Leveraging Technology for the Wellbeing of Individuals With Autism Spectrum Disorder and Their Families During Covid-19

Introduction The current coronavirus 2019 (COVID-19) pandemic not only poses a large threat to the physical health of our population, if we fail to act now, it will also have detrimental long-term consequences for mental health. Though social distancing is a crucial intervention to slow down the destructive effects of the pandemic, it can lead to isolation, decreased physical activity, and increased rumination, which might particularly hurt those with pre-existing mental illness. Further, the stream of disheartening COVID-19 news provides fodder for increased worry and distress, which can be detrimental for people with anxiety disorders. Early cross-sectional surveys in the United States, Canada, and Europe show an increase in symptoms of depression and anxiety for the general population, associated with COVID-19 concerns (1). Thus, this crisis is exacerbating existing mental health conditions and creating conditions for the development of new ones. Further, if lessons from other outbreaks such as Ebola (2) and SARS (Severe Acute Respiratory Syndrome) (3) are any indication, even after an outbreak is controlled, there will likely be a substantial increase in need for psychological support. Crucially, this public health crisis will magnify and deepen existing shortcomings of mental health care systems. The US was already facing a mental health crisis before the pandemic: less than half of those with mental illness receive the care that they need (4). Underserved populations, such as low-income or ethnic minority populations, are disproportionately affected; they show the lowest utilization of mental health services (5). Early data suggest that underserved populations pay a larger health toll from COVID-19: they show higher mortality rates (6, 7). They are more likely to work in essential jobs putting them at greater risk of contracting COVID-19, and suffer greater economic consequences. All these factors lead to increased stress and anxiety. We will therefore be faced with an even greater relative shortage of trained professionals and means to mental health care during and after this pandemic. We argue that what we need during a public health crisis like this is a digital mental health revolution: scaling up the delivery of confidential mental health services to patients across a wide range of platforms, from telemental health to mobile interventions such as apps and text messaging. Here, we provide an overview of technological tools which could help to decrease the mental health burden of COVID-19, provide recommendations on how they could be used and scaled-up, and discuss considerations and limitations of mental health technology applications. Telehealth There is a crucial role for the use of teleconferencing software for therapy sessions during the COVID-19 pandemic. Most studies of teleconferencing services showed that effectiveness is comparable to in-person services across disorders including depression, posttraumatic stress disorder, and anxiety disorders (8). China has had some success with this approach. Researchers recently wrote in a Lancet Commentary that during the worst of the outbreak in January, China successfully provided online psychological counseling and self-help was widely rolled out by mental health professionals in medical institutions, universities, and academic societies (9). In the US, the pandemic has also catalyzed a rapid adoption of telehealth (10). Medicare now allows for billing for telehealth. Further, the Health Insurance Portability and Accountability Act (HIPAA) has been revisited to permit more medical providers to use HIPAA compliant platforms to communicate with patients. This removes a major barrier to wider adoption of telemedicine and could also provide an outstanding opportunity for patients who previously did not feel comfortable seeking mental health care to now approach these services. However, it is important to attend to disparities in technology access and digital literacy. Before the pandemic, only one in ten patients in the US used telehealth, and 75% said that they were unaware of telehealth options or how to access it (11). Recent data from primary care clinics showed that, though video care consults went up by 80% in late March and early April, minority groups represented a smaller portions of these visits (12). This is partly explained because of a lack of Internet availability, which varies due to limited data plans and lack of Wi-Fi, and inability to use smartphone features such as downloading apps (13). At the moment, some US telecom providers are offering free Internet services (14). However, longer-term strategies need to be developed to prevent further widening of the digital divide (15), including providing affordable, high speed Internet access, improving usability of telehealth programs, and providing appropriate guidance/training for patients using these services. Mental Health Smartphone Applications Importantly, the use of personal mobile phones presents an opportunity for broad scaling of interventions. Over 90% of Americans have some type of mobile phone and over 80% have smartphones (16). Even among low-income Americans (71%) and older adults (53%) smartphone ownership is high. Mental health apps have shown effectiveness in decreasing symptoms of depression (17) and anxiety (18). Because of COVID-19, multiple meditation and wellness apps designed by the private sector have now temporarily opened up