Telehealth implementation for children with attention deficit hyperactivity disorder: a scoping review

1. Study Design

The research design details the general structure and methodology of this study, including the techniques employed for data collection and analysis. This ensures that the research questions are efficiently addressed. We adopted Arksey and O’Malley’s five-stage approach for a comprehensive review [20]. This study followed the criteria of the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist [21].

2. Study Process

The study process included: (1) formulating the research question, (2) identifying relevant studies, (3) selecting studies, (4) organizing the data, and (5) summarizing and presenting the results [22].

3. Research Question

This review aims to explore current telehealth practices for managing children with ADHD and to assess how the Virtual Care Value Framework influences these practices. The selection of questions aligns with the increasing importance of telehealth in managing chronic conditions in the current healthcare landscape [23]. This scoping review aims to fill a gap in the literature on specific telehealth practices and frameworks for ADHD management. In doing so, they seek to optimize telehealth services [24,25], improve guidelines [26], develop training programs [27], and create tailored healthcare delivery strategies [24], ultimately enhancing patient outcomes and healthcare efficiency in children with ADHD.

The research questions were: (1) What are the current telehealth practices for managing ADHD in children? (2) How does the Virtual Care Value Framework inform the care provided to children with ADHD through telehealth services?

4. Inclusion and Exclusion Criteria

The criteria for inclusion in this review were established by selecting articles that met the following requirements: (1) published between January 2000 and July 2024 (as telehealth studies related to children with ADHD began to emerge from 2000 onwards); (2) written in English; (3) involved children with ADHD, their parents or caregivers, family members, teachers, and healthcare professionals; and (4) included telehealth interventions. Studies related to telehealth for children with ADHD began to emerge in 2000. Review articles, opinion-based articles, editorials, conference proceedings, and studies published in languages other than English were excluded. The search strategy adhered to the Joanna Briggs Institute’s three steps: initial search, second search, and reference list search [28].

5. Finding Relevant Studies

A librarian formulated the search strategy and determined the appropriate databases to search for relevant studies. Initially, a preliminary search was conducted in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database to identify appropriate search terms. These terms were modified and refined to formulate the final accurate search terms. Subsequently, a comprehensive search was performed in the CINAHL, PsycINFO, and PubMed databases using the final search terms. CINAHL and PubMed are widely regarded as dependable and trustworthy databases unlikely to yield citations from predatory publications [29]. Additionally, PsycINFO can be used to locate specialized databases [29]. Table 1 presents the keyword search list.

Table 1.

Keywords Search

6. Selecting Studies

To facilitate the selection of studies, the search results were exported to Endnote, a reference management tool, following PRISMA guidelines [22]. A four-step approach was adopted to ensure systematic and transparent screening. The initial screening involved evaluating the relevance of articles based on their titles. Subsequently, the abstracts of the potentially relevant articles were reviewed to determine their suitability for inclusion. For articles that passed the abstract screening, the full text was thoroughly examined. In addition, the reference lists of the selected articles were searched to identify additional relevant studies that may have been missed. Three reviewers were involved throughout the screening process, including the initial screening, to ensure consistency and minimize bias. In case of disagreement regarding the inclusion of certain papers, discussions were held to reach a consensus.

7. Organizing Data, Summarizing, and Reporting the Results

This scoping review included 22 articles that the research team carefully extracted and organized into a Microsoft Excel 2021 (Microsoft) spreadsheet. The data extraction form was initially tested in two articles for comprehensive information coverage [30,31]. Subsequently, this method was applied to the remaining articles, which were divided equally between two reviewers (SC and DS). The accuracy and consistency of the findings are verified. Discrepancies were resolved through consultation with a third reviewer (HS). The extracted information included key details such as author, title, year of publication, study aim, study design, sample size, and the specific telehealth device used in each study. Furthermore, the team identified and documented information related to telehealth implementation according to the framework of the AMA [19]. The studies were systematically delineated using tables that detailed demographic characteristics and provided a year-based chronology.

