Pediatric neuropsychological evaluation via telehealth: Novel models of care

Abstract

Objective:

As the coronavirus pandemic extends across the globe, the impacts have been felt across domains of industry. Neuropsychology services are no exception. Methods for neuropsychological assessments, which typically require an in-person visit, must be modified in order to adhere to social distancing and isolation standards enacted in an effort to slow the pandemic. How can providers continue to meet the needs of patients referred for neuropsychology evaluations, while respecting federal and state guidelines for safety and ethical mandates? We offer a novel, tiered model of care, successfully implemented in response to mandated social distancing, in a large, pediatric neuropsychology program.

Method:

We describe the considerations and challenges to be addressed in transitioning a large neuropsychology department to a new model of care, including triaging referrals, developing –or rediscovering — types of services to meet the needs of a virtual patient population, and helping patients, parents, and providers to adjust to these new models.

Conclusions:

Lessons learned as a function of rapid changes in care models have implications for the field of neuropsychology as a whole as well as for future flexibility in meeting the needs of pediatric patients and their families.

The current international medical crisis launched by COVID-19 has compelled a substantial transition in healthcare services and the ways in which providers interact with patients. To this point, the vast majority of pediatric psychological and neuropsychological assessment has been conducted via face-to-face interactions; however, this is not currently feasible as a result of the necessity for social distancing. Indeed, it is unclear how long the current uncertainty will persist and, even when restrictions are loosened, how long it may take for face-to-face assessment visits to fully resume. Thus, the field of pediatric neuropsychological assessment must flexibly adapt in order to be able to offer services that are effective and useful within the telehealth framework. Transitioning to telehealth service delivery has substantial implications for the types of services provided, and challenges our traditional, comprehensive assessment practices. This shift requires that pediatric neuropsychological assessment services consider new (or revisit old) models of care in order to be nimble enough to survive in this new environment. Here we describe how this conversion was accomplished, and the new models of care implemented as part of transitioning a large pediatric outpatient neuro/psychological assessment clinic to telehealth services.

Psychological and neuropsychological assessment of children has largely adhered to a traditional model of comprehensive evaluation for all patients (Baron, 2004; Barr, 2008; Bernstein & Waber, 1990; Mahone & Slomine, 2008). Indeed, it has been argued that a part of the value of pediatric neuropsychological assessment lies in the extent to which such assessment addresses each domain of neurobehavioral functioning, allowing for thorough consideration of comorbidities that might otherwise be overlooked (Pritchard et al., 2011). Training in pediatric assessment tends to emphasize thoroughness rather than efficiency (Baron, 2004; Barr, 2008; Bernstein & Waber, 1990; Mahone & Slomine, 2008), contributing to a mindset common among clinicians, patients/families, and educators that anything less than a full day assessment is an incomplete one, and is thus of lesser value. However, this mindset may be responsible for, at least in some cases, inefficient assessment practices that are unnecessarily burdensome for clinicians, patients and families, and even payors.

A 3-tiered telehealth service model

In transitioning traditional, face-to-face, outpatient pediatric neuropsychological assessment services to telehealth, we implemented a 3-tiered model of care that seems to best serve patients and clinicians alike. Naturally, pre-established models of tele-neuropsychology set the foundation for this model of care (Brearly et al., 2017; Cullum et al., 2014; Grosch et al., 2011). However, due to pandemic-related social distancing restrictions, unique circumstances related to setting (providers and patients completing telehealth visits from home) and available resources (lack of onsite technicians or facilitators) were influential considerations in developing our novel model. Our clinic’s assessment services are provided in the context of a large pediatric outpatient program (over 2000 unique patients evaluated per year) that is part of a specialized pediatric hospital.

Implementation of the model outlined below will necessarily be practice-specific, but the core principles may share some features across neuropsychology practices. Characteristics of our outpatient pediatric neuro/psychology program that may be relevant to our implementation of telehealth include: large size (29 licensed psychologists and neuropsychologists), high patient volume (over 2000 patients seen for evaluation each year, and a substantial waitlist), diverse patient population (primarily neurodevelopmental disabilities, approximately 40–50% with medical conditions), and medical setting (outpatient program located within a hospital dedicated to care of children with neurodevelopmental disabilities in a large metropolitan area). A unique feature of the program that supports the three-tiered model described is the combination of psychological and neuropsychological assessment services offered to youth and young adults referred for mental health and/or medical disorders.