free memberships to aid in easing anxiety, the majority of these being mindfulness apps (19). However, there are over 10,000 consumer-available mental health apps in app stores and many of these are not evidence-based (20). Further, though many people download mental health apps, research shows low rates of continued use over longer periods of time (21). It is crucial that mental health providers recommend apps that are backed up by evidence. One helpful resource is Psyberguide (www.psyberguide.org), a non-profit that rates apps based on the strength of the scientific research that supports it, ease of use, and its privacy policies (22). Lastly, in order to improve engagement, providers should follow up with patients on their usage of these apps and integrate the app content into their treatment. Texting Applications In addition to apps, text-messaging platforms could be leveraged to help people cope with mental health challenges evoked by COVID-19. Because texts are also delivered via individuals' devices, they are easy to provide to many at once using automated text-messaging platforms. Text-messaging interventions have demonstrated effectiveness in behavioral health promotion and disease management (23). Importantly, text-messaging is an appropriate tool for low digital literacy populations and underserved groups (24). For instance, our own HIPAA approved texting platform, HealthySMS, was developed with and for low-income populations (mostly Spanish speakers) and shows high acceptability in underserved populations (25). We recently rolled-out a text-messaging study to provide wide-scale support to interested individuals in the US via daily automated text-messages, containing tips on coping with social distancing and COVID-19 anxiety. For crisis situations, Crisis Text Line provides free confidential help via text-message. This platform has seen the mention of “coronavirus” in 24% of conversations from March 30th to April 6th (26). Furthermore, Caremessage, a non-profit organization, has temporarily provided free access to their messaging platform and COVID-19 template text-messaging library with health information (27). In addition, reliable information can also be delivered by health and government organizations automated via text messages. Scaling of information delivery to patients and the public could also relieve health professionals and public health departments, who are already understaffed, underfunded, and overburdened (14). Social Media Social media plays a complicated role in the management of mental health. On the one hand, it can provide positive and supportive connections during a time of physical isolation. Earlier work shows that many people with mental illness are increasingly turning to social media to share their experiences and seek mental health information and advice (28). On the other hand, it can also serve to increase depression and anxiety symptoms based on negative social comparisons and the spread of distressing information (29). For instance, in a recent cross-sectional survey of almost 5,000 participants in China, increased social media exposure on COVID-19 was associated with increases in anxiety and depression symptoms (30). Social media has played a large role in the spread of information since the start of the COVID-19 outbreaks, including misinformation and “fake news”. Large social media platforms are now reportedly taking steps to remove false content or conspiracy theories about the pandemic, using artificial intelligence (AI); and distribute reliable information, such as developed by the World Health Organization (31). In China, the government provided online mental health education through popular social media platforms, such as WeChat, Weibo, and TikTok during the height of the outbreak in January (9). In the UK, the National Health Service (NHS) is working with Google, Twitter, Instagram, and Facebook to provide the public with accurate information about COVID-19 (32). Social media also provides a unique opportunity for health professionals to distribute accurate information to their patients and the public, or to highlight available mental health resources. In Wuhan China, mental health professionals uploaded videos of mental health education for the general public through WeChat and other Internet platforms at the early stage of the outbreak (9). In the US and Europe, many physicians have turned to Twitter to share medical information. The social media site has now implemented a mechanism to verify physicians and other scientific experts in an effort to counteract coronavirus misinformation (33). However, because of the overload of information on social media, misinformation might still spread too fast to be intercepted by AI algorithms (34, 35). A recent report of responses from more than 8,000 people from six countries showed that one third reported seeing a significant amount of false or misleading COVID-19 information on social media or messaging platforms (36). Further, posting information on social media raises the question of how health professionals should respond to the information posted by patients, and how that can impact the therapeutic relationship. Currently, there are no clear guidelines for health professionals, to determine how to act on social media. This calls for a push in quickly establishing such a consensus (37). Discussion The COVID-19 crisis has fast-forwarded the use of technology in mental health care. Technology is crucial in scaling up access to mental health services during and after COVID-19. Given that people