1. Search Result

A systematic review was conducted using the PRISMA flowchart, involving a comprehensive search across multiple databases (Figure 1). Initially, 389 articles were identified from CINAHL (n=76), PsycINFO (n=215), and PubMed (n=98) databases. After eliminating duplicates, 291 articles underwent relevance screening, and 220 were excluded for various reasons, such as differing themes and participants. The remaining 71 articles underwent full-text screening, of which 13 were excluded because of language (not in English) or lack of full-text availability. Following the eligibility assessment, 36 articles were excluded based on participant-related factors, opinion/editorial content, misalignment with the study’s theme, and methodological issues. Finally, the review included 22 articles, and no additional articles were identified through the reference list searches.

Figure 1.

Preferred Reporting Items for Systematic reviews and Meta-Analyses flowchart for the scoping review.

We divided the content into charting the data and collecting, summarizing, and reporting the results.

2. Charting the Data

Charting data involves organizing and systematically arranging the collected data to facilitate analysis. This step ensures that all relevant information is accurately captured and categorized. Twenty-two studies were included in this review. These studies employed diverse methodologies, including randomized controlled trials (n=16) [24,30-44], cluster randomized trials (n=3) [45-47], and quasi-experiments (n=3) [48-50]. Geographically, the studies were primarily conducted in the United States (US) (n=12), with additional locations including Germany (n=3), Australia, Brazil, China, Canada, Israel, Japan, and the United Kingdom (UK), each contributing to one study. The most frequently used methods of interaction were videoconferencing (n=8) and web-based platforms (n=8), followed by telephone-based interactions (n=6) and mobile apps (n=3). Regarding professional engagement, psychiatrists participated in 11 studies, followed by psychologists (n=8), physicians (n=8), and nurses (n=6). Telehealth usage was mainly as a means for treatment (n=22), and two for diagnostic purposes. Other key aspects of each study, such as authors, publication year, aims, participant demographics, devices used, and health professionals involved, and main findings are shown in Table 2.

Table 2.

Study Demographics (N=22)

3. Collating, Summarizing, and Reporting the Results

Collating, summarizing, and reporting results involve synthesizing organized data to draw meaningful conclusions and effectively communicate the findings. The implementation of telehealth services for children with ADHD has been evaluated using a Virtual Care Value Framework [19]. This framework considers six aspects: (a) patient clinical outcomes, quality, and safety; (b) access to care; (c) patient, family, and caregiver experience; (d) clinician experience; (e) financial and operational impact; and (f) health equity. Studies were classified into these categories by examining their purpose, method, intervention, and results. Most studies focused on patients’ clinical outcomes (19 studies), while other areas included access to care (4 studies), patient, family, and caregiver experiences (12 studies), clinician experience (2 studies), and financial and operational impact (5 studies). However, no study has examined health equity.

The reviewed studies on patient clinical outcomes, quality, and safety explored the impact of telehealth interventions in improving diagnostic accuracy, promoting treatment adherence, and alleviating ADHD symptoms. Research on access to care has primarily focused on evaluating attendance and participation rates. Studies on the experiences of patients, families, and caregivers have examined satisfaction, levels of engagement, and overall perceptions of telehealth services. Additionally, research on clinicians’ experiences has assessed health professionals’ behavior following educational programs and psychiatrists’ adherence to evidence-based protocols when utilizing telehealth. Finally, studies on the financial and operational impacts have investigated the cost-effectiveness and key operational factors associated with telehealth implementation. Detailed information on the implementation of telehealth services in each study is presented in Table 3.

Table 3.

