Feature

Novel tools upcoming for screening, treating patients with autism

The prevalence of autism in children continues to rise, with CDC data suggesting it affects 1 in 68 children several years ago vs. more recent data suggesting it now affects 1 in 59.

While the number of children affected is on the rise, evaluations among younger children that can lead to earlier treatment are still lagging, Daisy Christensen, PhD, Developmental Disabilities Branch surveillance team lead, CDC National Center on Birth Defects and Developmental Disabilities said in an interview with Healio Family Medicine. She pointed to a finding that 17 of every 20 children in the agency’s Autism and Developmental Disability Monitoring Network who were ultimately diagnosed with autism in 2014 had a developmental concern by the age of 3, but just 40% of those children had undergone a developmental evaluation.

“We want to see the percentage of children with [autism spectrum disorder] getting their first developmental evaluation by age 36 months going up,” Christensen said. “What’s concerning to us is that the percentage has been largely unchanged.”

New tools in development may help primary care physicians implement screening protocols that can lead to earlier evaluations. Healio Family Medicine spoke with the designers of two such tools that are in development, as well as independent experts, to weigh the pros and cons of using these tools in the medical community.

Autism screening app

One tool under development that could screen children for autism is an app that provides caregiver consent forms and survey questions. The phone's camera gathers videos of the child’s reactions while the child watches movies that were chosen due to their ability to evoke autism risk behaviors, such as patterns of emotion and attention. These data are then analyzed by automatic behavioral coding software that tracks the discreet movements on the child's face and quantifies the child's attention and emotion. The entire test takes about 20 minutes to complete, with only a small amount of that time involving the child, developers said.

Geraldine Dawson
Geraldine Dawson

Geraldine Dawson, PhD, director of the Duke Center for Autism and Brain Development in North Carolina, gave Healio Family Medicine a real-world example of how the app, which was called Autism and Beyond but will undergo a name change as it moves forward in development, offers the chance for greater accuracy in making a diagnosis.

“Typical babies will, by at least 12 months of age, turn and look at you if you call their name, and we’ve been able to show, using the app, that some of the children with autism do in fact turn when their name is called, but they do that much more slowly. They’re actually about 1 second delayed in turning their heads, and this is something that you would not notice with a naked eye,” Dawson said.

“That’s one of the exciting things about using a computer to measure behavior — it is allowing us to measure what might be subtle differences but are critical early flags of autism that a clinician might miss because they don’t have the ability to measure behavior in the same way that a computer would,” she continued.

Autism App Implementation
Researchers at Duke University are developing an app that uses the phone's camera gathers videos of the child’s reactions while the child watches movies that were chosen due to their ability to evoke autism risk behaviors, such as patterns of emotion and attention. These data are then analyzed by automatic behavioral coding software that tracks the discreet movements on the child's face and quantifies the child's attention and emotion.
Photo source:Duke University

Dawson co-authored an article in NPJ Digital Medicine that evaluated the app’s effectiveness during a 12-month period among 1,756 patients, their parents and clinicians. Usable data were gleaned from the app 87.6% of the time, according to researchers. They concluded that although additional studies with “representative populations” are needed, most of the users found it acceptable, and that PCPs who participated in the study seemed equally supportive of the technology.

“They really enjoyed using it,” Dawson said of the PCPs’ response. “In one of our studies that we conducted in primary care, we asked the physicians whether they liked to use these tools and 90% of the physicians said they really appreciated it because they simply don’t have the time during a typical well-child visit.”

According to Dawson, another NIH-funded trial with further refinements to the app gleaned from the study — an easier-to-use interface, more effective stimuli to pick up symptoms — is underway with 9,000 patients through Duke primary care clinics. Depending on how well that trial goes, she said, “we will feel much more confident in considering this as a potential screening tool.”

Apps can complement evaluation

Healio Family Medicine asked Sonia Monteiro, MD, a developmental-behavioral pediatrician at The Meyer Center for Developmental Pediatrics and Texas Children’s Autism Center in Houston, who was not affiliated with Dawson and colleague’s research, to review the NPJ Digital Medicine article.

Sonia Montiero
Sonia Monteiro

She said that while apps can possibly be an “exciting resource” for PCPs and pediatricians to use for screening for autism, they should be used to complement personal interactions.

“I see the potential role of mobile technology for enhancing but not replacing the evaluation with a trained specialist by giving us an additional view of a child in their natural setting,” Monteiro said. “Social deficits are frequently the most difficult part of autism to treat. My concern is that the use of mobile applications in the treatment of autism should not replace the benefits of early intensive behavioral interventions that are evidence based and involve face to face interaction.

“For some patients with autism who are minimally verbal, apps have sometimes aided in communication. Being able to communicate their wants and needs can decrease the frustration many children with autism experience when they are not understood,” she continued. “Improvements in screening could also potentially decrease the time many children have to wait for an evaluation with a specialist.”

