Development & validation of a scalable mobile platform for screening of developmental neuropsychiatric disorders in low-resource settings

在世界范围内，每161名儿童中就有1名被诊断或可诊断患有自闭症谱系障碍（ASD）。在印度，我们自己的研究发现，2至9岁儿童的患病率略高于1%。尽管父母可能早在24个月大时就注意到自闭症谱系障碍的症状，但由于社会和经济方面的障碍，无法接触到合格的卫生人员，这意味着这些儿童中的大多数没有得到早期诊断或干预——或者根本没有得到任何诊断或干预。此外，许多家长没有意识到与年龄相适应的发育里程碑，因此只有在症状变得明显且无法忽视时才寻求临床意见。有证据表明，一线工作人员提供的、父母介导的干预措施（例如PASS）可带来更好的行为和社会结果，因此，这种本可避免的延误是一场正在上演的悲剧。标记可能的ASD的可扩展方法将促进早期转诊到稀缺的专业诊断设施，将家庭与负担得起的、可扩展的、基于社区的干预措施联系起来。我们将通过开发一个低成本的移动筛查平台（“使用技术的自闭症风险筛查工具”（START））来实现这一目标，该平台可由提供PASS或其他一线干预措施的非专业卫生工作者在家庭或常规卫生机构中使用。START将从多个来源收集数据。首先，父母将被问及关于孩子日常行为的简单问题，这些问题是基于在印度文化背景下得到验证的既定问卷。为了帮助家长识别和报告细微的异常，这些问题将通过视频来补充，说明典型的与ASD的行为。这份视频问卷将通过平板电脑发送。其次，同一台平板电脑上的低成本眼球追踪技术将用于监测儿童在简单任务中的眼球运动，例如评估对社交与非社交图像的偏好，以及测量注意力转移到屏幕上出现的新物体上的速度。最后，一段父母和孩子的互动将被记录使用内置摄像头，并用于编码的非典型行为的迹象。这种多种措施的结合将提供在单一平台上收集的独立数据渠道，有可能改进目前仅依赖一种技术的筛选方法。在ASD认知不足可能影响家长报告异常行为（例如，父母可能没有注意到他们的孩子避免直视）的情况下，结合这些技术变得尤为重要。START的核心创新是通过将高收入国家成功采用的方法应用于中低收入国家的环境和资源，与中低收入国家现有的一线工作者进行整合。由于其设计要求最少的培训，它将促进任务转移——世界卫生组织将这一概念定义为“一种授权过程，在适当情况下将任务转移给不太专业的卫生工作者”，从而将惠及更广泛的人口。这种转移任务的方法减轻了中低收入国家少数高技能精神卫生专业人员的负担，他们可以自由地集中精力确认诊断和规定适当的干预措施，这些措施反过来也可以由非专业工作者提供。由此产生的对自闭症谱系障碍检测的加强也可能有助于提高社区意识，并从长远来看，解决这些地区对服务需求低的障碍。START平台的开发和应用涉及基础科学和应用科学的广泛合作，包括公共卫生研究、技术、临床心理学和神经科学，并将由英国和印度的世界级机构领导。这种全球伙伴关系将建立印度的研究能力，以弥补在资源匮乏环境中对神经精神疾病的这些广泛发现差距。

Worldwide, 1 in 161 children are diagnosed or diagnosable with Autism Spectrum Disorders (ASD). In India, our own study found a prevalence just over 1% in children aged 2 to 9 years. Although parents may notice ASD symptoms as early as 24 months, social and economic barriers to access to qualified health personnel mean that most of these children do not receive early diagnosis or intervention - or indeed any diagnosis or intervention at all. Moreover, many parents are unaware of age-appropriate developmental milestones and therefore clinical opinion is sought only when symptoms become obvious and impossible to ignore. This avoidable delay is an unfolding tragedy in light of evidence showing that front-line worker-delivered, parent-mediated interventions (e.g. PASS) lead to better behavioural and social outcomes. Scalable methods to flag up probable ASD would promote early referral to scarce specialist diagnostic facilities, connecting families with affordable, scalable, community-based interventions. We will realise this goal by developing a low-cost mobile screening platform ('Screening Tools for Autism Risk using Technology' (START)) usable in the home or in a routine health facility by the same non-specialist health workers who deliver PASS or other front-line interventions.START will collect data from multiple sources. First, parents will be asked simple questions about their child's everyday behaviour, based on established questionnaires that have been validated in the Indian cultural context. To help parents identify and report subtle abnormalities, these questions will be supplemented by videos illustrating typical versus ASD behaviours. This video-enabled questionnaire will be delivered on a tablet PC. Second, low-cost eye-tracking technology on the same tablet PC will be used to monitor the child's eye movements in simple tasks, such as those assessing preference for social versus non-social images, and measuring how quickly attention shifts to new objects appearing on the screen. Finally, a segment of parent and child interaction will be recorded using the inbuilt camera, and used to code for signs of atypical behaviour. This combination of multiple measures will provide independent channels of data collected on a single platform, potentially improving on current screening methods that rely on one technique solely. Combining these techniques becomes especially important in a setting where challenges such as poor awareness about ASD may impact on parent reporting of abnormal behaviour (for example, parents may not have noticed that their child avoids direct gaze).START's central innovation is its integration with existing front-line workers in LMICs, by adapting methods successfully employed in high income countries (HICs) to LMIC environments and resources. By virtue of its design to require minimal training, it will promote task-shifting - a concept the World Health Organization defines as "a process of delegation whereby tasks are moved, where appropriate, to less specialized health workers" and thus will reach wider populations. This task-shifting approach reduces the burden on the small number of highly-skilled mental-health professionals in LMICs, who then are free to focus on confirming diagnoses and prescribing appropriate interventions which, in turn, can also be delivered by non-specialist workers. The resulting enhancement to detection of ASD may also help develop community awareness and, in the longer term, address the barrier of low demand for services in these areas.The development and application of the START platform involves collaborations across the breadth of basic and applied sciences - including public health research, technology, clinical psychology and neuroscience, and will be led by world-class institutions in the UK and India. Such global partnerships will build research capacity in India to bridge these wide detection gaps for neuropsychiatric disorders in low resource settings.