Classification of Studies According to Virtual Care Value Framework

1. The Development of Telehealth Practice

The study revealed that majority of studies were conducted in the US, which has emerged as a pioneer in this field, as is evident from the work exemplified by Epstein’s investigation into the use of internet portals to enhance care in community settings for children diagnosed with ADHD [45]. This trend aligns with a systematic review of telehealth implementation in neurodevelopmental disorders, which showed that most studies were conducted in the US (64%), Asia (17%), and Europe (14%) [51]. Given that telehealth in the US has already been extensively used for various conditions such as cardiovascular disease [52], the application of this technology to ADHD management in the US. is a logical progression. However, telehealth studies on the care of children with ADHD have also been conducted in countries such as Australia, Brazil, Canada, China, Israel, and the UK. Nonetheless, there remains a lack of studies conducted in other countries. This gap can be attributed to various factors, including variations in technological infrastructure, healthcare systems, and government support for telehealth initiatives.

Additionally, excluding non-English articles may have contributed to this gap, as significant research in other languages may have been overlooked. An examination of telehealth implementation across Asia, Latin America, and Europe revealed a complex landscape of challenges including regulatory hurdles, technological limitations, resistance due to attitudes, ethical dilemmas, and geographic disparities, all of which significantly impede the rapid integration of telehealth [53]. This has resulted in a different pace of research on telehealth, particularly regarding its implementation in children with ADHD.

Notably, despite setting the search criteria from 2000 to 2024, the earliest article retrieved was published in 2011. Over the past decade, the reviewed studies have indicated a heightened level of research activity in telehealth for children with ADHD, with notable exceptions in 2014, 2019, 2021, and 2022. Although the onset of the COVID-19 pandemic might be expected to stimulate telehealth studies owing to the increased demand for remote healthcare services, it is interesting to note that no studies were published in 2021 and 2022. This delay may be attributed to barriers, such as logistical challenges, shifting research priorities, and publication delays.

Web portals and videoconferencing were used in 2011 and 2012, respectively. Although these technologies enable remote access and communication, privacy concerns have emerged [45]. With advances in telehealth, both devices and interventions have progressed. From 2015 to 2017, telehealth options expanded significantly, such as web-based interventions [33,34,46,47] and video teleconferencing [24,36,37,44]. This change signifies growing confidence in employing technology to support the care of children with ADHD. In 2018, the introduction of computerized tests and mobile applications advanced telehealth to a new level of ADHD assessment and management. These advances have enabled accurate diagnostic decision-making [35], facilitated symptom monitoring, and supported medication adherence [40]. Progress persisted until mid-2024 with studies incorporating text messaging, mobile applications, and web-based interventions in telehealth for ADHD management. Text messages and mobile applications have emerged as valuable tools for providing timely reminders [48], delivering educational content, and offering personalized support [30,34] and diagnostic purposes [39], resulting in increased patient engagement and improved adherence to treatment regimens.

In the reviewed studies, telehealth programs for children with ADHD emphasized parental education [24,30-32,34,36,38,41-43,46,49], behavioral therapy [30,50], support for medication adherence [40,46,48], quality improvement [33,45,47], diagnostic evaluations [35,39], and consultation [31]. These programs align with the comprehensive treatment approach for ADHD, which includes multimodal treatment, pharmacological interventions, and non-pharmacological strategies [54]. Ten reviewed studies on telehealth for children with ADHD have highlighted the importance of parental education, including psychoeducation, which is a multimodal treatment. Psychoeducation should be provided not only to individuals diagnosed with ADHD but also to their families and caregivers, aligning with established guidelines [54,55]. Ongoing telehealth-based education is essential because its effectiveness is comparable to face-to-face method [32,34,36,38,41-43,49]. Their results highlighted the importance of ongoing parental education during and after the pandemic. Regarding diagnostic assessment, one study utilized telehealth to administer a computerized test of attention and activity (QbTest) for diagnostic decision-making, which was found to be efficient in the ADHD assessment process [35]. Another study employed remote assessment, with results aligned with face-to-face evaluations, enabling the accurate identification of ADHD in children [39]. Further studies are required to validate the effectiveness of telehealth in diagnosing ADHD.