interact differently with technology, people of various ages, technical abilities, languages, and levels of literacy will need distinct types of interventions (38). Older people are particularly vulnerable during this pandemic and already suffer from high rates of loneliness (39). This is strongly associated with greater symptoms of depression and anxiety (40), and physical morbidities and mortality (41). Previous work shows that older adults are interested in using technology to support their mental health, and that mobile health technology is feasible and reliable for assessing cognitive and mental illness (42). However, older adults and those with low digital literacy might lack prior knowledge of digital technology to fully benefit from these tools (43). Digital health tools suffer from usability issues: they do not always consider digital literacy, health literacy, age, or English proficiency in their design (44). For instance, previous work showed that even the most basic functions of apps are difficult to use for diverse populations (45). Top-funded digital health companies test only 30% of their apps in people with clinical conditions (46). These factors are important because individuals with lower health literacy have worse health outcomes over time due to difficulty making informed health choices (47). Therefore, interventions should be specifically targeted toward vulnerable groups, and adapted to their specific needs. This includes design choices such as easy to navigate user interfaces and tailoring vocabulary to older adults or those with low English proficiency (48). Training for individuals with low-tech skills, through outreach programs by healthcare staff may help patients to understand and use digital tools (49). Health systems should prioritize implementation of this crucial service (12). Further, the right infrastructure needs to be set up to provide digital interventions securely, without personal privacy violations and minimizing the risk of data breaches. Apps and text-messaging must not only be effective, but also safe, secure, and responsible, similar to how therapists are held to standards of responsible practice and confidentiality (42). Therefore, it is imperative that cybersecurity specialists also become involved in ensuring safe technological services (50). Finally, just as they have now shown flexibility with telehealth, insurance companies and health systems should begin covering digital and mobile health interventions. Conclusion We are now in the midst of an acute health crisis which calls for a grand upscaling of mental health resources. Technology provides a medium for delivering mental health services remotely and on a wide scale, which is particularly important during social distancing measures. Even when the worst of the COVID-19 pandemic has subsided, it is likely that a large need for mental health support and services delivered through technology will remain. Digital mental health tools should be affordable, accessible, and appropriate for a wide group of individuals with varying ages, languages, and digital literacy. The time to massively invest in high quality and accessible online and mobile mental health in the face of the COVID-19 pandemic, and possible future pandemics, is now. Author Contributions CF wrote the first draft of the article. AA contributed to the writing and editing of the manuscript. Both authors contributed to the editing of the final manuscript. Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

During disasters and pandemics, vulnerable populations such as patients with mental conditions are known to be overly influenced. Yet, not much is known about how the individuals with autism spectrum disorder (ASD), one of the most common neurodevelopmental conditions globally with a prevalence of 1%, are affected from health-related disasters, especially the current Covid-19 pandemic. Therefore, we conducted an investigation of how individuals with ASD responded to Covid-19 in terms of comprehension and adherence to implemented measures; changes in their behavioral problems; and how their caregivers' anxiety levels relate with these behavioral changes. Our sample consisted of 87 individuals with ASD (15 girls; ages ranged from 3–29, with an average of 13.96 ± 6.1). The majority of our sample had problems understanding what Covid-19 is and the measures it requires. They also had challenges in implementing social distance and hygiene-related regulations of the pandemic. The majority stopped receiving special education during this period. We observed a Covid-19-related clinical presentation that resembled PTSD in individuals with ASD in terms of increased stereotypies, aggression, hypersensitivity, behavioral problems, and sleep and appetite alterations. All subscales of Aberrant Behavior Checklist (ABC) differed significantly between before and after the pandemic conditions. The number of hours the children slept significantly decreased from before to during Covid-19. The anxiety levels of caregivers were high and correlated with the current behavioral problem levels of their children, but not with the level of their behavioral problems before the pandemic. The difference in ABC total score and specifically the lethargy/social withdrawal subscale score predicted parents' anxiety score. Our results suggest that the Covid-19 period inflicts specific challenges to individuals with ASD and their caregivers, underlining the need for targeted, distance special education interventions and other support services for this population.