Eye tracking software

Another forthcoming tool involves eye tracking in which near-infrared light and high-speed cameras are used to ascertain a person’s eye position and pinpoint what the eye is focusing on. Eye tracking is used to determine individuals’ visual behavior, according to Katherine B. Martin, PhD, a senior research scientist at Tobii Pro, which is a company that provides eye tracking technology used to study neurological conditions such as autism spectrum disorder.

Katherine Martin
Katherine B. Martin

“Eye tracking is a technology that very accurately tracks where, when and what a person is looking at. Human perception holds rich insights on the physical, social and psychological mysteries of human behavior. Eye tracking is a proven research methodology for articulating that insight,” she said in an interview. Recently, eye tracking is being used more frequently in intervention work in clinical populations. “You can imagine a day not too far off in the distant future where a parent who has a child with autism spectrum disorder would be sent home with an eye tracker and an app on their phone,” she said. “The app would tell the parent where the child is looking so that the parent can redirect attention back to the area of interest to increase learning. These interventions are already being developed and we look forward to seeing what physicians do with our tools in their future work.”

In addition to basic and applied research, eye tracking is also used in augmented and alternative communication devices, or AAC devices, she said. Eye tracking is not widely available in the primary care setting but that could change, according to Martin.

She also discussed some of the misunderstandings surrounding eye tracking.

“One common misconception is that if an individual uses an AAC device for communication, they will never learn to talk,” she said. “Research does not support this notion — AAC devices facilitate verbal communications.

“Furthermore, eye tracking in AAC devices may also decrease behavior problems in individuals with [autism spectrum disorder]. Consider a patient who is not able to communicate, for example. Their frustration would be quite high, and they would likely exhibit many behaviors, not all of them positive, to try to communicate their needs. Now, if the patient were given the chance to communicate through an AAC device, he or she could learn to communicate his/her needs in a more positive way and thus, the patient’s need to communicate through maladaptive behaviors would likely decrease,” Martin said.

Eye tracking may help children with autism in other ways, such as helping them feel less isolated from their peers without autism, she said, which previous research suggests occurs in about 27% of young adults with autism.

“There is nothing about eye tracking that necessitates the patient must be isolated. As a matter of fact, plenty of research has used eye tracking to focus on interaction between individuals in social settings,” she said. “The work done with AAC devices is all about improving social interaction.”

Martin acknowledged there will be those who are critical of this approach.

“There may be some resistance to using eye tracking for interventions and as an AAC. Today, almost all children use technology for learning, so the concern for children with [autism spectrum disorder] using technology for learning should not be heightened, unless future research warrants it,” she said.

Independent expert provides perspective

Eye tracking technology can help to provide more specific data on social interactions than is otherwise available, and recent advances have made it more accessible outside of the research setting, according to John D. Herrington, PhD, an assistant professor of psychology and psychiatry at The Children’s Hospital of Philadelphia, who is not affiliated with Tobii Pro’s research.

John Herrington
John D. Herrington

“I am very excited by the technology for several reasons. For decades eye tracking technology has been prohibitively expensive. But in the last 5 or 10 years we’ve gone from products that cost thousands of dollars to products that now cost hundreds of dollars. So, it’s a lot easier to imagine these products getting into places where we can actually use it better, he said.

“It can also be very difficult to come up with a hard, quantifiable number about how much social attention someone with autism is paying to someone else. We know typical-developing people take for granted that they can tell if a social interaction is going well, or if they are picking up on social cues or not. To put a number on that is really hard and what eye tracking allows us to do is more or less [obtain] data about how much social attention someone is paying to a person or thing,” Herrington said.

Herrington agreed that the advances technology offers should be integrated into a comprehensive diagnostic and management strategy.

“There are components of social interaction that are important, such as language, that an eye tracker is not ever going to measure. In addition, one of the main ways clinicians try to help patients with autism is to make them more effective in social situations and, of course, any piece of technology or device provides people an opportunity to avoid those situations rather than engage in them more.”

This limitation is not deterring the development of the eye tracking technology, he said.

“The market and space surrounding these products is exploding. It’s not hard to imagine a future not too far off where our smartphones and our different devices can do some rudimentary eye tracking. And that’s sort of huge.” – by Janel Miller

Disclosures: Dawson reports being on the scientific advisory boards of Akili, Inc., Janssen Research and Development, and Roche Pharmaceuticals, has received grant funding from Janssen Research and Development, LLC., received royalties from Guildford Press and Oxford University Press, and is a member of DASIO, LLC. Montiero reports no relevant financial disclosures. Healio Family Medicine was unable to determine neither Herrington nor Martin’s relevant financial disclosures prior to publication.

