Scalable Transdiagnostic Early Assessment of Mental Health (STREAM): a study protocol.

INTRODUCTION: Early childhood development forms the foundations for functioning later in life. Thus, accurate monitoring of developmental trajectories is critical. However, such monitoring often relies on time-intensive assessments which necessitate administration by skilled professionals. This difficulty is exacerbated in low-resource settings where such professionals are predominantly concentrated in urban and often private clinics, making them inaccessible to many. This geographic and economic inaccessibility contributes to a significant 'detection gap' where many children who might benefit from support remain undetected. The Scalable Transdiagnostic Early Assessment of Mental Health (STREAM) project aims to bridge this gap by developing an open-source, scalable, tablet-based platform administered by non-specialist workers to assess motor, social and cognitive developmental status. The goal is to deploy STREAM through public health initiatives, maximising opportunities for effective early interventions. METHODS AND ANALYSIS: The STREAM project will enrol and assess 4000 children aged 0-6 years from Malawi (n=2000) and India (n=2000). It integrates three established developmental assessment tools measuring motor, social and cognitive functioning using gamified tasks, observation checklists, parent-report and audio-video recordings. Domain scores for motor, social and cognitive functioning will be developed and assessed for their validity and reliability. These domain scores will then be used to construct age-adjusted developmental reference curves. ETHICS AND DISSEMINATION: Ethical approval has been obtained from local review boards at each site (India: Sangath Institutional Review Board; All India Institute of Medical Science (AIIMS) Ethics Committee; Indian Council of Medical Research-Health Ministry Screening Committee; Malawi: College of Medicine Research and Ethics Committee; Malawi Ministry of Health-Blantyre District Health Office). The study adheres to Good Clinical Practice standards and the ethical guidelines of the 6th (2008) Declaration of Helsinki. Findings from STREAM will be disseminated to participating families, healthcare professionals, policymakers, educators and researchers, at local, national and international levels through meetings, academic journals and conferences.

The integration of head and body cues during the perception of social interactions.

Humans spend a large proportion of time participating in social interactions. The ability to accurately detect and respond to human interactions is vital for social functioning, from early childhood through to older adulthood. This detection ability arguably relies on integrating sensory information from the interactants. Within the visual modality, directional information from a person's eyes, head, and body are integrated to inform where another person is looking and who they are interacting with. To date, social cue integration research has focused largely on the perception of isolated individuals. Across two experiments, we investigated whether observers integrate body information with head information when determining whether two people are interacting, and manipulated frame of reference (one of the interactants facing observer vs. facing away from observer) and the eye-region visibility of the interactant. Results demonstrate that individuals integrate information from the body with head information when perceiving dyadic interactions, and that integration is influenced by the frame of reference and visibility of the eye-region. Interestingly, self-reported autistics traits were associated with a stronger influence of body information on interaction perception, but only when the eye-region was visible. This study investigated the recognition of dyadic interactions using whole-body stimuli while manipulating eye visibility and frame of reference, and provides crucial insights into social cue integration, as well as how autistic traits affect cue integration, during perception of social interactions.

Autistic traits modulate the influence of face masks on gaze perception.

Detecting when others are looking at us is a crucial social skill. Accordingly, a range of gaze angles is perceived as self-directed; this is termed the "cone of direct gaze" (CoDG). Multiple cues, such as nose and head orientation, are integrated during gaze perception. Thus, occluding the lower portion of the face, such as with face masks during the COVID-19 pandemic, may influence how gaze is perceived. Individual differences in the prioritisation of eye-region and non-eye-region cues may modulate the influence of face masks on gaze perception. Autistic individuals, who may be more reliant on non-eye-region directional cues during gaze perception, might be differentially affected by face masks. In the present study, we compared the CoDG when viewing masked and unmasked faces (N = 157) and measured self-reported autistic traits. The CoDG was wider for masked compared to unmasked faces, suggesting that reduced reliability of lower face cues increases the range of gaze angles perceived as self-directed. Additionally, autistic traits positively predicted the magnitude of CoDG difference between masked and unmasked faces. This study provides crucial insights into the effect of face masks on gaze perception, and how they may affect autistic individuals to a greater extent.

Examining the value of body gestures in social reward contexts.

Brain regions associated with the processing of tangible rewards (such as money, food, or sex) are also involved in anticipating social rewards and avoiding social punishment. To date, studies investigating the neural underpinnings of social reward have presented feedback via static or dynamic displays of faces to participants. However, research demonstrates that participants find another type of social stimulus, namely, biological motion, rewarding as well, and exert effort to engage with this type of stimulus. Here we examine whether feedback presented via body gestures in the absence of facial cues also acts as a rewarding stimulus and recruits reward-related brain regions. To achieve this, we investigated the neural underpinnings of anticipating social reward and avoiding social disapproval presented via gestures alone, using a social incentive delay task. As predicted, the anticipation of social reward and avoidance of social disapproval engaged reward-related brain regions, including the nucleus accumbens, in a manner similar to previous studies' reports of feedback presented via faces and money. This study provides the first evidence that human body motion alone engages brain regions associated with reward processing in a similar manner to other social (i.e. faces) and non-social (i.e. money) rewards. The findings advance our understanding of social motivation in human perception and behavior.

Human body motion captures visual attention and elicits pupillary dilation.

The social motivation theory proposes that individuals naturally orient their attention to the social world. Research has documented the rewarding value of social stimuli, such as biological motion, to typically developed individuals. Here, we used complementary eye tracking measures to investigate how social motion cues affect attention and arousal. Specifically, we examined whether viewing the human body moving naturally versus mechanically leads to greater attentional engagement and changes in autonomic arousal (as assessed by pupil size measures). Participants completed an attentional disengagement task in two independent experiments, while pupillary responses were recorded. We found that natural, human-like motion produced greater increases in attention and arousal than mechanical motion, whether the moving agent was human or not. These findings contribute an important piece to our understanding of social motivation by demonstrating that human motion is a key social stimulus that engages visual attention and induces autonomic arousal in the viewer.

Decreased reward value of biological motion among individuals with autistic traits.

The Social Motivation Theory posits that a reduced sensitivity to the value of social stimuli, specifically faces, can account for social impairments in Autism Spectrum Disorders (ASD). Research has demonstrated that typically developing (TD) individuals preferentially orient towards another type of salient social stimulus, namely biological motion. Individuals with ASD, however, do not show this preference. While the reward value of faces to both TD and ASD individuals has been well-established, the extent to which individuals from these populations also find human motion to be rewarding remains poorly understood. The present study investigated the value assigned to biological motion by TD participants in an effort task, and further examined whether these values differed among individuals with more autistic traits. The results suggest that TD participants value natural human motion more than rigid, machine-like motion or non-human control motion, but this preference is attenuated among individuals reporting more autistic traits. This study provides the first evidence to suggest that individuals with more autistic traits find a broader conceptualisation of social stimuli less rewarding compared to individuals with fewer autistic traits. By quantifying the social reward value of human motion, the present findings contribute an important piece to our understanding of social motivation in individuals with and without social impairments.