Telehealth for Neurodevelopmental Assessment and Intervention

Screening and Assessment

Many practices developed innovative strategies to perform developmental screening and diagnostic assessments for neurodevelopmental disabilities, including autism spectrum disorder (ASD), using telehealth. Common strategies across these practices included the following:

• Collaborate with families/caregivers and practice/institution staff to develop a workflow which allows for families/caregivers to complete developmental screening tools digitally.
  • Use a HIPAA compliant platform that allows for completion of developmental screening tools virtually. A few platforms currently exist, including CHADIS and MeHealth. Note that the AAP does not endorse or support the use of any one platform for completion of developmental screening virtually.
  • If access to a specialized HIPAA compliant platform is not available, this capability may be available within practice electronic health records or through patient portals. Families/caregivers can be sent the screeners in advance and can upload the completed screening tools via the patient portal.
• Conduct diagnostic assessment for developmental disabilities and delays using telehealth. There are multiple different strategies and tools that practices used to accomplish this task in a telehealth environment.
  • These tools may include the TELE-ASD-PEDS and the Childhood Autism Rating Scale (CARS). Please note that the AAP does not support or endorse the use of any screening tool over another.

For more information on emerging practices related to use of telehealth for developmental surveillance and screening during the COVID-19 pandemic, click here.

^{These screening and assessment tips and strategies outlined in this promising practice were provided by Anonymous Contributors.}

Parent/Caregiver-Mediated Interventions Using Telehealth

The following strategies were shared to support use of parent-mediated interventions through telehealth for children with autism spectrum disorder (ASD) as well as other developmental-behavioral disorders and disabilities.

• Train clinicians to support families in implementing parent-mediated interventions.
  • New clinicians can undergo a brief training process where they observe more senior level clinicians with expertise in this topic, review session content, and role play.
  • Trainings can also be self-directed and offered online or through interactive workgroups.
• Develop a manual and/or other form of instruction guide for families/caregivers and the coach.
• Develop a web site that includes video examples of intervention techniques, handouts, and other resources for families.
• Prepare families/caregivers in advance for the appointment.
  • Share with families/caregivers what they will need to participate, including access to a smartphone or computer/laptop, reliable internet connection, as private space as possible, age-appropriate toys for children.
  • If families/caregivers do not have reliable access to internet at home, provide other options through community resources. More information on how to support families that may be facing technology barriers is available via this tip sheet.
• Use photos and screen sharing to support implementation of interventions with families.
• Provide group or individual coaching sessions for families via telehealth.
• Provide administrative and technical support to facilitate HIPAA secure video sessions.

Preliminary outcomes include:

• Improved access to parent mediated interventions, especially for families living in rural areas or those that are located far from a clinic.
• Clinician and family/caregiver satisfaction.
• No difference in patient outcomes when compared to in-person visits.
• Reduced travel time for families, resulting in cost savings typically associated with transportation needs.

^{The tips and strategies outlined in this promising practice were provided by Texas Children's Hospital, Project ImPACT and the Association of University Centers on Disabilities (AUCD). We are grateful to the Association of University Centers on Disabilities (AUCD) for their partnership in collecting these tips and strategies.}

Specific Examples of Implementation Tips and Strategies Within These Programs

Standard Telehealth Evaluation Protocol for ASD Diagnostic Evaluation

One practice implemented a standard telehealth evaluation protocol for young children referred for ASD assessment. The standardized telehealth ASD evaluation protocol included the following components:

• A diagnostic interview with the family/caregiver
• Review of DSM-5 ASD history and symptoms
• Administration of screening and diagnostic tools for use in a telehealth environment

Strategies to support this promising practice included the following:

• Develop a post-evaluation follow up protocol, which includes the following:
  • A follow up appointment 1-2 months post evaluation with a social worker who helps the family/caregiver understand the diagnosis, access intervention services, and identify/connect with state and community resources.
  • Additional follow up appointments or conversations via phone 9-12 months post evaluation.
  • Documentation of all points of contact following the telehealth evaluation protocol.
• Support clinicians in engaging in the protocol through the following strategies:
  • Provide training to clinicians who self-select to be trained in the use of screening and diagnostic tools designed for use in a telehealth environment. This includes participation in a remote training.
  • Convene regularly with the clinician team to discuss experiences, successes, challenges, and opportunities for improvement with the protocol.
  • Develop guidelines for faculty and staff to support clinical billing and documenting, obtaining consents and other needed documentation, and disseminating evaluation reports to families.
• Support families/caregivers in engaging with the protocol through the following strategies:
  • Ask families/caregiver to log into appointments prior to the appointment start time, so that administrative and support staff within the practice can assist with any technology issues.
  • Standardize and streamline the format of emails to families/caregivers.
  • Develop written scripts, instructional resource guides, and technology assistance hotlines to assist families in the use of this platform.

Preliminary outcomes include:

• Improved access to high quality diagnostic ASD services, especially for rural and underserved communities.
• Reduced transportation/travel time for families.
• Ability of clinicians to provide a confirmed diagnosis using a standardized telehealth evaluation protocol.
• Enhanced ability of clinicians to build trust with families/caregivers, observe children and families in their natural environment, and engage with families/caregivers and children in an unstructured way.
• Improved ability to provide family-centered and culturally competent care.

One challenge encountered by this practice is that some insurance carriers may not be able to reimburse an ASD evaluation completed through telehealth.

