Exploring the Acceptability and Feasibility of a Mobile Assessment Platform: START (Screening Tools for Autism Risk Using Technology)

Background: Paucities of trained specialists and low community awareness mean that most children with autism spectrum disorders (ASD) in low- and middle-income countries (LMIC) do not receive timely diagnosis. Simultaneously, expensive proprietary diagnostic measures obstruct the dissemination of gold-standard tools in LMIC. In such settings, a digital application administered by non-specialist workers (NSW) to screen for ASD could facilitate early identification, enabling timely intervention.

Objectives: To explore acceptability to families, and feasibility in the hands of NSWs of START (Screening Tools for Autism Risk using Technology), a mobile platform for assessing multiple domains of neurodevelopment which could eventually be used to screen for autism and other neurodevelopmental disorders in in household settings.

Methods: START, an Android application, incorporates six tasks adapted from those used in laboratory settings. Four gamified tasks have been designed to capture metrics of social motivation, sensory interest and fine motor ability. Tablet-based eye tracking captures low-resolution gaze data for measures of preferential looking and attentional disengagement. The app also includes questionnaires and video recording of parent-child interaction. NSWs were provided a two-day classroom training and practice on START administration. Following this they conducted assessments in Delhi, India with children aged 2-7 years; typically developing (TD) N=40, clinically diagnosed ASD N=40 and intellectual disability (ID) N=40. A researcher accompanying each worker documented details of assessment process and household environment using observational checklists. Acceptability and feasibility of household assessments were explored by interviews with parents of children assessed, NSWs and the researcher.

Results: With minimal training, NSWs having no prior experience with tablet computers or child mental health were comfortable using the START app and able to independently carry out assessments. Lighting conditions for capture of eye tracking data were adequate in 98% of households. A table-chair arrangement was available in only 6%. Other settings included tablet placement on bed (56%), floor (22%) and other objects, e.g., stairs, stool (16%). Although there were some distractions during the assessment (e.g., 10% interruptions from other siblings/family members), these did not interfere with the assessment process. None of the families had tablet computers but majority owned smartphones with which children were familiar. When shown the tablet, all children were interested and rapport typically was established within ten minutes (99% of sample). Compared to 94% of children who completed all START tasks in the TD group, completion rates were lower in the atypical groups (40% ASD and 50% ID). Child factors such as loss of interest were the main reason for varying task completion rates; this observation was corroborated by experience of NSWs who felt typically developing children engaged more readily throughout the assessment. Parents were at ease with the use of tablet-based technology and duration of the household visit, and supportive of assessments' being conducted at home where their child was comfortable.

Conclusions: The ability of NSWs to deliver START in LMIC household settings and START’s acceptability to families offer potential for scaling up as part of regular community health assessments.