The Society for Developmental and Behavioral Pediatrics (DBP) consists of approximately 900 members, including pediatricians, psychologists, advanced practitioners, and other professionals specializing in developmental and behavioral disorders in children. Telehealth refers to the use of electronic and telecommunications technology to provide remote clinical and nonclinical health care services, while telemedicine refers specifically to remote clinical services.1 To maintain the provision of care while protecting patients and health care workers from viral exposure when possible, all 50 states passed mandates requiring provider reimbursement for telehealth services by executive order.2 Temporary legislation was passed that also allowed for expanded access to telehealth, such as allowing patients to complete visits in their own home, lifting provider licensure requirements for visits across state lines, and reimbursement not only for video visits but also for telephone encounters.3 The successful utilization of telehealth by DBP providers during the COVID-19 pandemic has transformed the way DBP delivers care to the community. As a result of expanded access to and therefore utilization of telehealth, DBP providers across the country have been able to perform diagnostic evaluations, manage chronic medical conditions, and provide therapeutic supports4,5 for children with developmental disorders, including autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), and genetic disorders. A recent survey of 35 academic DBP practices revealed that all responding sites used video-based telehealth to perform assessments and provide follow-up care.6
Below, we share some case examples that highlight the unique benefits of home-based telehealth care for DBP.
Goodness of Fit: Unique Benefits Regarding Developmental and Behavioral Pediatrics and Telehealth
Developmental and behavioral pediatrics is well-positioned as a specialty to deliver care through telehealth.7,8 Similar to our psychiatry colleagues,9 little modification is needed when compared with many in-person visits. The emphasis of DBP care is on clinical observations, communication skills (verbal and nonverbal), and behavioral data collected from family, school, and therapists. Clinical disorders, such as ASD, ADHD, and anxiety, can often be diagnosed without direct physical contact. Furthermore, follow-up care, including behavior management, medication management, and family navigation, can be provided successfully through telehealth. For example, here are case vignettes of children whose needs have been met through telehealth.
Before the pandemic, a single mother of 2 children requested an autism evaluation for her 2-year-old son with delayed communication skills. Despite being on the DBP waitlist well over 16 weeks, she had already rescheduled her appointment twice. Although she knew her son needed help, she did not have child care for her other child, and the clinic was nearly 2 hours away from her house. She was concerned that by the time they arrived in the clinic, his exhaustion from the long commute would make it very difficult to assess his skills. She was relieved when the DBP office called and offered her a telehealth visit.
The interprofessional DBP providers were able to perform a developmental assessment through telehealth and observe her child in his natural environment, including his interactions with his sibling. He was diagnosed with ASD, and an action plan for therapies and next steps were developed with the mother, who completed the telehealth appointment feeling satisfied with the evaluation, without the inconvenience of a 4-hour travel to and from the office.
A teenage girl with intellectual disability and severe disruptive behaviors sees a DBP physician for medication management. Each time she comes to the office, she is overwhelmed and distressed by the medical environment and disruption to her daily schedule. This leads to instances of physical aggression with her family members and attempts to elope the clinic, and at least 2 visits had to be abandoned. During the COVID-19 pandemic, she completed a telehealth visit from home, which the family found more successful because they were not distracted by their daughter's behaviors, allowing the clinician to make naturalistic observations and the family to participate in shared decision regarding medications.
Key Benefits of Developmental and Behavioral Pediatrics Care Delivered Through Telehealth
Improved Access to Care
Telehealth provides improved access10 to subspecialty care for families who otherwise would not have access because of distance, lower geographic penetrance of providers, or other family obligations (e.g., child care or time off work11,12). This is especially important in DBP because access to DBP providers continues to be limited by workforce shortages.13 Some areas have a particular scarcity of providers and extremely long waitlists to see a DBP subspecialist,14 with an average nationwide wait time of more than 16 weeks.13
Increased Patient-Centered Care Delivery
For some families and children with neurodevelopmental disabilities, clinic visits create significant stress and anxiety due to changes in routine and memories of previous negative clinic experiences. Provision of telehealth services in a familiar environment can buffer the stress that families experience and allow patients and families to communicate their concerns and needs more clearly.15
Increased Naturalistic Observations
Providers can observe children in their natural environments, which may more accurately represent their developmental skills and behavioral challenges.16,17 However, home-based methods to accurately measure and record vital signs for children with developmental-behavioral issues should be developed and tested because these data are important for medication monitoring and adjustment. One might consider options such as collaborating with school nurses or primary care provider offices closer to home for these measures.
