Bridging the Access Gap: Telemedicine as a Promising Approach for Developmental Pediatrics

Telehealth adoption has experienced rapid growth since the 1990s and has proven to be an effective method for enhancing health care accessibility; the COVID-19 pandemic has resulted in a significant surge in the utilization of telemedicine services, both in our country and worldwide.^1-4 In this article, we aimed to conduct a narrative review regarding the usage of telemedicine in developmental pediatrics, supplemented by our own practical insights.

Telemedicine refers to the application of telecommunication technology to exchange medical information and deliver clinical care to patients remotely and encompasses the utilization of advanced communication systems, such as high-resolution videoconference equipment with interactive audio and visual capabilities, as well as diagnostic cameras and clinical assessment tools like otoscopes, ophthalmoscopes, and digital stethoscopes. Despite the term “telehealth” had a wider scope, in current usage, telemedicine and telehealth are often used interchangeably and can be considered synonymous and be used for various purposes, such as tele-education, teleconsultation, telepractice, and teleresearch.

Real-time telehealth, which involves synchronous communication, encompasses videoconferencing sessions that connect health care providers with patients, as well as consultations conducted between different health care providers.^5-8

It is known that the limited availability of physicians in numerous pediatric subspecialties poses challenges for children and their families in accessing timely health care services. The scarcity of pediatric subspecialists often necessitates traveling considerable distances to receive care, enduring prolonged wait times for subspecialist appointments, foregoing necessary care altogether. This issue may arise as a significant concern, particularly within the realm of developmental pediatrics due to very limited specialists.^9-11 Another issue of concern within developmental pediatrics pertains to the characteristics of patients. Notably, it is widely acknowledged that individuals with developmental disabilities encounter notable difficulties in accessing sufficient health care services. Moreover, considering the vulnerable nature of certain populations, such as lower socioeconomic groups and individuals with physical or mental limitations, telehealth holds even greater potential benefits. In the light of these circumstances, telehealth emerges as a viable option within the field of developmental pediatrics.^7,12,13

Patients with autism spectrum disorder (ASD), a pivotal cohort in developmental pediatrics, serve as a noteworthy exemplification poised to experience substantial advantages with the implementation of telehealth. Telehealth has gained recognition as a feasible approach for providing health care, information, and intervention to children diagnosed with ASD and their families. While further research is necessary to use telehealth to diagnose ASD, it presents a potential alternative for evaluation and intervention services like functional behavioral assessments, early intervention, cognitive-behavioral intervention, provider training, and family support groups, and many studies have been conducted to explore the effectiveness and feasibility. ¹⁴ Although it is undeniable that certain aspects of clinical practice require in-person interaction to observe a child’s response during social interventions, telehealth services have the potential to provide access to professionals who can consult and ensure treatment accuracy for various issues, including diagnosis. In addition, telehealth can offer educational training for families, schools, and the community. Thus, making telehealth services more accessible for children with ASD can be highly beneficial due to the significant role it plays. ⁷

Children with feeding and sleeping disorders also commonly seek assistance at developmental pediatrics clinics. Two distinct models of telehealth have been utilized for children with feeding disorders: the “store and forward” method, enabling families to record and transmit meal information or food logs to health care providers, and real-time interactions allowing direct communication between providers, patients, and their families. ¹⁵

A study examined the use of teleconsultation for implementing a behavioral feeding intervention in a child with Avoidant/Restrictive Food Intake Disorder showed increased consumption of nonpreferred foods following successive increases in criteria. High acceptability, interobserver agreement, and treatment integrity were observed, highlighting the effectiveness of teleconsultation for Avoidant/Restrictive Food Intake Disorder (ARFID) treatment. ¹⁶ The findings of the another research revealed that synchronous pediatric feeding assessments conducted in family homes via telemedicine demonstrating feasibility and reliability. ¹⁷ The recommendations endorsing the use of telemedicine in the sleep field align with those applicable to feeding disorders. The present consensus affirms that telemedicine is a viable approach for delivering comprehensive care to children with sleep disorders. The capability of telemedicine to provide comprehensive and high-quality care for sleep problems, particularly in vulnerable populations, holds immense value. ¹³

Parenting programs represent another domain in developmental pediatrics where telehealth can be utilized. Evidence-based parenting interventions play a crucial role in preventing childhood emotional, behavioral, and social challenges that are linked to more severe mental health and conduct issues later in life, and telehealth may increase the accessibility. Recent studies provide growing evidence that web-based parenting support is effective in reducing disruptive child behaviors when accessed even in a self-directed manner.^18,19

