Telehealth Services for Children With Autism Spectrum Disorders in Rural Areas of the Kingdom of Saudi Arabia: Overview and Recommendations

Factors Influencing Telehealth Adoption in Managing Healthcare in Saudi Arabia: A Systematic Review

Background

The utilization of telehealth as an effective means to provide quality services is steadily rising across different tiers of the health system. However, advancing telehealth utilization relies on the current healthcare systems' infrastructure, policies, cultural factors, and utilization requirements can influence the utilization of telehealth within Saudi Arabia's healthcare system.

Purpose

This study seeks to systematically review the literature related to examining the factors influencing telehealth adoption and identifying the barriers and determinants of the use of telehealth in Saudi's healthcare system.

Methods

A systematic review methodology was utilized in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The methodology included an exploratory and narrative design, a dual-phase search strategy, eligibility criteria, and analysis. The Joanna Briggs Institute (JBI) tool was employed to assess the quality of the chosen papers.

Results

The search yielded 3197 articles to which eligibility criteria were applied. Thirteen articles were deemed eligible, screened, and utilized for comprehensive analysis in the present study. Numerous articles indicated that the utilization of telehealth has risen in Saudi Arabia, particularly during the COVID-19 pandemic. The investment strategies have aligned with the demand for telehealth systems. The primary challenges were resource limitations and the absence of cultural frameworks conducive to the utilization of telehealth in the country.

Conclusion

Telehealth represents a major technological breakthrough in the healthcare industry. However, there are some drawbacks to its adoption. The limited availability of Telehealth technologies poses a significant challenge. Secondly, relying solely on privatization might not adequately address the issue at hand. Third, there is a lack of knowledge and awareness regarding its associated benefits among healthcare staff. The establishment of telemedicine and telehealth infrastructure necessitates significant financial investment, which serves as a major factor and obstacle to the widespread adoption of telehealth.

Ayres Sensory Integration® Intervention for Autistic Children: A Telehealth Adaptation

IMPORTANCE

Ayres Sensory Integration® is an evidence-based, manualized occupational therapy intervention for autism that is delivered in person. A telehealth adaptation could bridge service gaps for families who may have challenges accessing services.

OBJECTIVE

To create a telehealth adaptation of the evidence-based manualized protocol of Ayres Sensory Integration using best practice for telehealth guidelines and to obtain input on the adaptation from experts.

SETTING

Online survey of U.S. telehealth experts and occupational therapy clinicians in fall and winter 2022.

PARTICIPANTS

Two telehealth experts and six occupational therapy clinicians.

OUTCOMES AND MEASURES

Two Qualtrics surveys focused on perceived feasibility and acceptability, resources included, and clarity of instructions.

RESULTS

Telehealth experts and occupational therapy clinicians rated the Ayres Sensory Integration telehealth adapted manual as easy to follow, aligned with telehealth best practices, and feasible for remote delivery. Suggestions for additional adaptations included adding resources for technology troubleshooting, intervention planning, rapport building, and continuing education.

CONCLUSIONS AND RELEVANCE

Suggested adaptations were made; the manual is ready for feasibility testing. Plain-Language Summary: This report is the first to describe a telehealth adaptation of Ayres Sensory Integration®. The manual provides comprehensive training and resources to support clinicians in delivering sensory integration, telehealth-based interventions to autistic children. Two telehealth experts and six occupational therapy clinicians rated the Ayres Sensory Integration telehealth adapted manual as easy to follow, aligned with telehealth best practices, and feasible for remote delivery. The manual will be available to clinicians after feasibility and pilot testing.

Challenges, practices, and impact of COVID-19 among mothers of children with autism spectrum disorder in cities and remote areas in Saudi Arabia

BACKGROUND

Mothers of children with autism spectrum disorder (ASD) across Saudi Arabia have experienced tremendous challenges during the COVID-19 pandemic. However, the challenges may be different for mothers living in a city compared to those living more remotely.

AIMS

We investigated challenges and practices related to COVID-19 and their impact among Saudi mothers of children with ASD in cities and remote areas during the pandemic.

METHODS

A sample of 99 mothers (60 in cities and 39 remote) who had a child with ASD was surveyed using an electronic questionnaire.