Another critical aspect of the setting, which has important implications for the model, is the COVID-19 emergency in which this model was developed. This aspect of the setting may have substantial implications for interpretation of the results of telehealth assessments provided in this context, and our documentation of assessment validity must reflect the unique challenges inherent in providing services via telehealth at this time.

The old model

Our neuropsychology program, comprised of eight specialty clinics, has traditionally evaluated the majority of patients using a single day, comprehensive model. In this model, a child is evaluated by the clinician (and in some cases, by a psychology associate or trainee) over the course of a single day, with the evaluation process including clinical diagnostic interview or neurobehavioral status examination; performance-based testing; rating scales completed by patients, families, and/or teachers; review of available records; and feedback provided to the family. Completing such comprehensive evaluations efficiently, in a single day to minimize family travel and work/school disruption, relies heavily on obtaining a substantial amount of information from families (and sometimes teachers) before the visit via an online history and symptom rating questionnaire. This pre-visit information provided by the family is used both to triage patients to the appropriate specialty clinic and to facilitate clinical case conceptualization.

The new model

Telehealth services are now offered via a three-tiered model, based upon a variety of considerations specified below.

Tier 1: Comprehensive interview and review of records

Tier 1 services are comprised of a comprehensive diagnostic interview (most often involving the family as well as the pediatric patient) and/or neurobehavioral status examination, in addition to review of any available medical or school records, as well as parent and teacher ratings provided via online questionnaires before the visit. Tier 1 services may be a good fit for:

Patients with less complex presentations

• Example: A patient referred by the pediatrician for a second opinion/clarification regarding an ADHD diagnosis prior to initiating medication, and for whom few concerns with primary academic skills, social-emotional functioning, or overt behavioral functioning are reported by parents or teachers (e.g., via pre-visit questionnaires).

Patients with more complex presentations but for whom some components have already been diagnosed and are being addressed

• Example: A patient who has a history of mild traumatic brain injury and who has been diagnosed with ADHD and dyslexia, and is receiving intervention for both, but continues to struggle academically and emotionally and is referred to rule out comorbid anxiety or mood symptoms.

Patients for whom many records are available for review (especially recent psychoeducational testing)

• Example: A patient who received cognitive (IQ) and academic achievement testing through their school district within the past year and receives support services via an Individualized Educational Program (IEP), but for whom the parents or pediatrician are requesting diagnostic clarification around ADHD vs. learning disabilities and recommendations for additional supports and/or treatment. In this case, the neuropsychologist may be ideally suited to review findings of existing evaluations with the parents/patient, clarify or reinterpret results, and make referrals for interventions–without requiring further testing.

Patients who present with psychiatric concerns that may be well-suited to a structured or semi-structured psychiatric diagnostic interview

• Example: A patient for whom parents and treatment providers are requesting diagnostic clarification around anxiety, depression, and/or bipolar disorder.

Tier 1 services can allow the clinician to answer some specific diagnostic questions, provide psychoeducation around a patient’s presenting concerns, and make recommendations for supports and interventions. Specifically, in the case of the COVID-19 emergency and associated school closures, these might include interim supports around learning and behavior in the context of home and distance education, as well as long-term supports for when normal life resumes.

Tier 2: Comprehensive interview, review of records, and targeted tele-testing

For patients whose needs cannot be fully met by Tier 1 services alone and who require some additional testing that can be accomplished remotely, Tier 2 services are offered. Tier 2 services include a comprehensive clinical interview and/or neurobehavioral status exam and review of records, as in Tier 1, but also include targeted testing via videoconferencing. Critical considerations related to the reliability and validity of tele-testing, including test security concerns and management of internet-specific challenges, as well as specific ethical and safety considerations, are addressed in detail in Hewitt, Rodgin et al. (2020). Tele-testing may include mailed or electronic administrations of parent, self-report, and/or teacher rating scales through an online evaluation program (e.g., Q-Global, PARiConnect, MHS Assessment center+, WPS Online Evaluation System). These rating scales may be administered either through a link sent to an examinee to complete independently or through supported administration during videoconferencing. A variety of assessment stimuli are available digitally. If necessary, response booklets can be placed in a sealed envelope with instructions not to be opened until the telehealth visit, and mailed to a patient prior to their scheduled appointment. In order to minimize threats to test security, when utilizing this procedure it is recommended that the clinician observe the patient removing response booklets from the envelope, using them, and then returning them to the envelope and sealing it on camera. Additionally, clinicians should discuss the importance of not photographing, recording, or otherwise reproducing any test materials at the start of the testing session, and should require patients and family members to provide oral and written agreement to refrain from doing so. Some videoconferencing software also allows the host to disable recording for participants, which is recommended for tele-testing as well. For an expanded discussion of test security and related issues in tele-testing, please see Hewitt, Rodgin et al. (2020).

