Using mobile health technology to assess childhood autism in low-resource community settings in India: An innovation to address the detection gap

Abstract

A diagnosis of autism typically depends on clinical assessments by highly trained professionals. This high resource demand poses a challenge in low-resource settings. Digital assessment of neurodevelopmental symptoms by non-specialists provides a potential avenue to address this challenge. This cross-sectional case-control field study establishes proof of principle for such a digital assessment. We developed and tested an app, START, that can be administered by non-specialists to assess autism phenotypic domains (social, sensory, motor) through child performance and parent reports. N = 131 children (2–7 years old; 48 autistic, 43 intellectually disabled and 40 non-autistic typically developing) from low-resource settings in Delhi-NCR, India were assessed using START in home settings by non-specialist health workers. The two groups of children with neurodevelopmental disorders manifested lower social preference, greater sensory interest and lower fine-motor accuracy compared to their typically developing counterparts. Parent report further distinguished autistic from non-autistic children. Machine-learning analysis combining all START-derived measures demonstrated 78% classification accuracy for the three groups. Qualitative analysis of the interviews with health workers and families of the participants demonstrated high acceptability and feasibility of the app. These results provide feasibility, acceptability and proof of principle for START, and demonstrate the potential of a scalable, mobile tool for assessing neurodevelopmental conditions in low-resource settings. Lay abstract Autism is diagnosed by highly trained professionals– but most autistic people live in parts of the world that harbour few or no such autism specialists and little autism awareness. So many autistic people go undiagnosed, misdiagnosed, and misunderstood. We designed an app (START) to identify autism and related conditions in such places, in an attempt to address this global gap in access to specialists. START uses computerised games and activities for children and a questionnaire for parents to measure social, sensory, and motor skills. To check whether START can flag undiagnosed children likely to have neurodevelopmental conditions, we tested START with children whose diagnoses already were known: Non-specialist health workers with just a high-school education took START to family homes in poor neighbourhoods of Delhi, India to work with 131 two-to-seven-year-olds. Differences between typically and atypically developing children were highlighted in all three types of skills that START assesses: children with neurodevelopmental conditions preferred looking at geometric patterns rather than social scenes, were fascinated by predictable, repetitive sensory stimuli, and had more trouble with precise hand movements. Parents’ responses to surveys further distinguished autistic from non-autistic children. An artificial-intelligence technique combining all these measures demonstrated that START can fairly accurately flag atypically developing children. Health workers and families endorsed START as attractive to most children, understandable to health workers, and adaptable within sometimes chaotic home and family environments. This study provides a proof of principle for START in digital screening of autism and related conditions in community settings.

App Characteristics and Accuracy Metrics of Available Digital Biomarkers for Autism: Scoping Review

“…A total of 4 studies involving 4 unique apps were included in the review ( Figure 2 ), of which 1 (Canvas Dx [ 16 ]) was an FDA-cleared commercial product and 3 (Guess What? [ 17 ], START [ 18 ], and SenseToKnow [ 19 ]) were research apps.…”

“…Our work also outlined exciting trends toward the development of mobile-first digital technologies. It has been shown that while individuals in underserved communities often do not have access to desktop computers or laptops, the availability of mobile phones is typically higher [ 18 ]. Therefore, developing mobile-first tools could help ensure health equity in communities where conditions like autism suffer from greater diagnostic delays [ 40 ].…”

Scalable Transdiagnostic Early Assessment of Mental health (STREAM): Study Protocol

“…The STREAM platform’s content and design are built upon three established and complementary child development measurement tools, previously developed, field-tested, and validated by the team for use in low-resource settings: the Malawi Developmental Assessment tool (MDAT; Gladstone et al, 2010), DEvelopmental assessment on an E-Platform (DEEP; Bhavnani et al, 2019), and the Screening Tool for Autism Risk using Technology (START; Dubey et al, 2024). The integration of these tools within STREAM was piloted on N=15 children in India and N=17 in Malawi to assess the need for cultural adaptation and to inform the development of Standard Operating Protocols (SOPs) and assessor training procedures.…”

“…The feasibility and acceptability to stakeholders of the three established tools included within the STREAM tablet-based platform have been assessed previously (Gladstone et al, 2010;Dubey et al, 2024;Bhavnani et al, 2019). Local stakeholders within the recruitment catchment areas were consulted before commencing STREAM data collection.…”

“…The STREAM platform's content and design are built upon three established and complementary child development measurement tools, previously developed, field-tested, and validated by the team for use in low-resource settings: the Malawi Developmental Assessment tool (MDAT; Gladstone et al, 2010), DEvelopmental assessment on an E-Platform (DEEP; Bhavnani et al, 2019), and the Screening Tool for Autism Risk using Technology (START; Dubey et al, 2024).…”