RESULTS

Mothers who lived in remote areas reported more challenges, while mothers in cities reported adopting more new practices with children than remote mothers. Regression analyses revealed that place of residence and age of the child were significant predictors of the challenges experienced by mothers of children with ASD.

RECOMMENDATIONS

Intervention services, community-based education programs, and electronic media are recommended for use with mothers in Saudi Arabia to increase awareness of COVID-19, improve practices, and minimize challenges in protecting their children with ASD.

Potential impact of autism services on the quality of life of individuals with autism spectrum disorder and their families

Autism spectrum disorder (ASD) is a lifelong condition that requires autism-specific services. However, the quality of autism services in Saudi Arabia has rarely been examined. Therefore, exploring issues from the parents' perspective is crucial to improve the quality of life (QOL) outcomes for such a population. Semi-structured interviews were administered to nine parents of individuals with ASD, and thematic analysis was used for data analysis. Results showed that parents' experiences regarding the quality of autism services varied. In addition, the quality of autism services must be further developed to meet the diverse needs of individuals with ASD and their families, in line with the 2030 vision of Saudi Arabia, which prioritises the QOL of individuals with a disability and their families. This study highlighted some influencing factors of the quality of autism services and QOL of individuals with ASD and their families from the parents' perspective. This study concluded that further research is necessary to gain in-depth understanding of the influencing factors of the quality of national autism services. Overall, the reasons behind the diversity in experiences amongst parents of individuals with ASD regarding the quality of autism services must be further explored.

The experiences of speech-language therapists providing telerehabilitation services to children with autism spectrum disorder

Background

There has been an increased emergence of the use of telerehabilitation by speech-language therapists (SLTs) in South Africa since the COVID-19 pandemic in 2020.

Objectives

To explore the criteria that SLTs use when recommending telerehabilitation for children with autism spectrum disorder (ASD), the technical skills required, strategies used by SLTs, the restrictions encountered when conducting telerehabilitation and the views of SLTs on telerehabilitation in comparison to face-to-face therapy for children with ASD.

Method

A descriptive, phenomenological, qualitative study design was utilised. Purposive and snowball sampling techniques were employed. Six SLTs from the private sector, who had experience providing telerehabilitation to children with ASD, were recruited from three provinces in South Africa. Data were gathered via semistructured online interviews and analysed using thematic analysis.

Results

Two out of five themes that emerged from this study are presented in this paper, i.e. approaches to telerehabilitation and the benefits of telerehabilitation. Results revealed that telerehabilitation was used to provide assessment and therapy during the COVID-19 pandemic lockdowns as an alternative method of service delivery. Assessment and treatment strategies included synchronous and asynchronous methods, family collaboration, social stories, frequent breaks and interactive sessions. Telerehabilitation reduced the client’s and SLT’s travel costs and increased caregiver and clinician satisfaction. Client progress and increased awareness of SLT were viewed as further benefits.

Conclusion

Telerehabilitation was found to be beneficial to most children with ASD, and in most cases, the benefits far outweighed the challenges encountered. Clinical implications included the need for caregiver support in facilitating effective carryover, an increase in SLTs’ knowledge and the opportunity to provide services to a broader geographical range. Limitations of the study are included.

Exploring telehealth during COVID for assessing autism spectrum disorder in a diverse sample

Due to the coronavirus disease 2019 (COVID-19) pandemic, the importance of telehealth has rapidly increased, in particular as many in-person clinics have closed. Early intervention is crucial for improving outcomes in children with autism spectrum disorder (ASD). As such, the need for timely assessments and diagnoses remains despite COVID-19-related closures. This study offers preliminary data collected from 23 children assessed through a no-cost autism clinic in Southern California using a novel telehealth model. This includes an overview of an adapted, telehealth version of in-person observational assessment techniques for diagnosing autism. In addition, preliminary data on social validity assessed at two points are presented. Findings suggest that caregivers found the telehealth assessment procedures acceptable and convenient, and overall were satisfied with both the assessment and the written report/verbal feedback. Implications for future uses of telehealth are discussed, including how telehealth can assist with decision-making around school-based services and/or placement.