Behavioral observations are an essential component of any neuropsychological evaluation, and providers may have concerns that the telehealth format could limit their ability to thoroughly observe a patient’s behavior. This issue is also discussed in Hewitt, Rodgin et al. (2020). In the context of pediatric evaluations, with some adjustments to camera angles and, in some cases, use of multiple devices with cameras to capture several different views, it is typically not difficult to observe a patient’s behavior during teletesting in much the same way as it would be observed during in-person testing. It may even be possible to obtain more accurate behavioral observations for some patients, as they may be more comfortable in their home setting and therefore demonstrate a more typical behavioral presentation.

Tier 2 services may be a good fit for:

Re-evaluations

• Example: A patient who has previously received a comprehensive neuropsychological evaluation, but parents/providers are requesting updated information regarding specific areas of functioning that are assessable via tele-testing (e.g., verbal knowledge, attention, aspects of working memory and other executive functions, verbal memory, receptive and expressive language skills, and reading skills and/or conceptual math problem solving).

Evaluation of response to interventions or medical treatment

• Examples: A pediatric cancer survivor who has recently completed chemotherapy for whom targeted, post-treatment assessment of attention, executive function, processing speed (e.g., via verbal fluency, naming speed, timed academic tasks), and/or memory is warranted; a patient with ADHD who recently began medication management or changed medication type or dosage and for whom targeted assessment of symptom severity, attention, and executive function is requested by the prescribing provider.

Some specific differential diagnoses or questions about function

• Example: A patient presents with academic and behavioral difficulty and is referred for differential diagnosis of ADHD vs. reading disability; the ADHD symptoms can be assessed via rating scales and diagnostic interviewing, while foundational and higher-order reading skills can be assessed via tele-testing (e.g., phonetic decoding/phonological processing, single word reading, reading fluency, rapid naming, and/or reading comprehension tasks). While no standard battery exists for tele-testing, a sample battery that might assist in differentiating ADHD from a reading disability could include: screening of intellectual ability via expressive vocabulary, verbal reasoning, and nonverbal fluid reasoning via matrices type tasks; assessment of attention via auditory span tasks as well as informant rating of attention and hyperactivity symptoms; screening of memory via list learning or story memory; screening of executive function and automaticity via verbal fluency, sequencing, and/or rapid naming tasks as well as informant ratings of day-to-day executive behavior; and academic screening of word-level reading and phonetic decoding, reading fluency, and/or comprehension. When determining the order of the test battery, we suggest beginning the testing session with an assessment, such as a measure of expressive vocabulary or untimed verbal reasoning, that is not dependent on single-exposure test stimuli in order to ensure stability of internet connection.

  Tier 2 services can assist with making some specific differential diagnoses, can help track and document development and change relative to previously documented levels of functioning, and can make recommendations for supports and interventions. In cases where prior test data are available for review, particularly for a known patient, the tele-testing profile as well as specific scores may be compared to prior face-to-face test data. Indicators of performance validity administered during the tele-testing session (e.g., Reliable Digit Span, list learning forced choice delayed recognition, Memory Validity Profile verbal) can be useful in interpreting tele-testing data.

Tier 3: Comprehensive interview, review of records, and face-to-face testing

Tier 3 services are reserved for those patients for whom face-to-face assessment is required. While a clinical interview and review of records can still be completed via video as in Tier 1, the majority of the testing for these patients will need to be completed in the traditional, face-to-face format.

This approach may be best suited to patients with very complex neurocognitive, emotional, and/or behavioral presentations who require testing of most or all domains of functioning in order for an effective differential diagnosis and accurate recommendations to be made. Patients for whom an intellectual disability is among the primary diagnostic considerations may also require a comprehensive, face-to-face assessment, in order to ensure that adequate documentation of the disability for purposes of eligibility for services through state agencies or within the school system. In the context of the COVID-19 emergency, however, given that the federal government has determined that special education services and required timelines remain in place, despite school closures (Maryland State Department of Education, 2020; US Department of Education, 2020), evaluations for special education eligibility will need to continue to be performed. Thus, it may not be entirely appropriate to assume that “high stakes” testing, such as for special education eligibility, can or should be postponed. In fact, it seems likely that school systems will be required to, in some cases, perform evaluations remotely with students, which could increase the likelihood that they will accept evaluations performed via telehealth from other providers.

