**8. Role of telemedicine: an important part of a comprehensive mitigation framework**

Telemedicine plays an important role in our collective efforts to prevent and mitigate toxic childhood stress in the COVID-19 era [52, 60]. By leveraging technology to deliver patient care remotely, telemedicine enables interpersonal connectivity while overcoming many of the limitations related to either social distancing or lack of resources (e.g., transportation). Health care providers, through virtual visits and other telehealth platforms, may be able to provide effective emotional support and psychosocial buffering for families experiencing acute stress [61].

Through the provision of frequent interpersonal touchpoints, telemedicine can furnish an important platform to support the well-being of children [62]. One of telemedicine's main strengths resides in the ability to reduce costs associated with access to care, primarily by reducing the time and expense of travel, waiting, and paid time off [63, 64]. Moreover, health systems can leverage the lower associated cost(s) to perform more frequent virtual check-ins (and thus provide more support). More face-to-face time, in turn, helps build trust and creates opportunities for providers to affirm families' strengths and resiliencies, as well as reinforce strategies that are effective in combating acute stress, including balanced nutrition, *Toxic Stress Affecting Families and Children during the COVID-19 Pandemic: A Global Mental… DOI: http://dx.doi.org/10.5772/intechopen.104991*

physical activity, quality sleep, mindfulness practices, supportive relationships, and mental health care [65–67].

In the wake of widespread parental fears regarding the potential for exposure of children to COVID-19, telemedicine can help make all stakeholders feel safer, especially in terms of public immunization programs. This is a very important aspect of the overall care provision since visit volume in many outpatient pediatric offices decreased by >50% and vaccine orders have fallen by 2.5 million since March 2020 [68]. The American Academy of Pediatrics has urged the continued provision of routine immunizations for children. In response, some practices have begun offering curbside and drive-through immunization clinics [68]. Utilizing telemedicine for interpersonal connection and relationship building alongside socially distanced medical procedures such as immunizations and biometrics could help optimize the balance between putting patients at ease and bringing them up to date with care.

Telemedicine has its limitations in evaluating the well-being of children and parents. Establishing and maintaining a personal connection with a family is more easily done with an in-person visit. Signs of child abuse may be missed as physical exams are limited during a telemedicine visit. Bruising and intentional skin trauma may not be appreciated through a camera. Intraoral trauma would be difficult to identify [69]. It is more difficult to speak with children alone through a virtual visit and they may be less willing to identify stressors with parents present [69]. Mental health evaluation may be challenging if children do not feel comfortable divulging information while at home or in front of their parents. 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 or parent 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, but they could also risk exacerbating household tensions [61].

In light of the above considerations, approaches aimed at specific educational initiatives have been proposed by domestic violence and toxic stress experts during the COVID-19 pandemic. Beyond virtual visits, advances in telemedicine could empower patients through easily (and confidentially) accessible information and resources [61]. 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 (i.e., seekwellbeing. org), which incorporate social work collaboration, have been shown to effectively prevent child maltreatment. 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 [28]. Adopting such approaches to the telemedicine space could be highly promising. Various sets of specific considerations applicable to health security may also be applicable 'by proxy' due to the benefits gained via telemedicine-based behavioral health interventions.

### **9. Conclusion**

The COVID-19 pandemic has ushered dramatic social and economic upheavals, leading to a highly stressful period in our history, especially challenging for families and children. The identification and prevention of toxic childhood stress in the COVID-19 era may be especially difficult during this time. Much remains to be learned about risk factors and ways to remediate this serious health security threat, especially when considering its potential long-term consequences. The initial steps to begin healing our children from a hopefully once-in-a-lifetime pandemic include: 1) widespread recognition and identification of the effects of toxic stress on children, as measured by validated tools, such as Adverse Childhood Event (ACE) scores, and

## *Contemporary Developments and Perspectives in International Health Security - Volume 3*

its possible impact on the development of chronic diseases and mental health issues later in life; 2) increase in vaccination rates across all eligible candidate groups; and 3) implementation of telemedicine to support access to health needs, and to build and maintain relationships between healthcare workers and the community. Although the implementation of the above steps may be challenging, continued support and necessary resources must be put forth toward one of our most vulnerable populations to help remediate the long-lasting impact of TS for years to come.