^{The tips and strategies outlined in this promising practice were provided by Indiana University School of Medicine and the Indiana Leadership Education in Neurodevelopmental Disabilities (LEND) program.}

Virtual Integrated Developmental Assessment

One practice developed a virtual Integrated Developmental Assessment (IDA) model to improve follow up care for children 4 months to 6 years who were previously identified through developmental screening as at risk for developmental delays or disabilities. The IDA model provides a comprehensive developmental assessment for these children, and includes the following components:

• Comprehensive interview
• Assessment of development using standardized measures
• Developmental observation
• Development of comprehensive report to families/caregivers
• Strategies to support this practice included the following:
• Provide a 45-minute training to clinicians to familiarize them with the IDA model.
• Provide guidelines and training to administrative staff to support scheduling of patients and families/caregivers, requesting insurance pre-authorizations, assisting families/caregivers with accessing the telehealth platform, and securing language interpreters as needed by families/caregivers.

Preliminary outcomes include increased continuity of care and referral to needed services for families/caregivers and young children. Observations of the child and family/caregiver through telehealth in their home environment can offer additional opportunities for clinicians to provide support to families/caregivers to facilitate healthy growth and development.

^{The tips and strategies outlined in this promising practice were provided by Michigan Medicine.}

Virtual Evaluation Diagnostic Assessment

One practice implemented a Virtual Evaluation Diagnostic Assessment (VEDA) model, designed to provide interdisciplinary diagnostic assessments for ASD in a telehealth environment. The model includes three sessions:

Session 1: Completion of a structured interview for diagnosing ASD and an interview measure of developmental and/or adaptive skills.

Session 2: Completion of a clinical interview, speech and language assessment, and Adapted Virtual Autism Behavior Observation (AVABO).

• Families/caregivers play a key role in the administration of observational tasks during the AVABO protocol, with guidance from the clinician. This allows the clinician to see family/child interactions in a more naturalistic environment and allows for families to be more integrated int the assessment process.

Session 3: Optional third session to collect further information on developmental skills, cognitive functioning, and academic skills to aid in contextualizing a neurodevelopmental disorder diagnosis and development of individual recommendations.

Additional components:

• Questionnaire data from families/caregivers, teachers and other care providers.
• Follow up appointment to provide comprehensive clinical feedback, including development of a care plan.

Strategies to support this practice included the following:

• Provide training to clinicians to support utilization of different interview and observation tools, the VEDA format and AVABO protocols.
• Offer training and support to families/caregivers to ensure access to needed technology, as private of a space as possible, and access to the telehealth application/platform.
• Support infrastructure adaptations such as converting the electronic health record to support a virtual platform and developing a set of procedures to support families/caregivers to access the telehealth platform.
• Develop a short letter to provide families/caregivers prior to participation in the VEDA model outlining how to prepare for the sessions, including the AVABO protocol.
  • The letter can explain the basic structure of the AVABO, how to set up the home environment, what materials are needed, and information about the possibility of an in-clinic appointment if needed in some cases.
• Develop a decision-making protocol to help determine if and when in-clinic follow-up may be necessary to obtain additional observation of the child for diagnostic accuracy.

This model may not be suitable for all children and families, depending on the complexity level of symptoms, home environment, physical limitations of families/caregivers and or language barriers. In-person options in a clinic setting should also be available.

Preliminary outcomes include:

• Increased access to neurodevelopmental assessments
• Decreased travel costs and transportation needs for families
• Enhanced family/professional partnerships and provision of family-centered care, especially due to the increased role of the family/caregiver in the AVABO protocol
• High family/caregiver satisfaction
• Time savings, as the evaluations are often completed quicker than they would through an in-person visit. This may also translate into cost savings.

^{The tips and strategies outlined in this promising practice were provided by Nationwide Children’s Hospital.}

Early Diagnostic Evaluation and Intervention for Children with ASD

Through a collaboration between a Part C Early Intervention program and an academic medical center, one practice implemented an innovative model to support tele diagnostic evaluation for children with ASD and subsequent follow up education/support sessions for families/caregivers. Components of this model included the following:

• Participation in a tele diagnostic process for ASD.
  • This can occur in the family/caregiver’s home setting and be facilitated by the family/caregiver with support from the clinicians.
  • This can also occur in the family/caregiver’s primary care medical home. The medical home team can set up the telehealth platform and engage in the appointment with a tertiary care center/subspecialist that is not located nearby geographically. The family/caregiver and patient may be physically located within the pediatric practice that serves as their medical home for this telehealth appointment.
• Follow up education and support visits (occurring via telehealth, in-person, or through hybrid model) for families.
  • Six follow-up visits are offered to all families/caregivers who participate in the diagnostic process, regardless of diagnostic evaluation outcome.
  • Follow up appointments are provided by clinicians trained in principles of Applied Behavior Analysis (ABA), communication disorders, and/or early intervention.
  • Session topics are grounded in a curriculum that includes: addressing challenging behavior, basics of communication, developing social and play skills, beginning toilet training, and addressing sleep concerns.
  • Follow up services are provided in collaboration with the family’s Part C Early Intervention provider.

Strategies to support this practice included the following:

• Provide support to families/caregivers so they are prepared for the tele-diagnostic ASD process.
• If the appointment occurs from the family/caregiver home, ensure the family has audio and video capabilities and is able to access the telehealth platform.
• Provide access to interpreters for families/caregivers as needed.
• Provide an option to engage with the family through audio only appointments if video appointments are not an option.

Preliminary outcomes include:

• Improved access to tertiary care and subspecialty services, particularly for underserved families and those living in rural areas. This includes:
  • Reduced travel time and transportation costs for families.
  • Reduced wait times for diagnostic evaluation of ASD for families/caregivers.
• Improved system integration and coordination resulting from engagement of Part C early intervention services within the medical team
• Increased capacity building among Part C early intervention professionals
• High family satisfaction
• Improved child communication development
• Ability to provide a family-centered approach to care

^{The tips and strategies outlined in this promising practice were provided by Vanderbilt Kennedy Center - TRIAD at Vanderbilt University Medical Center.}