Clara Faria: Hello, I'm Clara Faria, I'm a ACAMH Young Person Ambassador and in today's episode I have the pleasure to talk to the Associate Professor Thomas Gargot His research focuses on technology applied to mental health and in particular applied to children and young people with neurodevelopmental conditions. Professor Gargot is also the winner of the 2024 ACAMH Awards in the category Digital Innovation Award for Best Digital Intervention. It's a huge pleasure to have you here today. Thank you so much for making the time. Can you start with an introduction? Thomas Gargot: Hello Clara, hello everyone. Thank you for the invitation and this opportunity. I am a medical doctor trained in child and psychiatry. I did a master's degree in cognitive science and after that I did a European PhD in computer science about the measure and the treatment of writing difficulties with electronic tablets. I will focus this podcast on this research that I do and follow up that we plan. I did this research in Paris and since I am in Tours, I am working in sensory in children with non-inflammatory disorder, have the development and the design of a deep pressure chair based on the work of Temple Grandin for children with autism, so the auto chair. And I am working also in virtual reality exposure treatment for children with sensory difficulties and children with autism. Clara Faria: That all sounds fantastic. And to have a deeper look at your research, one of the interventions you recently developed was a rehabilitation robotic companion for children with neurodevelopmental disorders such as autism. And can you tell us a little bit more about this project? Thomas Gargot: So like everyone knows, research is a teamwork in the École Polytechnique Fédérale de Lausanne in Switzerland. They developed a robot with dysgraphia, with writing difficulties, and an interesting scenario, motivating scenario in which the child was asked to teach a robot how to write. So by teaching the robot how to write, you need to give feedback to the robot, need to correct your own handwriting and you are motivated to see the improvement of the robot. And so you are motivated to improve your writing. This system was called the protégé effect in which you have a little protégé that you want to improve a little student, a little pupil. And it was very motivating for children because it's like there was a robot who was even worse, had even worse writing than themselves and so forth. CephalSim, was very good and they felt responsible for the robot. So it was a very good proof and principle that we did with our children, we know the experimental disorders, with dyslexia. So, dysgraphia the idea was to tackle writing difficulties, dysgraphia, but often the children have over-know developmental difficulties like ADHD, a social deficit, hyperactivity disorder, dyslexia, or developmental coordination disorder. Clara Faria: To follow up on that, another project you have in paper you published was around helping with dysgraphia, which is, as you mentioned, the difficulty in writing. And I was wondering, and also part of our audience is made up of parents and teachers, how common is the co-occurrence of dysgraphia and autism or other neurodevelopmental difficulties? And if you also can comment on what was the role of technology in this project? Thomas Gargot: So dysgraphia writing difficulties are very, very frequent. It's like in any neurodevelopmental difficulties, if you want to see how frequent is it, you need to put a threshold. You need to say, this is normal, this is pathological. This is quite artificial because how we understand the development of children, there is a continuum between what is normal at one stage, what is completely pathological at another age, and especially dysgraphia. There is a lot of children in the grey zone. What we saw was that it's very, very frequent, 10 to around 10 % of the population. When it's not pathological itself, it's not, for instance, in our psychiatry book, like a diagnostic and statistical mental disorders book, the DSM, but it's often associated with with no developmental disorders and can be a specifier. ADHD, for instance, is very frequent. 5 % of the population, autism, 1 % of the population, all of these disorders are very frequent. And we see that we can see dysgraphia in all of these difficulties. you have cognitive costs and you are more exhausted because you... You have to tackle a lot of information, motor information, how you handle with space, visual spatial difficulties, or your knowledge of letters. If you have dyslexia, it's difficult and these disorders can be associated. So we can say around 10 % of the population, but it's quite arbitrary to give a prevalence and quite complicated, not completely consensual. Clara Faria: When working with children with dysgraphia, do you think technology plays a role or do you think it's more traditional research methods that are better? Thomas Gargot: Yes, so it's completely paradoxical this idea because with new technologies people write mails, people go on social media. It's still important, I think, for two reasons to still to continue to be interested in handwriting because when you learn how to write, when you learn some stuff, the capacity for you to memorize and to learn is much better when you write than... when you type on letters, because when you use a keyboard, when you type on different letters, the movement you doing is completely the same. When you need to learn the letter and you draw it, it's much easier for you to learn it. So it's still important, on a cognitive point of view, it's still important to know how to write and to know your letters. In some children, it's too difficult. It's not possible to invest too much time in re-education, it's too costly, it's too tiring. And so it will be