Introduction and problem statement On March 11, 2020, the World Health Organization declared Coronavirus Disease 2019 (COVID-19) as a pandemic [1]. The rapidly spreading and deadly virus has infected over 100 nations, including the USA, where it has been declared a public health emergency [2]. As part of their mitigation strategies, the Centers for Disease Control and Prevention recommend limiting community movement and practicing social distancing [3], and the Federal Government recommends avoiding gathering of groups of more than 10 people [4]. Coping with the illness of self, family, or loved ones while managing hospital- or home-based isolation may be stress-provoking, and with the crisis projected to last weeks to months, it is expected that mental health conditions will only worsen over time. Infected people experience elevated stress levels due to fear, uncertainty, financial stress, and limited in-person interactions [5, 6]. As a result, and paired with confinement in limited spaces, generally, in single-patient rooms with restricted movement and contact precautions from the health personnel [5], people are more likely to experience anger, confusion, hopelessness as well as present symptoms of anxiety, depression, and post-traumatic stress disorder [7, 8]. Similarly, asymptomatic people with potential exposure, generally in self-imposed home quarantine, may also report distress, frustration and fear as a result of long quarantine duration, risk perception, and inadequate information [7, 8]. Moreover, people with pre-existing mental health conditions are disproportionately affected since they are more susceptible to stress than the general population [9]. Not only is the treatment of people with mental health comorbidities more challenging and possibly less effective [9], but also those who need ongoing evaluations and treatment might not be able to access mental health services for logistic reasons such as travel restrictions and risk of infection [5]. Disruption in care is concerning as it increases the risk of symptom exacerbation and relapse. Despite the aforementioned adverse repercussions, contact precautions and public health recommendations have to be implemented. Accordingly, alternative methods to deliver mental health care are necessary to bridge the significant health gap, and Telemental Health has a unique potential in addressing the psychological side effects of social distancing. Telemental health utility in the COVID-19 pandemic Telemental Health refers to the use of information and communications technologies, including videoconferencing, to deliver mental health care remotely, including evaluations, medication management, and psychotherapy [10]. Telemental Health has been successfully implemented with multiple populations, across a wide range of mental health conditions, and multiple clinical settings [11, 12]. Among its many proven advantages, its most pertinent utility to the current situation is to expand access to care for hard-to-reach and underserved populations with restricted mobility due to mental, medical, or geographical challenges. Telemental Health reduces or eliminates the need for travel for both patients and clinicians and delivers remote services cost-effectively while maintaining the quality of care [13]. As a result, in times of public health crises and national and international emergencies, the value of Telemental Health cannot be overstated. The COVID-19 is highly contagious and may be deadly for at-risk and elderly individuals [3]. However, these risks should not prohibit individuals from receiving mental health care. Therefore, Telemental Health may be an ideal solution to reduce the risk of clinicians or patients being infected while still providing care, especially in settings with shortages of mental health professionals. The value proposition of Telemental Health is that it can effectively respond to the mental health needs of people in isolation, quarantine, or restricted mobility while reducing patient and clinician infection risk. Thus, Telemental Health adheres to social distancing, avoids care interruptions, and maximizes public health outcomes. Current actions and future recommendations Significant steps have been taken at multiple levels. On the reimbursement front, under the Section 1135 waiver, the Centers for Medicare and Medicaid Services (CMS) waived restrictions on originating sites for telehealth, including Telemental Health, during the crisis [14]. Prior to the implementation of this waiver, Medicare reimbursement had significant geographic and originating site restrictions for telehealth services [15]. This waiver means that reimbursement would occur regardless of whether the patient is seen while at home or a healthcare facility. At the regulatory level, the ability of healthcare professionals to prescribe remotely has been expanded to cover controlled substances [15]. The Ryan Haight Online Pharmacy Consumer Protection