In addition, younger children, or children who are very behaviorally dysregulated may require a face-to-face evaluation in order to ensure compliance with testing procedures. In the context of the COVID-19 emergency, during which extremely limited face-to-face assessment services are being offered, Tier 3 services will only be appropriate for those patients who are able to wait (likely some months) to receive care.

Logistics of telehealth implementation

The transition to telehealth services was initiated in our program on March 15, 2020, in response to the COVID-19 emergency. During the first week of the transition, some patients continued to be seen face-to-face while arrangements were made to ensure that necessary telehealth scheduling, billing, and documentation procedures were in place. Clinicians were informed of the planned immediate transition to telehealth services and telehealth-related equipment needs were assessed. Legal, practical, and ethical issues, such as those outlined in the guidelines set forth by the American Psychological Association (APA, 2013) and the Inter Organizational Practice Committee (IOPC, 2020; Hewitt et al., 2020), were carefully considered. The first patient was seen in our program using the telehealth model outlined above on March 23, 2020.

Consistent telehealth visits began during the fourth week of March, with 22 of 24 patient visits occurring that week via telehealth. Since that time all patient visits have been conducted remotely, with a steady increase in telehealth appointments in April (i.e., 57 patients seen the first week, 89 the second, and 103 the third) as compared to an average of 45 face-to-face visits per week pre-COVID. It is notable, however, that the number of patients seen per week may not be the best metric of success given that the majority of the patients seen pre-telehealth-implementation received Tier 3 assessments while the majority of patients seen in the telehealth format received Tier 1 assessments. Revenue generated might offer a more accurate comparison of pre- vs. post-telehealth-implementation program performance. Gross revenue for the month of March 2020 (the first month impacted by COVID-19 in our state) equaled 68% of gross revenue for February 2020 (no appreciable COVID-19 impact in our state). Revenue generated during April 2020 exceeded pre-COVID levels (109% of gross revenue for February 2020), while May 2020 revenue was at 90% of pre-COVID (February 2020) levels. These data suggest that although telehealth services were approached out of necessity, and may look considerably different from the traditional assessment model, they have allowed our department to continue to operate at approximately its preCOVID-19 level financially. Whether patients and families are equally satisfied with the model remains to be determined empirically, though anecdotal reports suggest that this is the case.

Once psychologists developed familiarity and confidence with telehealth service provision, psychometrists and trainees were incorporated in service provision efforts. Psychometrists and trainees across levels of training have received experience with both Tier 1 and Tier 2 services, in much the same ways as they have been involved in traditional in-person assessment (i.e., interviewing families and patients, reviewing records, performing testing, offering feedback, writing reports). Including trainees in telehealth service provision has offered them opportunities to learn an increasingly important set of skills. In addition, this model allows for close supervision, as the supervising psychologist can turn off both their own audio and video, but continue to observe the patient and trainee.

Changes to service models create challenges

For patients and families

Challenges exist for patients and families across both traditional face-to-face and novel telehealth service models. Face-to-face services present particular obstacles for families who lack access to reliable transportation, live far from the clinic, or who live in rural or underserved areas. Comprehensive, full-day assessment appointments can be challenging for caregivers whose jobs are less flexible and for those who are the sole caregivers for other children. Additionally, comprehensive evaluations are costly, and not consistently and/or fully covered by third-party payors, adding burden to families who may already face extensive medical bills due to their child’s complex medical needs.

Services delivered via telehealth can be difficult for families who have limited access to or familiarity with technology (Kruse et al., 2018; IOPC, 2020). While many families use smartphones, allowing them to run videoconferencing programs such as Zoom, Vidyo, or GoToMeeting, delivering assessment services remotely is not ideal, and perhaps not advisable, on such a small screen. For tele-testing to be feasible, a larger screen such as that on a desktop, laptop, or large tablet is preferable (e.g., not less than 9.7 inches measured diagonally; Daniel, 2014); however, not all families own such devices. In our program, a telehealth interest survey emailed to parents of patients scheduled or waitlisted for in-person clinic visits found that 94% of respondents were interested in a telehealth appointment, but 26% of those did not have access to needed technology (e.g., laptop or desktop computer with webcam). Additionally, families who are less familiar or comfortable with technology may require some direct instruction and assistance in the process of preparing for the telehealth visit. This is true with regard to both the check-in process and the appointment itself. We have found that a combination of the following has allowed families to access the technology needed to complete a telehealth appointment: 1) clear information provided in the form of brief, illustrated ‘how to’ documents emailed to families in advance of the visit, 2) assistance with the electronic check-in process (including signing consent for treatment, financial consent, releases of information, etc.) provided by an administrative staff member in the days leading up to the visit, and 3) assistance from the clinician with setting up the video conferencing platform at the start of the visit. In many cases, a pediatric neuropsychology practice has the advantage of screen-savvy school-aged patients who are already schooling via videoconference software and can assist their parents or manage the technology independently.

