Tele-rehabilitation Program: An Innovative and Sustainable Early Intervention Service for Children With Autism Spectrum Disorders

In Singapore, Autism Spectrum Disorders (ASD) is ranked number one in disease burden for children 0-14 years of age. The Child Development Unit at the National University Hospital serves 3000 children annually, of which 25-30% of children have been diagnosed with ASD. Therapist roles are to provide interim therapy for these children before entry into community-based Early Intervention Centres (EIPIC), which currently have waiting times of 6-9 months. Current limitations with our interim care includes long wait times, high cost for families, lack of manpower and space to serve the patients, poor parental involvement due to their work commitments, parental difficulties attending frequent, needed, in-hospital therapy and difficulty generalizing patient treatment to the home/community setting (decreasing effectiveness). Currently, clinic-based environment does not include natural environments for learning development and hence spontaneous generalization is a challenge and impacts child outcomes. Standard interventions do not allow therapists to observe or facilitate a child's behaviour and skills during natural routines. Previous work on telerehab show that it ensures the best outcome for the child. It provides the best modality for therapists to observe the child during these routines in home environments and provide meaningful and relevant strategies in real time. Despite standard therapy, expected significant outcomes of parent training have not been achieved. The key factor has been the need to provide parents with more instruction and practice with the content inside real-life moments and interactions with children. Telerehab facilitates the provision of more sustained opportunities for parent coaching within the home setting (natural environment). A clinic based model of intervention requires transition of children into new environments. The intolerance of children with Autism to changes in their routine/environment is well known; typically presented with acute symptoms of agitation or anxiety. They are frequently distressed in clinical environments, making it difficult for the parent and professionals to continue with the early intervention program. Telerehab provides early intervention in safe and secure natural home contexts of the child thus averting the challenges of transition. Early intervention services provided in the clinical setting are often provided with only one caregiver present. Logistics and travel costs prevent participation of multiple caregivers in early intervention coaching programs. Telerehab makes it feasible for multiple caregivers to participate in early intervention and build their capacities through teleconferencing support from professionals. Previous models of home-based interventions have found to incur high costs for the provider with limited reach. Home visits by professionals incur expense in the form of travel time, travel costs and hence the number of families covered through this is limited. Telerehab maximizes impact of home based interventions without high costs and with wider reach. The cost of early intervention(EI) through Telerehab will be similar to the current costs of clinic-based interventions paid by families. Cost incurred is essentially technology investment and professional manpower investment. Current duration of EI is 16 hours, which is sustainable up to 20 weeks for each family based on current CDU caseloads of 150 new referrals per year. Telerehab proposes to sustain the core intervention across 47 weeks for a duration of 16 hours leading to better sustainability, which also contributes to gains in productivity. This demonstrates the scalability of the Telerehab program.

The current standard program for early intervention treatment is in-clinic therapy based on the Foundational Skills Curriculum (FSC): a framework for early intervention developed from outcomes of an Autism research project conducted in the UK. This framework provides a clear and systematic approach to understanding the child's functioning in 3 core areas of development (across 141 items): Play, Social Interaction, and Communication.

The telerehab program will provide parent coaching on EI through video conferencing using the FSC. The telerehab program aims to improve access to services and facilitate intervention in the natural environment of children and their families by developing video conferencing (VC) as a feasible and acceptable medium to build parent capabilities in EI. The specific service model objectives are to realize positive gains in service efficiency (i.e. reducing the total time and resource utilization per completed intervention course relative to current practice); reduce total costs and non-financial barriers for patients (i.e. access) as well as the total cost to the health system per completed course (i.e. sustainability) and realize positive gains in provider productivity and hence cost-effectiveness (i.e. reduced cost per unit outcome achieved).

Implementation Strategies and Patient Flow CDU receives referrals from polyclinics for children at risk of ASD. These referrals will be scheduled for a developmental assessment by the developmental paediatrician. Baseline assessments will be conducted under the program as well as under standard care. Children who are enrolled into the evaluation study will then continue with either the standard program (clinic-based therapy) or the telerehab program. The program schedule for the patient in terms of type of visits and intervention blocks for both the standard program and telerehab is shown in Annex 1: Program Schedule. The duration of clinic-based intervention sessions will be 60 min while the duration of VC based intervention sessions will be 45 min.

Baseline Assessments Visit 0/1: Child found to be at risk for ASD on clinical evaluation by the developmental paediatrician based on the DSM-5 criteria will be referred for this study. The informed consent will be obtained prior to undergoing any research-related activities.