Expectations and Concerns about the Use of Telemedicine for Autism Spectrum Disorder: A Cross-Sectional Survey of Parents and Healthcare Professionals

Telemedicine has recently been used for diagnosis and interventions inpatients with autism spectrum disorder (ASD), traditionally performed in-person, but little attention has been paid to user expectations prior to its use. The aim of this study is to compare the expectations and concerns of 50 healthcare professionals and 45 parents of children with ASD regarding the use of telemedicine for diagnostic or treatment purposes. Parents have higher expectations for the use of telemedicine as an alternative (p = 0.0223) and supplement (p = 0.0061) to in-person diagnosis of ASD, as well as a supplement to traditional intervention (p ≤ 0.0001). In addition, while they also have greater hope for improvement in family routines (p = 0.0034) and parenting skills in child management (p = 0.0147), they express greater concern about the need for active parental involvement/supervision during telemedicine services (p = 0.015) and changes in the behaviour of the child with ASD during telemedicine services (p = 0.049). On the other hand, healthcare professionals are more concerned about barriers such as lack of devices (p = 0.000), unfamiliarity with the technology (p = 0.000), poor quality of internet connection (p = 0.006), and severity of ASD (p = 0.000). To achieve promising healthcare for ASD patients, the telemedicine service should try to meet the needs and preferences of both healthcare professionals and parents, as well as identify and, if possible, reduce perceived barriers.

A scoping review of telehealth diagnosis of autism spectrum disorder

BACKGROUND

Considering the COVID-19 pandemic, understanding the reliability, validity, social validity, and feasibility of using telehealth to diagnose ASD is a critical public health issue. This paper examines evidence supporting the use of telehealth methods to diagnose ASD and outlines the necessary modifications and adaptations to support telehealth diagnosis.

METHODS AND PROCEDURES

Studies were identified by searching PubMed and PsychInfo electronic databases and references lists of relevant articles. Only peer reviewed articles published in English with a focus on using telehealth for the purposes of diagnosing ASD were included. Searches were conducted through June 3rd, 2021.

OUTCOMES AND RESULTS

A total of 10 studies were identified as meeting inclusion criteria. Of the eight papers that reported on reliability (e.g., accuracy), telehealth methods to diagnose ASD were between 80-91% accurate when compared with traditional in-person diagnosis. Six studies reported on validity (i.e., sensitivity and/or specificity). All six studies calculated sensitivity, with values ranging from 75% and 100%. Five of the six studies calculated specificity, with values ranging from 68.75% and 100%. The seven papers that reported social validity indicated that caregivers, as well as adult participants and clinicians, were mostly satisfied with telehealth. Feasibility was reported by seven studies and suggests that telehealth methods appear largely viable, though some challenges were reported.

CONCLUSIONS AND IMPLICATIONS

Although findings reviewed here are promising, more research is needed to verify the accuracy, validity, and feasibility of utilizing telehealth to diagnose ASD. Studies with larger sample sizes and samples across sites will be critical, as these will allow clinicians to identify subjects most likely to benefit from telehealth as well as those more likely to require an in-person assessment. This research is important not only due to the current pandemic, but also due to increased prevalence rates of ASD and an insufficient number of diagnostic providers-particularly in rural and/or otherwise under-served communities.

Case Report: ASI intervention on a child with autism in Saudi Arabia

Background: Ayres Sensory Integration (ASI) is widely employed by occupational therapists working with clients who experience challenges in sensory integration, including those with autism spectrum disorder (ASD). However, there is a dearth of research examining the feasibility of ASI outside of Western nations. This study documented the barriers associated with ASI in Saudi Arabia and assessed whether the intervention could improve process and participation skills. Methods: Single-Subject experimental design was used. The participant was a 4-year-old girl with ASD from Saudi Arabia. Data were gathered on sensory processing, motor skills, and participation in activities of daily living. The study used semi-structured interviews and assessments (Sensory Integration and Praxis Tests, the Sensory Processing Measure-Preschool, and the Peabody Developmental Motor Scale-2) to develop goals, identify outcome measures, and plan an ASI intervention. Results: Despite the limited availability of resources (e.g., toys, treatment spaces) and Arabic measures, improvements were observed on motor and sensory tasks and in occupational performance. Conclusion: ASI that adheres to the ASI fidelity tool can be of value for Saudi Arabian children with ASD. Additionally, the study provides a stepping-stone to further research for occupational therapists in Saudi Arabia working with children with ASD.