The prevalence of autism in children continues to rise, with CDC data suggesting it affects 1 in 68 children several years ago vs. more recent data suggesting it now affects 1 in 59.

While the number of children affected is on the rise, evaluations among younger children that can lead to earlier treatment are still lagging, Daisy Christensen, PhD, Developmental Disabilities Branch surveillance team lead, CDC National Center on Birth Defects and Developmental Disabilities said in an interview with Healio Family Medicine. She pointed to a finding that 17 of every 20 children in the agency’s Autism and Developmental Disability Monitoring Network who were ultimately diagnosed with autism in 2014 had a developmental concern by the age of 3, but just 40% of those children had undergone a developmental evaluation.

“We want to see the percentage of children with [autism spectrum disorder] getting their first developmental evaluation by age 36 months going up,” Christensen said. “What’s concerning to us is that the percentage has been largely unchanged.”

New tools in development may help primary care physicians implement screening protocols that can lead to earlier evaluations. Healio Family Medicine spoke with the designers of two such tools that are in development, as well as independent experts, to weigh the pros and cons of using these tools in the medical community.

Autism screening app

One tool under development that could screen children for autism is an app that provides caregiver consent forms and survey questions. The phone's camera gathers videos of the child’s reactions while the child watches movies that were chosen due to their ability to evoke autism risk behaviors, such as patterns of emotion and attention. These data are then analyzed by automatic behavioral coding software that tracks the discreet movements on the child's face and quantifies the child's attention and emotion. The entire test takes about 20 minutes to complete, with only a small amount of that time involving the child, developers said.

Geraldine Dawson
Geraldine Dawson

Geraldine Dawson, PhD, director of the Duke Center for Autism and Brain Development in North Carolina, gave Healio Family Medicine a real-world example of how the app, which was called Autism and Beyond but will undergo a name change as it moves forward in development, offers the chance for greater accuracy in making a diagnosis.

“Typical babies will, by at least 12 months of age, turn and look at you if you call their name, and we’ve been able to show, using the app, that some of the children with autism do in fact turn when their name is called, but they do that much more slowly. They’re actually about 1 second delayed in turning their heads, and this is something that you would not notice with a naked eye,” Dawson said.

“That’s one of the exciting things about using a computer to measure behavior — it is allowing us to measure what might be subtle differences but are critical early flags of autism that a clinician might miss because they don’t have the ability to measure behavior in the same way that a computer would,” she continued.

Autism App Implementation
Researchers at Duke University are developing an app that uses the phone's camera gathers videos of the child’s reactions while the child watches movies that were chosen due to their ability to evoke autism risk behaviors, such as patterns of emotion and attention. These data are then analyzed by automatic behavioral coding software that tracks the discreet movements on the child's face and quantifies the child's attention and emotion.
Photo source:Duke University

Dawson co-authored an article in NPJ Digital Medicine that evaluated the app’s effectiveness during a 12-month period among 1,756 patients, their parents and clinicians. Usable data were gleaned from the app 87.6% of the time, according to researchers. They concluded that although additional studies with “representative populations” are needed, most of the users found it acceptable, and that PCPs who participated in the study seemed equally supportive of the technology.

“They really enjoyed using it,” Dawson said of the PCPs’ response. “In one of our studies that we conducted in primary care, we asked the physicians whether they liked to use these tools and 90% of the physicians said they really appreciated it because they simply don’t have the time during a typical well-child visit.”

According to Dawson, another NIH-funded trial with further refinements to the app gleaned from the study — an easier-to-use interface, more effective stimuli to pick up symptoms — is underway with 9,000 patients through Duke primary care clinics. Depending on how well that trial goes, she said, “we will feel much more confident in considering this as a potential screening tool.”

Apps can complement evaluation

Healio Family Medicine asked Sonia Monteiro, MD, a developmental-behavioral pediatrician at The Meyer Center for Developmental Pediatrics and Texas Children’s Autism Center in Houston, who was not affiliated with Dawson and colleague’s research, to review the NPJ Digital Medicine article.

Sonia Montiero
Sonia Monteiro

She said that while apps can possibly be an “exciting resource” for PCPs and pediatricians to use for screening for autism, they should be used to complement personal interactions.

“I see the potential role of mobile technology for enhancing but not replacing the evaluation with a trained specialist by giving us an additional view of a child in their natural setting,” Monteiro said. “Social deficits are frequently the most difficult part of autism to treat. My concern is that the use of mobile applications in the treatment of autism should not replace the benefits of early intensive behavioral interventions that are evidence based and involve face to face interaction.

PAGE BREAK

“For some patients with autism who are minimally verbal, apps have sometimes aided in communication. Being able to communicate their wants and needs can decrease the frustration many children with autism experience when they are not understood,” she continued. “Improvements in screening could also potentially decrease the time many children have to wait for an evaluation with a specialist.”