Act restricts the prescribing of controlled substances via telehealth, with certain exceptions [16]. The Drug Enforcement Administration (DEA) leveraged the public health emergency exception to the Ryan Haight Act, thus lifting the restriction on prescribing controlled substances through telehealth [17]. The exception remains applicable as long as the public health emergency, declared by the Secretary of the Department of Health and Human Services, is in effect [17]. These steps will enhance the healthcare system’s ability to continue to provide Telemental Health services during this public health emergency. Further action by policymakers and public health decision-makers is needed to build on these initiatives and supports the provision of Telemental Health services, throughout this crisis and beyond. We urge related personnel to consider the following recommendations: From a public health perspective, it is important to prioritize the allocation of public and private funding and resources to expand the implementation of Telemental Health and its integration across multiple clinical settings, including primary care. Funneling funding in this direction may contribute to enhanced preparedness and management of current and future similar public health crises. The funding should also be complemented by training clinicians and familiarizing patients with the use of Telemental Health to overcome travel restrictions, to maintain access to treatment when mobility is compromised. Additionally, it may be essential to facilitate setting the infrastructural landscape for Telemental Health in terms of hardware and software in preparation, which includes enhancing connectivity and expanding access to broadband high-speed Internet across the country. From a reimbursement perspective, the lifting of CMS reimbursement restrictions, including those based on originating site and geographical locations of patients, should be made permanent. Expanding access to mental health services across the country contributes to supporting the continuity of care, particularly since the repercussions of this public health crisis are likely to be long term. Furthermore, efforts should be made to urge private payers and managed care organizations to expand Telemental Health coverage, with the goal of achieving full parity for mental health services regardless of whether delivered in person or remotely. From a regulatory perspective, the temporary lifting of the Ryan Haight Online Pharmacy Consumer Protection Act restriction on prescribing controlled substances via Telemental Health should be made permanent in order to ensure expanded access to care continues after the public health crisis is declared to be over. Lobbying for policy reforms by professional societies, such as the American Telemedicine Association and American Psychiatric Association, is needed to achieve this goal, particularly that the Act was passed in 2008 [18], and the landscape of Telemental Health has rapidly evolved since. Given that state licensure has been a documented barrier to the expansion of Telemental Health [13], it is crucial to temporarily suspend restrictions on licensure requirements to practice Telemental Health across state lines, to regions of the country that are most impacted by the pandemic [19]. In the long term, it is important to expand processes that facilitate interstate licensure for better preparedness for future crises. Finally, in the context of a public health crisis of this magnitude, and with the rapidly changing landscape of regulations and reimbursement for Telemental Health, consistent access to reliable information and updates on regulatory and reimbursement changes is crucial. While we urge healthcare professionals to remain vigilant and up to date, we also urge CMS, DEA, and other health authorities to continue to provide regular and clear guidance to healthcare professionals as we work diligently to overcome the COVID-19 public health crisis. The rapid spread and high economic cost of COVID-19 have exposed the shortcomings of the healthcare system writ large and have highlighted the urgency of rethinking how services are delivered in the USA. Social distancing measures paired with the realization of politicians, policymakers, and citizens of the importance of telehealth in the context of the pandemic are likely to lead to a significant shift in attitudes and behavior and result in a larger-scale adoption of telehealth in the long term. While we welcome the temporary changes made to improve access to care and address the psychological side effects of quarantine and isolation, we believe that some of these changes should be made permanent. Moving forward, the integration of telehealth, particularly telemental health, should not be seen as a temporary fix in times of emergency; rather, it is a safe, effective, convenient, scalable, and sustainable method of healthcare delivery that is as crucial as it is inevitable.