Case Report: ASI intervention on a child with autism in Saudi Arabia

Background: Ayres Sensory Integration (ASI) is widely employed by occupational therapists working with clients who experience challenges in sensory integration, including those with autism spectrum disorder (ASD). However, there is a dearth of research examining the feasibility of ASI outside of Western nations. This study documented the barriers associated with ASI in Saudi Arabia and assessed whether the intervention could improve process and participation skills. Methods: A pre-test/post-test case study design was used. The participant was a 4-year-old girl with ASD from Saudi Arabia. Data were gathered on sensory processing, motor skills, and participation in activities of daily living. The study used semi-structured interviews and assessments (Sensory Integration and Praxis Tests, the Sensory Processing Measure-Preschool, and the Peabody Developmental Motor Scale-2) to develop goals, identify outcome measures, and plan an ASI intervention. Results: Despite the limited availability of resources (e.g., toys, treatment spaces) and Arabic measures, improvements were observed on motor and sensory tasks and in occupational performance. Conclusion: ASI that adheres to the ASI fidelity tool can be of value for Saudi Arabian children with ASD. Additionally, the study provides a stepping-stone to further research for occupational therapists in Saudi Arabia working with children with ASD.

Culture-Specific Observations in a Saudi Arabian Digital Home Health Care Program: Focus Group Discussions With Patients and Their Caregivers

Background

There is growing evidence of the need to consider cultural factors in the design and implementation of digital health interventions. However, there is still inadequate knowledge pertaining to the aspects of the Saudi Arabian culture that need to be considered in the design and implementation of digital health programs, especially in the context of home health care services for patients who are chronically and terminally ill.

Objective

This study aims to explore the specific cultural factors related to patients and their caregivers from the perspective of physicians, nurses, and trainers that have influenced the pilot implementation of Remotely Accessible Healthcare At Home, a connected health program in the Home Health Care department at King Saud University Medical City, Riyadh, Saudi Arabia.

Methods

A qualitative study design was adopted to conduct a focus group discussion in July 2019 using a semistructured interview guide with 3 female and 4 male participants working as nurses, family physicians, and information technologists. Qualitative data obtained were analyzed using a thematic framework analysis.

Results

A total of 2 categories emerged from the focus group discussion that influenced the experiences of digital health program intervention: first, culture-related factors including language and communication, cultural views on using cameras during consultation, nonadherence to web-based consultations, and family role and commitment and second, caregiver characteristics in telemedicine that includes their skills and education and electronic literacy. Participants of this study revealed that indirect contact with patients and their family members may work as a barrier to proper communication through the Remotely Accessible Healthcare At Home program.

Conclusions

We recommend exploring the use of interpreters in digital health, creating awareness among the local population regarding privacy in digital health, and actively involving direct family members with the health care providers.

Families With Children With Neurodevelopmental Disorders During COVID-19: A Scoping Review

OBJECTIVE

Prolonged home isolation may lead to long-term negative consequences for both children and caregivers' psychological wellbeing, especially in families with children with neurodevelopmental disorders. Therefore, a scoping review was conducted to identify challenges faced by caregivers of children with neurodevelopmental disorders during the coronavirus disease 2019 (COVID-19) pandemic and to consolidate parenting interventions and guidelines.

METHODS

A systematic search was conducted on Embase, PsycInfo, PubMed, Scopus, and LitCovid. All article types published between December 2019 and November 2020 which reported on intervention guidelines and experiences of families with children with neurodevelopmental disorders during the COVID-19 pandemic were included. Qualitative themes, quantitative data, and article summaries were charted, and a thematic analysis was conducted.