As noted in published guidelines (IOPC, 2020; Hewitt et al., 2020), privacy cannot be ensured to the same extent during telehealth visits as during face-to-face clinic visits. This may impact disclosure of sensitive information and validity of the diagnoses made, and may be difficult to fully address in the context of “stay at home” orders and telehealth services.

Finally, the variety of services or “tiers” offered in this model may create confusion and concern for patients and families. When referred for a psychological or neuropsychological evaluation, referring providers often tell families that this evaluation will offer a day-long, comprehensive assessment of their child’s strengths and weaknesses. Indeed, this has been the case for many patients in our practice in the past, and remains the case for some patients even in the new, tiered model of service. However, families sometimes have concerns that a Tier 1 or Tier 2 assessment will result in their child receiving a less thorough, lower quality assessment that may ultimately be less useful for them. “Dosing” assessments to target each patient’s specific needs increases efficiency, reduces waitlist length and thus improves access to care, and, as such, benefits both the patient and the clinician (Bauer, 2016; Gur, 2018). The benefits of this approach, however, are often not readily apparent to families and providers who may lack a thorough understanding of the neuropsychological assessment process. In this new model, we have found that discussing these concerns with the family at the outset of the appointment often alleviates them entirely, particularly with an explanation of how the provider will acquire and use relevant information to address their question, and when assured that future face-to-face testing always remains an option if needed. Additionally, prior to their appointment, families receive the following information in plain language via email to help prepare them:

A telehealth visit will offer you:

• time to speak with a psychologist or neuropsychologist about your concerns for your child

• in many cases, help understanding why your child may be having trouble (such as what condition or diagnosis your child may have)

• ways to support your child’s learning and behavior during the COVID-19 school shutdown and once they return to school

• ideas for other things that might help your child (such as treatment or services)

• ideas for any follow-up your child may need, such as if in-person testing within the Neuropsychology Department is needed later (when it’s safe)

This transparency regarding the clinical decision-making process tends to be appreciated by families and seems to enhance satisfaction.

Given these concerns, it is possible that the practice of tele-neuropsychology could introduce additional healthcare disparities among disadvantaged populations. Fortunately, our abrupt shift from 100% in-person practice to 100% telehealth practice allows us the unique opportunity to evaluate this issue preliminarily. Demographic characteristics for the group of patients seen between January 1, 2020 and March 23, 2020 (n = 549) and the group of patients seen for evaluation between March 24, 2020 and June 30, 2020 (n = 1230) were compared. Age at visit (t(1777) = 1.443, p = .925), sex (χ²(1) = 0.036, p = .851), and race (χ²(1) = 1.450, p = .229) did not differ between patient cohorts. A marginally significant difference in insurance type across the cohorts emerged (χ²(1) = 3.354, p = .067), with a slightly larger proportion of patients using medical assistance (43%) rather than commercial insurance after March 23^rd, in comparison to 38% using medical assistance prior to the implementation of telehealth. Based on these limited data, it seems possible that the use of a telehealth format for the practice of neuropsychology may not introduce healthcare disparities and may, in some ways, reduce them.

For providers

Our experience in transitioning from primarily face-to-face, comprehensive assessments to a tiered, primarily telehealth model of care has also highlighted the challenges that such a change holds for the psychologists and neuropsychologists providing that care. A quick transition to a somewhat unfamiliar approach requires great flexibility of clinicians, particularly in terms of how assessment services are conceptualized. The traditional view that all patients require comprehensive assessment is heavily entrenched in our training and practice. Modifications to this traditional view can be met with resistance and concern. While appropriate case conceptualization has always relied upon review of existing records, gathering patient history, and completing a thorough clinical interview, our new model requires clinicians to consider pre-existing data (e.g., information about a child’s birth and developmental history, teacher comments on report cards, history of academic or behavioral performance over time) as essential components of the evaluation that are of equal value to –or even serve the place of– test scores. Implicit in this model is the idea that assumptions about a patient’s functioning can be made on the basis of history and available records, and that these assumptions do not always require validation using performance-based tests.