very important to replace it, for instance, by using keyboards, but also to do oral evaluation. And you mustn't be too much obsessed with handwriting re-education, but handwriting in typical development and... In a lot of children, the grey zone can be very useful to better memorize the different letters, the alphabet, and to better memorize what you need to learn when you take notes. New technologies are also very important for handwriting because when you write on pen and paper, then you have only the result. What is written and is it good or not? When you write on an electronic tablet, is interesting is that you can record a lot of information, lot of data. You can record the position of the pen, you can record the tilt, you can record the pressure. And from this data, you can describe what is happening 200 times a second, how the tilt, how the pressure, how the position is changing through time. And you can extract a lot of information, for instance, the mean of the speed, how much... lift of your pen you have and this really allows to characterize very finely on writing something that isn't possible at all when you write on paper. From all of these features, all your data that you extract from writing on tablet, you can do a lot of games, lot of serious games, lot of exercise. You can exercise your teeth, you can exercise how much you need to... to lift your pen or not, exercise your position without special abilities. So it's opened a new world of re-education and serious game based on the training on this feature. Clara Faria: That sounds super interesting. I never thought actually that you could recall so much information out of a tablet, you know, how the child writing is going. And I know that to develop this kind of project and this kind of technology, you you ended up involved in the creation of a startup, Nummies and that startup was in partnership with another researcher, Esselborn and I wondered if you can talk about the process of working together with these companies and how can we optimize this relationship between academia and industry.

Thomas Gargot: Yeah, it's great because in fact electronic tablets like ⁓ Wacom or even some electronic tablets like iPad or other tablets can be found on the market very easily and are not a medical device, complex medical device that you could think of when you think about education. It's something that is already in the market and easy to use. So like I said, there was this prototype of this graphic robot or something coming really from a robotic lab, a robotic lab in a teaching environment, I would say, because the professor, Pierre Dylambour, the head of the lab, is a professor from primary school as a trainer, as training, but also a professor in computer science. And he was very interested in how we could use computer science to improve education. From this, we arrived at the same time with Dr. Thibault Esselborn, who was trained as an engineer in computer science, working together. So me trained as a medical doctor and he trained as an engineer in computer science to understand how we could extract all these features from handwriting on electronic tablets. And if we could use these features to better describe and to better see if we could automatize writing difficulties assessment on electronic tablets like a screener of this graphier based on electronic tablets. So it was like a large database assessment of different handwriting samples on electronic tablets. But you know, there is this idea as medical doctors to add at the same point, at the same time, to be able to better describe, to better understand what's happening, but also to suggest new opportunities for treatment. And there was already this idea of learning by teaching effect, you teach a robot how to write, but we found that we could use these tilt features, these pressure features, these position features to do a lot of serious games that could be useful for children. The cost of having a robot is quite complicated, so we replaced the robot by an avatar, a robot inside a tablet directly, so it's scalable. So I continued in academia, and come back to more clinical activity. ⁓ as a main activity. And Thibaut continued to improve the accessibility of this work by transferring all this lab work to something that was much more usable on an iPad application that could be helpful for anyone and continue in the more economic and startup world. So they were able to... to collect, to get some grants and to begin to construct ⁓ the product. They showed that there was a lot of interest about that. It could be complicated to completely validate how this software could be proven to be a screening technology, a screening procedure that could... be in main routine that could be as good as or even better than the gold standard that we are using in France at the moment, a BHK. And the BHK is a method in which we only ask a child to copy a text on pen and paper. To do it was validated, was disseminated. But now we can, like I said, record a lot of data, position, pressure, tilt data, and we can be much finer. But we need to... really confirm it on iPad with this app and confirm that this app could be useful for re-education. And so it needs some evidence-based medicine research protocols that can be easy to run. And we are still looking for funding to confirm that we can screen and re-educate dysgraphia with this software. So you need to tackle different challenges. You need to tackle the need of a doctor to be able to prescribe something which was validated. You need to tackle assurance companies, organizations of health, that you have proven the efficacy of the device. You need to prove to institutions that you validated this new method. And at the same time, you need to have a sustainable, motivated startup who wants to invest time and energy in