RESULTS

Twenty-nine articles were included in the review. Three themes were generated: (a) behavioral issues and health concerns, (b) disruptions of lifelines and daily routines, and (c) existing programs, models, and guidelines to support families. Additionally, a list of caregiver strategies such as scheduling regular online consultations, maintaining online therapy, educating a child on COVID-19, and preventive behaviors, creating a structured daily schedule and reinforcement system, and selecting child-appropriate activities was consolidated.

CONCLUSION

This review revealed a lack of evidence-based studies and articles on children with other neurodevelopmental disorders apart from autism and attention-deficit hyperactivity disorder. It also places emphasis on the importance of telehealth services as major lifelines to parents during this pandemic and urges healthcare organizations to provide funding to increase telehealth services to afflicted families.

Resilience and social support as predictors of post-traumatic growth in mothers of children with autism spectrum disorder in Saudi Arabia

BACKGROUND

There are few studies about the role of resilience and social support in post-traumatic growth (PTG) in parents of children with autism spectrum disorder (ASD).

AIM

This study examined the relationship between social support, resilience, and PTG and the predictive role of resilience and social support related to PTG in Saudi Arabian mothers.

METHODS AND PROCEDURES

A survey-based quantitative study was conducted in 88 mothers aged 18-46 years (M = 33.5; SD = 8.02) who had a child with ASD. They were sampled from nine day care centers in Riyadh and the Central-Eastern-Southern region.

OUTCOMES AND RESULTS

The findings showed a significant positive correlation between perceived social support, resilience, and PTG, and revealed that Resilience-competence was the only significant predictor of PTG-personal strength, appreciation of life, spiritual change new possibilities, and total PTG, while positive acceptance of change was a significant predictor of PTG-relating to others. Moreover, social support from friends and significant others were significant predictors of PTG-total.

CONCLUSIONS AND IMPLICATIONS

We found that, for mothers of a child with ASD in Saudi Arabia, the biggest factors predicting post-traumatic growth were a notion of personal competence and social support from friends. Intervention is suggested to lower the risk of trauma.

A systematic review of cultural adaptations in the global application of ABA-based telehealth services

With telehealth gaining acceptance as a service delivery method, behavior analysts are now providing services to individuals worldwide. This review highlights the cultural adaptations used in ABA-based telehealth treatments for individuals with ASD outside of the United States. Nine studies met our inclusion criteria and the data were synthesized narratively. All studies reported some type of cultural adaptation, with most studies reporting changes made to the service delivery method. This included using translated materials; training in the language of the client; and matching the trainer in birthplace, ethnicity, or gender with the participants. The adaptations described in published research can serve as a resource for behavior analysts who have interest in global telehealth services. However, given the emerging nature of this area of research, it is challenging to know which adaptations are necessary to achieve optimal outcomes. The review concludes with ideas for research development in this area.

Use of telehealth for facilitating the diagnostic assessment of Autism Spectrum Disorder (ASD): A scoping review

There is a significant delay between seeking help and a confirmed diagnosis of Autism Spectrum Disorder (ASD). This delay can lead to poor outcomes for both the families and individuals. Telehealth potentially offers a way of improving the diagnostic pathway for ASD. We conducted a scoping review examining which telehealth approaches are used in the diagnosis and assessment of ASD in children and adults, whether they are feasible and acceptable, and how they compare with face-to-face diagnosis and assessment methods. A search for all peer-reviewed articles, combining the terms of autism and telehealth was conducted from 2000 to 2019. A total of 10 studies were identified for inclusion in the review. This review of the literature found there to be two methods of using telehealth: (a) Real-Time method e.g. video conferencing that enables teams in different areas to consult with the families and to assess the child/adult in real time and (b) A Store-and-Forward method as Naturalistic Observation Diagnostic Assessment (NODA) system to upload videos of child's behaviors to a webportal that enables the clinicians to make an assessment remotely. The findings were positive, finding there to be high agreement in terms of the diagnosis between remote methods and face to face methods and with high levels of satisfaction among the families and clinicians. This field is in the very early stages and so only studies with small sample size using surveys and interviews were identified but the findings suggest that there is potential for telehealth methods to improve access to assessment and diagnosis of ASD used in conjunction with existing methods, especially for those with clear autism traits and adults with ASD. Larger randomised controlled trials of this technology are warranted.