Early Identification of ASD through Telemedicine: Potential Value for Underserved Populations

Background: There is growing evidence that accurate, stable diagnosis of ASD is possible during the second year of life and very young children with ASD receiving early behavioral intervention services demonstrate substantial gains in functioning. Although early diagnosis of ASD is possible in the first years of life, children from traditionally underserved communities are often not identified until much later ages. Substantial evidence suggests that families from low-resource communities struggle to access evaluation services through diagnostic centers, even when universal screening programs are implemented. Such diagnostic delays and health disparities contribute to family stress and restrict access to ASD intervention services. These struggles highlight the need for novel approaches to ASD screening, evaluation, and diagnostic decision-making that will realistically advance early detection and intervention, particularly for families facing geographical and resource barriers. Telemedicine and telehealth initiatives have improved access and care outcomes in other populations and may be a mechanism for accurately identifying young children with ASD.

Objectives: This work evaluated the benefit of a telemedicine evaluation procedure for young children at risk for ASD. First, we assessed telemedicine-based diagnostic accuracy in relation to blinded gold-standard evaluations. Second, we evaluated feasibility and family- and provider-rated acceptability of implementation in a telehealth facility serving a rural catchment

Methods: Children (n=20) and caregivers in the diagnostic accuracy study participated in a telemedicine evaluation [diagnostic interview and observation using Screening Tool for Autism in Toddlers (STAT)] with a licensed clinical psychologist (mean practice = 6.2 years) and then immediately were evaluated in person by a blinded clinician utilizing comprehensive assessment methods (Mullen, Vineland, ADOS-2, and diagnostic interview).

Children (n=45), their caregivers, and clinicians in the feasibility and acceptability study participated in the telemedicine procedures within a rural health clinic and provided data regarding the diagnostic experience via an anonymous follow-up survey.

Results: In the diagnostic accuracy study, all cases of ASD identified via telemedicine were confirmed by comprehensive in-person evaluation. However, 20% of children ultimately diagnosed with ASD in-person had not been assigned an ASD diagnosis as a result of the telemedicine procedure. Both clinician best estimate diagnosis and telemedicine assessment instrument yielded these results.

In the follow-up study, families and clinicians in the rural health clinic model indicated high levels of satisfaction with telemedicine procedures. Remote diagnostic clinicians felt it appropriate to issue an ASD diagnosis for approximately 62% of children evaluated with this model; approximately 24% were not diagnosed with ASD. They did not feel definitively capable of ruling-in or out ASD based on this consultation in a minority of (approximately 13%) of cases.

Conclusions: The findings support the feasibility, preliminary accuracy, and potential clinical utility of telemedicine-based assessment procedures for accurately identifying young children with ASD in traditionally underserved rural communities. Both families and system providers indicated that telemedicine consultation may be desirable and overcome traditional barriers to diagnosis in underserved communities. Future evaluation of broader applications of telemedicine-based diagnostic assessment procedures is warranted to more fully understand ultimate potential clinical and service system benefit.