As a medical student working in East Harlem, I see inequities in access to care on a daily basis. These inequities are exemplified amongst children suffering from neurodevelopmental conditions such as autism. In 2000, about 1 in 150 children were identified as having autism spectrum disorder (ASD). That rate has skyrocketed to 1 in 44 today. For parents and their children, it is well appreciated that an early diagnosis for conditions such as autism leads to better outcomes. The dilemma, as I appreciated on my pediatrics rotation at Elmhurst Hospital, is that the process for testing and obtaining a definite autism diagnosis is rarely straightforward. Early diagnosis requires close interaction with a skilled clinician, which is an elusive goal for many.
Early detection is important, yet is often not available to the most underserved members of our health care system. Statistics bear this out. Autism is four times more likely to be identified in boys than girls. Some believe this reflects a varying presentation of autism by gender, leading to underdiagnosis. Additionally, the rate of identified autism varies significantly by one’s community. Autism is identified in 1 in 60 children in Missouri but 1 in 26 in California. This startling statistic raises concern that external factors are leading to the underdiagnosis of those with autism. Prior analysis has even shown that Caucasian children are 20 percent more likely to be identified as having autism than Hispanic children. Socioeconomic barriers are likely driving these disparities, preventing thousands of young children from getting the evaluations and care they need at the age range when an early diagnosis can provide the most impact.
Health care barriers in underserved communities have been magnified during the COVID-19 pandemic. Fortunately, this reality has had a positive impact in highlighting the need for increased access to care. A recent systematic review highlighted that restrictions on in-person services have expedited the transition to telehealth services that were previously almost exclusively in-person. The study suggests that telehealth services for autism testing and treatment, when available for all communities, were equivalent or better than in-person services. The study compared several models for telehealth services. One model relied on using both children and their parents together. Others used behavioral interventionists or teachers of children with ASD. While these studies are limited by their small sample size, they demonstrate the feasibility of using telehealth for both diagnosis and assessment of children with ASD.
Additionally, telehealth autism services have the potential to significantly improve access to care, a critical barrier for underrepresented racial and ethnic groups. This disparity in access to in-person autism care has been magnified during the COVID-19 pandemic. The long-term impact of delayed access to autism diagnosis remains to be seen but may have a significant impact on educational attainment, social development, and workforce diversity.
The good news is that the availability and accessibility of telehealth for autism care are making valuable inroads for all families. On January 1, 2021, the Centers for Medicare and Medicaid Services permanently expanded the number of telehealth services for those eligible for Medicare reimbursement. There is evidence that the COVID-19 pandemic has been a catalyst for growth in telehealth demand. In 2020 only 49 percent of Americans said they would use telehealth for their mental health. In 2021 that number was 59 percent.
In conclusion, all indications show there is an increasing need for telehealth autism services, not only for the benefits they provide families but also for the access and outcome benefits they provide to both ethnically and regionally underserved. While a relatively new service, preliminary studies have shown that telehealth autism services are effective and beneficial. I look forward to the transformative impact telehealth will have on my patients at Elmhurst and others.
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