2. Telehealth Implementations According to Virtual Care Value Framework

A more comprehensive assessment of telehealth implementation in children with ADHD was conducted based on the AMA’s virtual care value stream framework [19]. Patient clinical outcomes, quality, and safety have emerged as prominent areas of investigation, with 19 studies examining these aspects. These studies explored the effectiveness of telehealth interventions in improving clinical outcomes, such as alleviating ADHD symptoms, promoting treatment adherence, and improving diagnostic accuracy. Studies on decision-making in diagnostics [35,39] are classified in this aspect, as they reduce the number of visits required for diagnosis correction [19]. Seven of these 19 studies showed similar or less favorable results from the intervention compared to the control groups [36,38-40], while the remaining studies demonstrated positive results. While the primary focus of a scoping review is not determining intervention efficacy [28], the positive outcomes observed in most of these studies suggest that telehealth could be a promising approach for managing children with ADHD. However, extensive research is warranted to validate these findings and establish definitive guidelines for telehealth interventions.

Four studies examined access to ADHD care services. The AMA defines access to care as an evaluation of a program’s influence on the availability, suitability, and cost-effectiveness of care. This can be assessed by considering variables such as the average time patients travel to receive care, the availability of insurance coverage, and the percentage of individuals who stop seeking treatment because of various obstacles [19]. Four studies reported attendance and participation rates [36,42,43,50]. Wähnke et al. [42] indicated high utilization and acceptance of a web-assisted self-help program, whereas Tse et al. [36] showed comparable attendance between teletherapy and in-person sessions, with over 90% attendance in both groups. In addition to the need for further studies to validate these findings, research on the factors influencing the high patient attendance rate is crucial for reinforcing and enhancing these factors.

Patient, family, and caregiver experiences were addressed in 12 studies exploring the implementation of telehealth services for ADHD. These studies have explored the satisfaction, engagement, and overall experiences of families receiving telehealth services. This study focuses on the distress caused by clinical and technological experiences. Six studies examined parent satisfaction [30-32,38,46,50]. Parent satisfaction is pivotal because it describes the acceptability of telehealth interventions [56] in situations involving underserved families [49]. This satisfaction resonates with the broader benefits of telehealth such as improved convenience, reduced disruptions to daily routines, and increased engagement in treatment [57]. Although quantitative studies provide valuable insights, qualitative research can provide a more comprehensive understanding of family experiences. For instance, a qualitative study in the US involving parents of children with developmental delays revealed barriers to access, Internet connectivity, and digital literacy [58]. Analogous qualitative studies in the context of ADHD could reveal the challenges that families encounter when utilizing telehealth services, thereby promoting the development of more effective solutions. Consequently, further qualitative research that focuses on the acceptance of telehealth and its perceived benefits is imperative.

Regarding clinician experience, two studies examined this aspect in the context of telehealth for ADHD [44,47]. These studies investigated health professionals’ behavior in post-education programs and psychiatrists’ fidelity in using evidence-based protocols with telehealth. The sub-streams of clinician experience include technology and work experience [19]. Clinicians’ experiences with telehealth are mixed, with telepsychiatrists demonstrating effectiveness and competence [44], while other interventions indicate the need for additional support and engagement strategies [47]. With only two studies, more research is needed to identify the experiences of healthcare professionals. Health professionals are expected to be competent in telehealth because of its quality and security [59].

Five studies explored the financial and operational effects of telehealth services. These studies assessed cost-effectiveness [35] and operational considerations associated with the implementation of telehealth services for ADHD [33,44,45,47]. They provide insights into the potential financial savings, quality improvements, and workflow modifications resulting from telehealth adoption in ADHD care. Notably, one study in this scoping review reported “cost neutral” implying that providing the QbTest report within the trial neither significantly increased nor decreased the overall cost of the health services [35]. However, this finding necessitates further analysis, as other studies have reported cost savings attributed to telehealth [60], citing per-visit savings ranging from $141.1 to $222.8, depending on the visit type and the model utilized [61]. According to a scoping review that compared the costs of telehealth and the healthcare system, telehealth may reduce costs by eliminating the need for patient travel and costly procedures while providing effective remote care. Furthermore, it enables healthcare providers to deliver efficient and high-quality care, thereby reducing overall expenses [62]. Limited research on cost and operational impacts, coupled with contradictory findings, necessitates further investigation and validation. Such an exploration is crucial for establishing clear guidelines on the cost-effectiveness of telehealth in ADHD care, potentially informing policies and service delivery improvements.

