a consent form prior to initiation of therapy to acknowledge an understanding that they might be overheard by a family member, that the sessions will not be recorded unless both the patient and clinician give their permission, that public WiFi should be avoided for confidentiality reasons, and that it may turn out that telehealth may not work for a particular patient.
An average of 10 patients a week have been treated with hypnosis (link) through telehealth. Patients were seen on average for a total of 5 sessions. Most of these patients were seen during three designated half days at the Syracuse office. The most common diagnoses treated included anxiety, depression, enuresis, needle phobia, headaches, irritable bowel syndrome, and shortness of breath. (Kohen & Olness, 2011). Notably, the latter three medical diagnoses frequently occur in association with mental health issues.
The ages of children treated through telehealth ranged from 3-21 years. The telehealth therapy platform generally was well received by most of the children, for whom use of technology is second nature. Further, during the pandemic children became even more comfortable with video interactions. However, in working with some children under the age of 7 use of telehealth proved to be challenging as they could not stay consistently within range of the camera.
Hypnosis and counseling methods used during telehealth were the same as used for in-person encounters including making suggestions regarding self-calming, progressive muscle relaxation, and interactions with the subconscious through ideomotor signaling, automatic talking, and even automatic word processing (Anbar & Cherry, 2021). These approaches helped treat the patients with anxiety and depression (Anbar, 2008). Two patients expressed suicidal ideation over the 6-year period and were referred through their primary care provider for an in-person evaluation by a psychiatrist.
Aside from the difficulties sometimes experienced with the youngest children, the pediatrician who provided the therapy has noted no difference in clinical outcomes for patients treated through telehealth, as compared to the patients he has treated at his in-person practice in California. His patient schedule fully integrated patients in La Jolla and Syracuse, while keeping in mind the 3-hour time difference between the locations.
An advantage of locating the hypnosis encounter in the office of the primary care practice was that occasionally the patient’s primary care pediatrician was consulted during the mental health therapy session, and this facilitated efficient follow-up, including for occasional medication management. On several occasions, pediatricians at this practice expressed their gratefulness for their ability to easily refer patients for effective mental health treatment on-site.
“Home visits” through video conferencing were used predominantly during the pandemic and provided the treating pediatrician with insights into the patients’ home environments that may have impacted their mental health. These visits also allowed for better rapport to be established as patients were able to easily share their interests, toys, and activities while they were at home. Because of insurance reimbursement issues, “home visits” could not be provided routinely despite their convenience for the patients and possible enhanced therapeutic benefit as the result of increased rapport.
The hypnosis and counseling visits through telehealth were reimbursed by medical insurance companies with minimal difficulty.
Prior to telehealth sessions, the pediatrician noted a phone number through which an adult might be contacted to help attend to the patient, should this be required. Only two events of this telehealth practice necessitated a phone call to be made. On one occasion a patient fell asleep during a session, and needed to be awakened by a nurse, and another patient at his home fell out of his chair during hypnosis and remained in a trance. The patient re-alerted without difficulty when his parent entered the room.
The pediatrician needed to ensure that he was framed well within the video. Sometimes, the camera angle needed to be adjusted by the patients to maximize the ability of the pediatrician to view the patients’ physical appearance, or to allow patients to be able to lie down within the visual field of the camera.
On a few occasions the video platform was unstable, which precluded a smooth interaction. In those cases, the pediatrician called the patients’ cell phones, and the sessions were continued. Hypnosis was not used in the sessions that mostly involved interactions over the phone because the patients could not be observed reliably.
On one occasion, a therapist reported in an on-line forum that the video picture froze without the therapist’s awareness. The therapist at first was alarmed when the patient appeared to be non-responsive, but ultimately realized the humor in the situation.
The establishment of telehealth at a pediatric and other primary care practices can be an efficient and effective way of providing mental health care and allows close coordination with their primary care physicians. An additional advantage of this approach is that one clinician can practice easily at several different sites and thus provide improved access to mental health care throughout the country.
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A version of this article was published in Psychology Today Online, October 26, 2021.
Anbar, Ran D. 2008. “Subconscious Guided Therapy with Hypnosis.” American Journal of Clinical Hypnosis. 50 (4): 323-334. doi: 10.1080/00029157.2008.10404299.
Anbar, Ran D., and Rebecca N. Cherry. 2021. “Communicating with the Subconscious: Ideomotor and Visualization Techniques.” In: Jensen, Mark P. Handbook of Hypnotic Techniques, Vol. 2.” Denny Creek Press, Kirkland, WA; pp. 196-231.
Kohen, Dan P., and Karen Olness. 2011. “Hypnosis and Hypnotherapy with Children.” Routledge, New York, NY.
Nelson, Eve-Lynn, Sharon Cain, and Susan Sharp. 2017. “Considerations for Conducting Telemental Health with Children and Adolescents.” Child and Adolescent Psychiatric Clinics of North America. 26 (1): 77-91. doi: 10.1016/j.chc.2016.07.008.
Olson, Christina A., S. David McSwain, Alison L. Curfman, and John Chuo. 2018. “The Current Pediatric Telehealth Landscape.” Pediatrics. 141 (3): e20172334.
doi: 10.1542/peds.2017-2334.
