Preventing Toxic Childhood Stress in the COVID Era: A Role for Telemedicine

The SARS-CoV-2 pandemic has sent unprecedented shockwaves of stress through American society. Severe stress in the absence of protective relationships quickly becomes toxic, impairing both physical and mental health. Toxic stress is especially harmful for children, whose developing bodies and brains are highly susceptible to its negative effects. Curve-flattening measures, including widespread closures and social distancing, have disrupted the relational networks of millions of U.S. children. Such disruption, in conjunction with the severe economic stress caused by the pandemic, represents a social crisis in the making. ¹

Telemedicine may play a crucial role in collective efforts to prevent and mitigate toxic childhood stress in the COVID-19 era. By leveraging technology to deliver patient care remotely, telemedicine enables interpersonal connectivity while maintaining social distancing. Through telemedicine, patients can maintain continuity with, and relational support from, their health care provider. If toxic stress is characterized by an absence of protective relationships, telemedicine may represent a potential solution. Trusted health care providers can, through virtual visits and other telehealth tools, provide emotional support and psychosocial buffering for families under stress.

The depth and severity of stressors facing American children and families are daunting. In April 2020 alone, national unemployment spiked 10%—the largest over-the-month increase in the history of the series since the Bureau of Labor Statistics began measuring in 1948. ² An estimated one-third of renters have been unable to pay rent on time. ³ Public schools, which provide up to two-thirds of daily nutritional needs for low-income children, ⁴ remain closed. The combination of prolonged household confinement, often in small spaces, and mounting financial worry has sparked a spiraling crisis of domestic violence. ⁵

With such dire circumstances, how can telemedicine help? First, through the provision of frequent interpersonal touchpoints. One of telemedicine's key strengths lies in the reduction of opportunity costs associated with accessing care. By avoiding the financial and time costs of travel, waiting, and missed work or (online) school, virtual visits greatly lower the bar to entry. Providers can leverage lower opportunity costs to do more frequent virtual check-ins. More face-to-face time helps build trust and creates opportunities for providers to affirm families' strengths and resiliencies. Providers can also reinforce stress-busting strategies, such as the six recommended by California Surgeon General Nadine Burke-Harris: balanced nutrition, physical activity, quality sleep, mindfulness practices, supportive relationships, and mental health care. ⁶

Second, in the wake of widespread parental fears about exposing children to COVID-19, telemedicine (again, leveraging technology to deliver care remotely) can help make families feel safe. Visit volume in many pediatric offices is down by >50%, ⁷ whereas vaccine orders have fallen by 2.5 million since March 2020. ⁸ The American Academy of Pediatrics has urged the continued provision of routine immunizations for children. ⁹ In response, some practices have begun offering curbside and drive-through immunization clinics. ¹⁰ Utilizing telemedicine for interpersonal connection and relationship building alongside socially distanced medical procedures such as immunizations and biometrics could hit the sweet spot between putting patients at ease and bringing them up to date with care.

Third, telemedicine can spur innovations for enhanced universal education, asynchronous communication, and team-based care. In contrast with in-person visits, where those present are seen and accounted for, situational awareness during virtual visits is more limited. For example, a violent partner could be present during a virtual visit but out of audio or video range. Traditional social screening questions such as “do you feel safe at home?” may not only have lower utility in a virtual visit, they could risk exacerbating household tensions.

In light of this, strategies oriented around universal education have been recommended by domestic violence experts during COVID-19. ¹¹ Beyond virtual visits, advances in telemedicine could empower patients through easily (and confidentially) accessible information and resources. Other helpful tools could include confidential two-way messaging platforms and clinical message pools for providers to streamline referrals. Provider education models, such as Safe Environment for Every Kid, which incorporate social work collaboration, have been shown to effectively prevent child maltreatment. ¹² Trauma-informed screening tools, such as the Pediatric Adverse Childhood Experiences and Related Life-event Screener, have demonstrated strong face validity in pediatric primary care. ¹³ Adapting such approaches for the telemedicine space could be highly promising.

Although uptake of telemedicine during COVID-19 has been meteoric, there are several limitations and caveats to consider. First, probably most important, is payment parity for telemedicine and in-person care. Since March 6, 2020, providers can bill for telemedicine visits at the same rate as in-person visits. ¹⁴ Although telemedicine existed far before the current pandemic, adoption was stymied by poor reimbursement. Similar to cannabis legislation, there remains inconsistency and confusion between federal and state policies on telemedicine. There also remains uncertainty as to whether payment parity will continue. To remain viable, long-term parity or near parity for telemedicine will be necessary.

Second, there are widespread disparities in telemedicine access and uptake. Many states have expanded or are expanding billable telemedicine visits to include phone care (i.e., audio without video). These provisions may be vital for revenue-strapped practices facing empty waiting rooms and flooded phone lines. Billable telemedicine by phone may also be important for addressing disparities in broadband access for the estimated 10% of Americans without reliable internet, and for those lacking devices or tech literacy. ¹⁵ Other considerations include the need for culturally and linguistically appropriate “web-side manner.” There may also be apprehension by patients about engaging with telemedicine and fears that “my provider doesn't want to see me in person.” Effective telemedicine infrastructure development and culturally sensitive marketing initiatives will be essential for bridging these gaps.

Third, and most challenging, is the issue of ensuring access to resources for families experiencing toxic stress or unmet needs such as food or housing. Charitable and safety-net resources such as food banks are now being stretched beyond capacity in the face of surging demand. ¹⁶ Is it ethical to screen for toxic stressors through telemedicine if real-time assistance is scarce or unavailable? What if there are safety concerns, for example, a bruise seen on a 4-month old infant? Solving these critically important problems will require robust evidence, clear guidelines, and professional humility.

Preventing toxic childhood stress in the COVID-19 era may be difficult. The societal challenges on the horizon seem at times massive and overwhelming. Yet telemedicine may have a central role to play, by enabling patients and providers to connect, relate, and engage, and by creating opportunities to share and convey compassion and empathy. Telemedicine may serve as a central conduit for fostering protective relationships, buffering toxic stressors, and promoting safety and healing. In the face of so much stress and uncertainty, simply being there virtually may be good medicine.