this field and to adapt the products to the end user, to the children, to the family, to the teacher, to have something who really fits the needs of the society and the children with dyspnea at the end. Clara Faria: You mentioned screening and you mentioned also the scalability and making sure that like the intervention started with robots and then you adapted this model into a tablet, which is something that is much more scalable as you said. And I was just wondering, and now you said you were in the stage of getting funding for trying to get funding to really test it and see the efficacy at a randomized controlled trial. And I was wondering, like, which is already kind of an implementation stage, right? And so. You know, what are your future plans to, you know, implement this, this intervention, this app for dysgraphia and yeah, and what are the challenges around implementation? Thomas Gargot: Next step, are preparing a European project and transforming healthcare system ground proposal to with zero objective to describe how we could to validate or we could detect dysgraphia with electronic. So there was a lot of work done in France, but it would be interesting to confirm also it's in different languages because the app is already working in French, Italian, English, German and Spanish. For the moment only on Latin alphabet, but it will be possible in future if there is interest and if there is a resource to adapt it in a different alphabet. We want to better understand what is the implementation of what is possible at the moment. What are people doing in France? It's very difficult to find resources for more severe difficulties. And so when you have only dysgraphia, it's not a care priority on a lot of children with only dysgraphia, have so much support and so much care. So it will be very interesting to have this new opportunity for these children and to have also opportunity for the children to maybe understand there are no developmental difficulties because they could have different... on writing styles. So it's a question that we have at the moment. We would like to confirm that it could be interesting in re-education. And to better understand the challenges of implementations, intercultural difference, is this app acceptable? Or we could change the life of a child with dysgraphia, but also the life of a teacher. Because you can imagine that dysgraphia screening could be done in schools. You can also imagine that some part of re-education could be suggested very early in schools when children learn to write. And so you have very early access to assessment on re-education procedure that we saw was very useful in many non-departure difficulties. Clara Faria: In recent years, we've seen a massive increase in the presence of technology in the mental health field. have, well, child robot interactions, which is a topic you are familiar with. We have digital mental health interventions. And we know that, as is your experience as well, lots of times to be able to make those interventions feasible, we need to work with mental health software developers. And I just wanted to ask you, what do you think are the main challenges of working with those companies and working with software developers to bring all those amazing research projects to life. Thomas Gargot: In fact, under any problem of research, we underestimate the complexity of what we wanted to do. But now it's for me quite clear that we are at different steps when we want to develop new technologies in the healthcare system. The first step is to understand what ⁓ is the treatment gap, how much we need to put energy to treat an unsolved problem or a problem which is a real or an everyday problem. A lot of engineers can't know what. We want what we need. We have new technologies, there are ideas, but to really understand what could be done, what are the everyday challenges, we need professional healthcare professional for that. After that, we need, as soon as we have an idea, we need to think about the user scenario. How I can use a new technology in a specific user scenario, in a specific setting. If this technology is visible. When it is feasible, can I begin a design on how to have a user-centered design approach to really tackle the need from the field? For instance, when we work on the auto chair, we did five iterations, five months of the chair between the day hospital and the factory. Or we can do the same thing in a lab, really to understand what is possible, how is it used and to refine each time to really focus on the need from the field. As soon as your design is fixed, which is quite complex when you think about big event software, Facebook, Twitter, LinkedIn are changing every time, but at some point you need to say, okay, this is basically the design I want, I need to finish this design. Only at this point you can begin to assess if... This is efficient if it's working because randomized controlled trials really change the practice of medicine in a lot of fields. In child-some psychiatry, it's more complicated because our therapies are more complex. Drugs can be enough, but in many situations, you need complex psychotherapy. And for re-education, like sensory difficulties or motor difficulties, to describe what we do, what we want to tackle, and how... the child evolves can be complicated. And as soon as you showed that it was efficient, you need to think about implementation, integration in healthcare, the system. You need to think also about acceptability, the new technology in the field, in the schools, in the hospital. And you have very hardcore engineer problem. You have evidence-based medicine, but you have also all the social impact, acceptability and implementation issues. And I think it's very important to understand that we need all this ecosystem. And after that, is it