Monday, 21 April 2014

Cognoa and the Dr Google Epidemic

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A new app aimed at helping parents who suspect their child is suffering from Autistic Spectrum Disorder has been announced. The app, Cognoa, offers to analyze the risk to the child's development based on a 2 minute video and a short parental questionnaire.

The CEO behind the app, Brent Vaughan, quotes the CDC, the US body responsible for disease control, that the number of cases of Autism has risen by 30% since 2010. The incidence of Autism is now 1 in 68 in the US, with 1 in 5 being diagnosed with learning difficulties.

At face value this app appears to be worthwhile. +TechCrunch mentions that it joins with the likes of Neurotrack, an automated cognitive test to which aims to predict the onset of Alzheimer’s Disease, as part of a new batch of startups which mash-up analytics, growth hacking and healthcare practice.

If this were a software package for clinicians, then that may well be fair. However, it's not. This is an app aimed at worried parents. That changes everything.

Post Hoc Ergo Propter Hoc, Doc

In the early April 14 BMJ, Michael McCarthy also quotes the CDC's findings. He highlights that the increase in diagnoses comes not from an increase in Autism rates but the widening of the diagnosis into a spectrum of disorders. This has led to more children with higher IQs and fewer symptoms being diagnosed with ASD.

So does this new app help parents caught up in a growing problem, or is it adding to the problem itself?

Apps Do Not Make Good Clinicians

The diagnosis of ASD is a complex process. Named ADOS (Autistic Diagnostic Observation Schedule), it involves a highly structured 1 hour interview designed to draw out the subtle signs of Autism and the video analysis of at least an hour’s worth of play by the child. Such is the complexity, three separate healthcare professionals are needed. First of all they analyze the data in private, then write down their diagnoses before coming together to compare notes and come to a common position.

The reason for this extended process is the complexity and subtlety of ASD. This is one area where following a prescriptive diagnostic flow-chart is simply impossible. Moreover, a misdiagnosis can be highly damaging; it may lead to inappropriate medicalization for a child at the extreme end of normal behavior and the labeling of that child in their own mind, in their parents and at their school.
Diagnosing ASD in children has added difficulties. Their stage of development and social context always play a factor. It's therefore reasonable to take extreme care in the assessment.

Providing an App for parents to jump in early on this process is highly inappropriate. Although the makers stress that the app is to assess risk, not diagnose, such a nicety is for research papers and not distraught parents. Inevitably it will lead to the parents forming a premature view.

Even if the App get’s it right, the child still needs formal assessment. But if it gets it wrong, a false-positive can lead to inappropriate worry for the parents, and insistence on treatment if the doctor they’re referred to does not agree, or a false-negative can lead to a child not being treated at all.

Dr Google Will See You Now

It’s also part of a wider trend reported in the BMJ as ‘Dr Google’. In a single blind study, Google proved to provide accurate medical information only 58% of the time. Nevertheless the use of Google to self-diagnose is on the increase.

To some extents that’s to be expected – people worry and seek information. But if it’s condoned by the medical profession it can seriously hamper the care that’s received, and tie up resources in the ‘worried-well’.

Whether Cognoa will follow this trend or pivot to a software package available to healthcare clinicians has yet to be seen. Currently, they are marketing directly to parents. As clinicians themselves they should perhaps stop and reconsider; Dr Google may well have a part to play in diagnosing a cold, or a broken arm, but has no place in complex, multifaceted disorders.