In studies conducted with patients in the field of developmental pediatrics, high rates of parental satisfaction have been reported. According to the telepractice to deliver pediatric feeding assessments study, 76% of parents reported that the telepractice appointment was comparable with a traditional in-person appointment. ¹⁷ In a study assessing parental satisfaction with tele-rehabilitation for children with neurodevelopmental disabilities, it was found that 80.5% of caregivers expressed satisfaction with the tele-rehabilitation services provided. ²⁰ Similarly, a review suggests that implementing early intervention through telehealth may be satisfactory and acceptable to families of children with developmental difficulties. ³ In a quantitative study that compared telemedicine with traditional face-to-face care for children with special needs, there were no discernible differences in how families perceived the level of care. However, parents or guardians perceived the system of care to be significantly more family-centered when utilizing telemedicine. ¹² And even a particular study found that children with severe anxiety and autism showed higher levels of engagement during telepsychiatry visits compared with traditional in-person visits. ²¹ Conversely, in a study involving adults, patients expressed varied perspectives regarding doctor–patient interactions. Some individuals experienced feelings of disconnection or alienation attributed to the use of technology, and there were difficulties encountered in doctor–patient communication. ²² With an awareness of these challenges, telehealth has become a necessity in the field of developmental pediatrics to the extent that numerous recommendations are now emerging as textbook knowledge to enhance the adaptation of both doctors and patients to virtual visits. ²³ Noteworthy, in a recent study evaluating the perspective of clinicians in telehealth neurodevelopmental evaluations, it was found that 74% of evaluations were rated with diagnostic certainty as either “completely” or “somewhat” certain. ²⁴ Nevertheless, the major limitation of telemedicine, especially during the initial consultations, arises from the clinician’s incapacity to conduct a thorough physical examination. Hence, it becomes imperative to carefully assess the necessity of a face-to-face visit, suggesting that an in-person examination for the first visit might be beneficial, followed by subsequent sessions conducted via telemedicine. ²⁵

In our own clinical experiences, we have observed a parallel development with global trends, which has gained momentum after the COVID-19 pandemic. Previously, our use of telemedicine was predominantly focused on non-real-time video evaluations for assessing family mealtime, feeding behaviors, or evaluating home-based play and behaviors in children with limited social interaction. However, COVID-19 has served as a driving force for us to expand our telehealth applications. In a study conducted at our center, we investigated the impact of the COVID-19 pandemic on children with special needs. As part of the study, we provided parenting tips and guidance to families through phone consultations during this challenging time. Surprisingly, this simple intervention was perceived as beneficial by 98.3% of the families, highlighting the effectiveness of telemedicine during critical periods. ²⁶ In addition to the small intervention conducted over the phone, we gained experience in monitoring children with feeding problems using a hybrid approach. After the initial face-to-face visit, we conducted online sessions. By virtually joining these children at their family meals, we were able to observe their challenges in real time, irrespective of distance. Furthermore, by addressing the mothers’ concerns through online visits, we made significant progress in meeting their needs. Similarly, a study which evaluated the use of telehealth in providing care for Developmental and Behavioral Pediatrics during the pandemic showed a significant rise in video-based telehealth visits and highlight the transformative potential of telehealth and emphasize the importance of optimizing its use in future practice. ²⁷ Furthermore, due to the uncertainty surrounding how the continuity of providing Developmental and Behavioral Pediatrics care through telehealth will develop in the post-COVID era, the Society for Developmental & Behavioral Pediatrics has issued a policy statement aiming to advocate for legislative measures and policies that promote continuous, fair, and home-based telehealth care for patients. ²⁷

Health care providers face important challenges when it comes to utilizing telehealth. A systematic review has identified these challenges, including limited proficiency, lack of confidence in technology quality and reliability, connectivity problems, concerns about legal aspects, increased administrative workload, and inability to conduct thorough examinations. ²⁸ Certainly, these challenges can vary based on the socioeconomic level of a country. It is crucial to have a comprehensive understanding of the differing obstacles faced by health care providers in different socioeconomic settings. In the Middle Eastern countries’ telemedicine usage was found to be insufficient and varied across the region, with several challenges hindering its full implementation. These challenges included cultural, financial, organizational, individual, technological, legal, and regulatory factors that limited the provision of comprehensive medical services through telemedicine. Resistance from physicians and patients, inadequate infrastructure, lack of funding, poor system quality, low language proficiency, and insufficient information technology training were identified as barriers to the widespread adoption of telemedicine.^29,30 When considering the role of telehealth in addressing inequality of opportunities, it becomes crucial to address these challenges for successful integration into health care practices. In areas where primary health care services can be effectively provided, primary health care providers may have the potential to play a crucial role in addressing the challenges faced by individuals in lower socioeconomic status due to limited access to technology and internet connectivity. By implementing solutions such as providing equipment, facilitating telehealth sessions, or incorporating mobile health care services, they can mitigate the vulnerability experienced by these groups and ensure that telehealth remains a means of overcoming barriers to health care access.

In conclusion, telemedicine presents a great opportunity to address health care inequalities and ensure equal access to health care resources for all individuals. The field of developmental and behavioral pediatrics, which suffers from a shortage of specialists, is highly suitable for the implementation of telemedicine and will provide significant advantages. To achieve this success, as clinicians, we need to change our mindset and adapt to the new era. We must gain experience to demonstrate acceptability, validity, and sustainability. In addition, with the support of policymakers, we should address the barriers to enhance the adoption and effectiveness of telemedicine.