In this scoping review, no study explicitly examined health equity within the context of telehealth among children with ADHD. Health equity is defined as having the conditions, resources, opportunities, and agencies needed to achieve optimal health. This implies the need to examine health equity across all five aspects of the AMA framework. Although no study has specifically addressed this aspect, the inherent characteristics of telehealth include health equity. This is particularly evident in a study focusing on underserved populations [49], in which telehealth interventions have the potential to bridge healthcare gaps and ensure equitable care delivery. Therefore, a more thorough examination is required to fully understand and quantify the impact of telehealth on health equity in children with ADHD.

According to the results of this study, the Virtual Care Value Framework is a suitable tool for analyzing the telehealth environment of children with ADHD. This framework comprehensively organizes a review of the key elements. For example, the framework’s focus on patients’ clinical outcomes, access to care, and patients’ and caregivers’ experiences allowed for a structured evaluation of how telehealth interventions improved ADHD symptoms, increased treatment adherence, and ensured high levels of family satisfaction. This structured approach highlights the strengths of telehealth and identifies areas in which further research is required, thereby making the review more comprehensive and focused.

3. Nursing Implications

This scoping review has important implications for both research and clinical practice. The geographic disparity in telehealth research and implementation for children with ADHD necessitates extensive research in countries other than the US, where the pace of telehealth development may be hindered by challenges such as regulatory, technological, and provisional issues. Additionally, as evidenced by the growing variety of telehealth devices and interventions, the evolution of telehealth technologies suggests a need for research on using new and current technologies in ADHD treatment. As telehealth technologies advance, the skills and competencies of healthcare professionals, including nurses, also evolve. Consequently, research focusing on the development and implementation of telehealth training programs is imperative to ensure that healthcare professionals possess the skills required to provide effective telehealth care. Future telehealth research should focus on treatments for ADHD, including multimodal, pharmacological, and non-pharmacological approaches. This entails evaluating how telehealth platforms can be modified to improve adherence to these treatments, enhance parental education, and effectively deliver non-pharmacological interventions, such as psychoeducation and cognitive behavioral therapies. A deeper understanding of the patients’, families’, and caregivers’ experiences is needed, particularly through qualitative studies. The mixed results of the clinician experience studies highlight the need for further confirmation. Additionally, more research is required to investigate and validate the cost and operational impacts, given the limited and contradictory findings of existing studies. Future studies should also aim to comprehensively cover the Virtual Care Value Framework, particularly the health-equity component, which has not yet been examined.

The results of this study have significant implications for clinical practice. Initially, the findings emphasized the essential function of nurses, who play a vital role in recognizing, intervening, and providing continuous support for children with ADHD. Furthermore, the findings of the ADHD interventions offer guidance for clinical settings. By incorporating evidence-based ADHD interventions, healthcare providers can enhance the care and support offered to children with ADHD. Implementing these interventions as part of regular practice enables nurses to effectively address the complex needs of vulnerable children, resulting in improved general health and developmental outcomes. It is essential for clinicians to engage in ongoing research and education on ADHD interventions to establish a comprehensive and effective approach to pediatric care.

4. Strengths and Limitations

To the best of our knowledge, this study is the first to map the landscape of telehealth research in children with ADHD and evaluate existing research gaps using a virtual care value stream framework. These findings provide a strong foundation for future research in this field. However, this study had some limitations. The exclusion of non-English literature may introduce a language bias, thereby potentially overlooking valuable research conducted in other languages. Additionally, the specific terms used for telehealth in this study may have excluded relevant studies using different terminologies.