Mitigation of Transportation Barriers
Telehealth improves access to DBP care for patients living in underserved areas; nearly 1 in 3 children travel 40 miles or more to receive care from a DBP physician.12 Telehealth can also improve access to care for families with limited access to transportation. One study examining telehealth access to DBP found families saved a median of 66.9 minutes in travel time and 63.8 miles in distance traveled for their appointment.18
Patient satisfaction through telehealth is high and provides opportunities to support the clinician-patient relationship.19
Increased Access to Evidence-Based Therapy
Many families of children with developmental disabilities reported increased emotional and behavioral concerns during the COVID-19 pandemic.20 There is a substantial evidence base for the successful provision of therapeutic interventions (e.g., behavioral parent training including parent-child interaction therapy,21 applied behavior analysis,4 and cognitive behavioral therapy22) through telehealth. Owing to the pandemic, many DBP and other mental health specialists were able to expand the services provided and improve patient/parent ability to receive rapid, problem-focused interventions through telehealth modalities. However, there continues to be a limited evidence base regarding the equivalence of DBP telehealth to in-person care.
Reduced Health Care Costs
Some studies have estimated that the costs of telehealth are lower compared with in-person visits for both families and providers.4
Telehealth Access Is a Complex Interplay of State and Federal Legislation
As state-level executive orders are ending, many have implemented state-level legislation efforts to maintain telehealth access.2 Similarly, there is movement at the federal level for policy related to telehealth,23 especially with the most recent renewal of a declaration of a national public health emergency by the US Department of Health and Human Services on July 19, 2021. In order for DBP providers to continue the use of telehealth postpandemic, it is critical that key areas of need be addressed.
Ensuring Equitable Access
Although telehealth has been a useful tool for increasing access to care, it has also highlighted significant disparities in broadband services. Telehealth is challenging without access to the internet and technology devices. Approximately 21.3 million Americans lack broadband internet services.24 Internet service is determined by neighborhood and geographic location, resulting in “digital redlining,” which creates and perpetuates inequities for already marginalized groups, specifically regarding the use of digital technologies, internet, and digital content.25 This disproportionately affects Black and indigenous people of color, people with disabilities, and people who live in rural areas.8 For families who have limited internet connectivity, access to providers through telephone encounters can be helpful; therefore, access to initial visits and consultations is needed. In addition, both video and telephone encounters require availability of appropriate interpretation services for family members with limited English proficiency and/or hearing impairments.
Equitable access to devices for telehealth visits is also a concern because there is a disproportionate access to needed technology and devices, especially in rural and underserved communities. The Federal Communications Commission has provided grants to eligible families to offset the cost, in part, for a laptop, desktop computer, or tablet.26 Information about these benefits needs to be disseminated to providers and families.
Geographic Barriers and Provider Reimbursement
Laws and policies regarding payment for telehealth services by Medicaid and private insurance are decided primarily at the state level, creating significant variability in reimbursement.27 In response to the pandemic, many states passed temporary executive orders that supported the implementation of telehealth by DBP providers. This included reimbursing telehealth visits at rates similar to in-person visits, reimbursement for telephone encounters, and loosening licensure requirements for care provided across state lines. The future of reimbursement to providers remains unknown once temporary executive orders expire, and it is crucial to address the need for ongoing legislation that supports ongoing telehealth utilization by providers.