For example: a sixth grade patient recently started struggling across academic domains, despite a solid history of academic success throughout elementary school in all subjects. This patient has never been tested previously, and no developmental delays are reported. In this case, the clinician might use the patient’s history and current symptom presentation to generate a list of diagnostic rule-outs that could reasonably include ADHD and emotional considerations such as anxiety or depression, or even a new-onset medical condition, but would not include a high likelihood of an intellectual disability (developmental and academic difficulties would likely have been observed earlier) or learning disabilities (unlikely to begin in middle school). A thorough diagnostic interview, in this case, can be used to elucidate the nature of the symptoms and to refine the differential diagnoses. Parent- and patient-completed rating scales may also be useful in this regard. If the differential diagnostic picture remains unclear, then it may make sense to consider performance-based testing via Tier 2 or Tier 3 services.

Transitioning to such a new model of service on a large scale has required continuing professional development and peer supervision opportunities for providers. This has been accomplished, at our site, in the form of practice manuals, ongoing disseminated guidance regarding all aspects of practice, and regularly scheduled “telehealth rounds” that include all providers and clinic staff. These rounds provide opportunities for dissemination and discussion of the new model, and for collaborative problem solving around issues that arise as part of telehealth in general and in relation to the new service model in particular. This collaborative problem solving approach has been useful in increasing providers’ level of comfort with the transition and in ensuring that they are well-prepared to operate within the new model.

Finally, providers, like families, have varying degrees of familiarity and comfort with the technologies needed to provide telehealth. Implementing a local support infrastructure has been a critical part of the process of developing providers’ skills and knowledge in this area, as described below.

The telehealth transition teams

A critical component of the successful rapid, large scale transition to a telehealth model necessitated by the COVID-19 emergency was implementation of a team structure to ensure that we could address diverse aspects of the transition process thoroughly and rapidly. Eight teams were assembled, each responsible for a particular component of the transition and for keeping up with the almost daily changes in the information available: 1) staff technical training and equipment needs for remote work, 2) educational and treatment resources for clinicians to offer families in the context of closures of schools and many outpatient services, 3) telehealth billing, 4) patient triage, 5) telehealth test batteries and relevant considerations, 6) insurance authorization for telehealth services, 7) telehealth scheduling, and 8) clinical considerations for telehealth. Teams included clinicians, trainees, and administrative and research staff, as appropriate and in an effort to utilize all available resources and expertise. Team leaders and department directors met several times per week for the first three weeks of the telehealth transition to share progress and problem-solve. Minutes and products of these meetings were shared with the department at large in order to increase communication and to supplement the weekly telehealth rounds.

Implications for future practice

The global pandemic, and the transition to telehealth services that it triggered, has had the unanticipated impact of functionally accelerating personalized healthcare within our department and, perhaps, in the field of pediatric neuropsychology more broadly. Implementation of a tiered service model that incorporates telehealth services can offer better differentiated care and more individualized and appropriate ‘dosing’ of assessment services.

Although we anticipate being able to return to providing face-to-face assessment services in the future, many of the changes made to service models may well remain. The benefits offered by the tiered model of services outlined here are significant, both in terms of personalized, efficient service for patients and families, and the extent to which this efficiency allows for more patients to be served with a shorter wait. Furthermore, this new practice model offers enormous benefit for patients who live in underserved areas (Barton et al., 2011; Burke & Hall, 2015; Wadsworth et al., 2016). Even when the bulk of assessment practice returns to the face-to-face visit format, patients for whom travel to a specialized assessment center is difficult will be served more easily using the telehealth services. Finally, the option for more frequent follow-up via telehealth, even when initial visits take place face-to-face, is another potential benefit that may make follow-up visits more convenient for many families.

The rapid transition to telehealth neuropsychological practice necessitated by the COVID-19 emergency has stressed health care resources and brought about many new challenges. At the same time, it has pushed the boundaries of pediatric neuropsychological practice, forced us all to challenge our assumptions and think flexibly, and allowed for unprecedented evolution in the field. While further work is needed to examine the degree to which remote telehealth evaluations such as those described here are comparable to –and as valid as– those conducted face-to-face, and whether such services disproportionately disadvantage those with only smartphones, thereby exacerbating healthcare disparities, it can be hoped that the healthcare system’s and third party payors’ recognition of the necessity of telehealth services will allow for use of such options long into the future, increasing our flexibility to serve patients and families.