Eye tracking software

Another forthcoming tool involves eye tracking in which near-infrared light and high-speed cameras are used to ascertain a person’s eye position and pinpoint what the eye is focusing on. Eye tracking is used to determine individuals’ visual behavior, according to Katherine B. Martin, PhD, a senior research scientist at Tobii Pro, which is a company that provides eye tracking technology used to study neurological conditions such as autism spectrum disorder.

Katherine Martin
Katherine B. Martin
 

“Eye tracking is a technology that very accurately tracks where, when and what a person is looking at. Human perception holds rich insights on the physical, social and psychological mysteries of human behavior. Eye tracking is a proven research methodology for articulating that insight,” she said in an interview. Recently, eye tracking is being used more frequently in intervention work in clinical populations. “You can imagine a day not too far off in the distant future where a parent who has a child with autism spectrum disorder would be sent home with an eye tracker and an app on their phone,” she said. “The app would tell the parent where the child is looking so that the parent can redirect attention back to the area of interest to increase learning. These interventions are already being developed and we look forward to seeing what physicians do with our tools in their future work.”

In addition to basic and applied research, eye tracking is also used in augmented and alternative communication devices, or AAC devices, she said. Eye tracking is not widely available in the primary care setting but that could change, according to Martin.

She also discussed some of the misunderstandings surrounding eye tracking.

“One common misconception is that if an individual uses an AAC device for communication, they will never learn to talk,” she said. “Research does not support this notion — AAC devices facilitate verbal communications.

“Furthermore, eye tracking in AAC devices may also decrease behavior problems in individuals with [autism spectrum disorder]. Consider a patient who is not able to communicate, for example. Their frustration would be quite high, and they would likely exhibit many behaviors, not all of them positive, to try to communicate their needs. Now, if the patient were given the chance to communicate through an AAC device, he or she could learn to communicate his/her needs in a more positive way and thus, the patient’s need to communicate through maladaptive behaviors would likely decrease,” Martin said.

Eye tracking may help children with autism in other ways, such as helping them feel less isolated from their peers without autism, she said, which previous research suggests occurs in about 27% of young adults with autism.

“There is nothing about eye tracking that necessitates the patient must be isolated. As a matter of fact, plenty of research has used eye tracking to focus on interaction between individuals in social settings,” she said. “The work done with AAC devices is all about improving social interaction.”

Martin acknowledged there will be those who are critical of this approach.

“There may be some resistance to using eye tracking for interventions and as an AAC. Today, almost all children use technology for learning, so the concern for children with [autism spectrum disorder] using technology for learning should not be heightened, unless future research warrants it,” she said.

Independent expert provides perspective

Eye tracking technology can help to provide more specific data on social interactions than is otherwise available, and recent advances have made it more accessible outside of the research setting, according to John D. Herrington, PhD, an assistant professor of psychology and psychiatry at The Children’s Hospital of Philadelphia, who is not affiliated with Tobii Pro’s research.

John Herrington
John D. Herrington

“I am very excited by the technology for several reasons. For decades eye tracking technology has been prohibitively expensive. But in the last 5 or 10 years we’ve gone from products that cost thousands of dollars to products that now cost hundreds of dollars. So, it’s a lot easier to imagine these products getting into places where we can actually use it better, he said.

“It can also be very difficult to come up with a hard, quantifiable number about how much social attention someone with autism is paying to someone else. We know typical-developing people take for granted that they can tell if a social interaction is going well, or if they are picking up on social cues or not. To put a number on that is really hard and what eye tracking allows us to do is more or less [obtain] data about how much social attention someone is paying to a person or thing,” Herrington said.

Herrington agreed that the advances technology offers should be integrated into a comprehensive diagnostic and management strategy.

“There are components of social interaction that are important, such as language, that an eye tracker is not ever going to measure. In addition, one of the main ways clinicians try to help patients with autism is to make them more effective in social situations and, of course, any piece of technology or device provides people an opportunity to avoid those situations rather than engage in them more.”

PAGE BREAK

This limitation is not deterring the development of the eye tracking technology, he said.

“The market and space surrounding these products is exploding. It’s not hard to imagine a future not too far off where our smartphones and our different devices can do some rudimentary eye tracking. And that’s sort of huge.” – by Janel Miller

Disclosures: Dawson reports being on the scientific advisory boards of Akili, Inc., Janssen Research and Development, and Roche Pharmaceuticals, has received grant funding from Janssen Research and Development, LLC., received royalties from Guildford Press and Oxford University Press, and is a member of DASIO, LLC. Montiero reports no relevant financial disclosures. Healio Family Medicine was unable to determine neither Herrington nor Martin’s relevant financial disclosures prior to publication.