Education and Research
Much can be learned from telehealth experiences and guidelines developed for the fields of psychology and psychiatry. For example, the American Psychological Association's “Guidelines for the Practice of Telepsychology”28 are applicable to visits run by DBP providers. The American Association of Medical Colleges also recognized the critical need for telehealth training before the beginning of the COVID-19 pandemic and articulated 37 specific skills to promote the delivery of high-quality virtual care.29 In addition to these already developed resources, general and condition-specific guidelines for DBP remote care are needed. For example, guidelines for the provision of culturally appropriate telehealth services for diverse populations are needed to maintain relationships with patients and families during times when social distancing is endorsed.30 More research is also needed to develop and validate standardized telehealth assessments for diagnosis of ASDs and measurement of developmental/cognitive skills and language skills. Furthermore, future study is required to determine whether telehealth is equivalent to in-person assessments for diagnostic formulations and patient outcomes. Further investigation is needed, too, to determine whether certain types of patient follow-up visits (e.g., those requiring physical examinations) require a specific frequency of in-person care to ensure the safety and tolerability of any treatments (e.g., medications) being prescribed and how interpersonal communication and family-centeredness are affected by the telehealth modality.
SOCIETY FOR DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS POLICY RECOMMENDATIONS
The Society for Developmental and Behavioral Pediatrics (SDBP) supports telehealth as an alternative to in-person clinical care when appropriate. To continue to provide telehealth care to the community, SDBP has identified the following areas of need:
- 1. Equitable infrastructure and technology access for telehealth utilization
Mitigation of geographic barriers to accessing DBP care
- a. Increase infrastructure to support broadband internet access to underserved areas at the federal, state, and municipal levels.
- b. Increase access to devices needed to connect children with neurodevelopmental disorders with critical health care services.
- c. Reimbursement for interpretation services through telehealth, including hearing-impaired services.
3. Ensuring ongoing reimbursement
- a. Permitting patients to access telehealth from their home or whichever physical location provides opportunities for safe and timely care, especially for established patients.
- b. Ensuring more engagement by state medical licensing boards to join the Interstate Medical Licensing Compact31 to provide care by telehealth when there is already an insufficient geographic distribution of that type of provider in state, as is being conducted in the field of psychology.32
4. Support for ongoing telehealth research and education to ensure delivery of best practices in care
- a. Continued payor reimbursement by public and private insurance programs for telehealth services provided by interprofessional developmental and behavioral pediatrics providers at federal and state levels.
- b. Parity in reimbursement for telehealth versus in-person visits.
- c. Include telephone encounters when a video encounter is unavailable or not feasible.
- d. Allowance of initial visits/consultations to take place through telehealth.
- a. Increased funding for research looking into outcomes, quality, and effectiveness of telehealth services at the federal and state levels.
- b. Ensure interprofessional educational competencies and training programs implement required curriculum for conducting effective telehealth.
The Society for Developmental and Behavioral Pediatrics advocates for federal, state, and municipal entities to maintain and further promote equitable telehealth access and payment. Specifically, this includes requiring parity in reimbursement by payors for pediatric telehealth services, further development of infrastructure providing equitable access to broadband services and related technology, and funding for research and training to examine and improve long-term outcomes, quality, and effectiveness of telehealth. Many patients have found telehealth to be a convenient, accessible, and satisfying way to access developmental and behavioral pediatrics (DBP) care. With supportive policies in place, DBP providers can continue to use telehealth to meet the needs of families and the children and adolescents they serve.
SOCIETY FOR DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS
As the leading voice for interprofessional developmental and behavioral pediatric care, our mission is to improve the health and well-being of children and families by promoting high-quality research, education, advocacy, and practice. www.sdbp.org.
SDBP Leadership: Carol Weitzman, MD, President SDBP. SDBP Board: Marilyn Augustyn, MD; Tanya Froehlich, MD, MS; Robyn Mehlenbeck, PhD; Alan L. Mendelsohn, MD; Britt A. Nielsen, PsyD; Neelkamal Soares, MD; Robert G. Voigt, MD; Jennifer Walton, MD, MPH; Kimberly Zlomke, PhD, BCBA-D. Contributing authors: Robert D. Keder, MD; Shruti Mittal, MD; Neelkamal S. Soares, MD; Kimberlly Stringer, MD, MPH; Jenna E Wallace, PsyD; Kate E Wallis, MD, MPH.
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