possible to have the device reimbursed? Is it possible to have a startup? And I'm not sure we are completely sure about that. Can we have a startup ecosystem that can be sustainable and financially viable enough to really go through to all these different stages. We have a lot of startups that develop software apps that are not validated, that were not developed with end users, that were not developed with mental health professionals, that are not tackling a real problem and the efficacy is not good enough. At the same time, we have lot of opportunities to improve access to healthcare problems and to... have scalable new possibilities of care, think. Wow. Clara Faria: That sounds really amazing work and that sounds a lot of work as well, which leads me to my next question, because I know that besides being a researcher, you're also a chat and lesson psychiatrist. In the beginning of the podcast, you mentioned you're currently working as a consultant in the emergency department. And I imagine this is very, very busy. And we also here at ACAMH have ⁓ a considerable early career audience. And I wanted to ask you about the importance of research in your career journey. Do you think it helped to become a better clinician as well? Like, do you think these two areas of your career fattened to each other? Yeah, and how do you juggle it all? Thomas Gargot: So you see it's a fascinating field because you need to speak with engineers, sociologists, health economists, specialists in evidence-based medicine, with teachers. Being able to be fluid, assertive enough to better understand the challenges of everyone is very, very important in research and I think very useful to deal with the complexity of... health and education organization that we deal with in everyday life as a clinician. It helps when you do research to better understand the different steps of research because this research was based on research from the over and you climb on the shoulders of giants to better understand the process of collecting data or writing a paper and publish it, allow to understand the process and to get used to read the literature. And the literature that can be useful for potential literature that can be useful for a child and adolescent psychiatrist is very, very wide because we need to deal with a brain which is thinking itself in its environment. So you need to have some basis in biology, in psychology, in sociology, in our environment. And I think we need to balance. And the best questions that we can have as clinician and researchers are questions from the field and questions from the patients. These kinds of questions are interested by two other clinicians, other researchers and can spread, but we need to be very open to different fields. What I saw in this research is that in computer science, you have lot of opportunities to better describe what's we do describe the difficulties of the children we see, and not only by reducing the difficulties, reducing the functions. It's not only assessing the genes or looking at what's happening in the brain. It's really describing how he writes, how he moves, how he interacts. And we can have a lot of information that we perceive, that we feel as clinicians, but difficult to... to describe and to characterize and these new technologies can give us a lot of opportunities to do this job. Clara Faria: Super interesting and thank you so much for sharing this experience with us. And going back to your own research work a little, I wanted to ask you what are your hopes for the future of your field and can you share with us any glimpses of current research projects you are involved in and you are excited about? Thomas Gargot: So next to be would be to understand if the auto chair what they do with the pressure in children with autism is working. So now we know that it was well designed following a good methodology of design. It was we are ⁓ showing by focus group on simulation that it is well accepted and how we can impact different institutions from the point of view of children with autism with or without anti-heterodeficiency, parents and professionals. And we have working with more fundamental researchers on understanding how it can work, how it could impact the development or peripersonal space, how we can perceive our body. So for me, it's really fascinating to both understand from the same product, from the same... children's experience, how is it accepted, if it is working, and how is it working. It's different fields, different methodology to find synergy between these different points of view is really fascinating. We are doing virtual reality in children with autism to tackle anxiety and to tackle, to improve flexibility and autonomy. And we would like to, so we're assessing efficacy, but we would like to add some captures to measure movement to measure physiological response to better understand how this exposure therapy technique works and how we could improve this ⁓ exposure therapy techniques to improve our care. Clara Faria: Well, that all sounds fascinating and I wish you all the success in your future research endeavors. Thank you so much, Dr. Gargot, for sharing your research with us and for taking the time on what I know is a very, very busy routine to discuss a little bit of your work with us here at ACAMH. And for more details on Dr. Gargot's work, please visit the ACAMH website. We're also going to link his website here in the page of this podcast. ACAMH is spelled A-C-A-M-H and do keep an eye out for other podcasts in the series. Don't forget to follow us on your preferred streaming platform and let us know if you enjoyed this podcast with a rating or review and do share with friends and colleagues. Thank you so much. Thomas Gargot: Thank you again for the invitation and thank you for this prize and thank you to ACAMH