Facilitating Other-Awareness in Low-Functioning Children with Autism and Typically-Developing Preschoolers Using Dual-Control Technology

Enhancing Pragmatic Language skills for Young children with Social communication difficulties (E-PLAYS-2) trial: study protocol for a cluster-randomised controlled trial evaluating a computerised intervention to promote communicative development and collaborative skills in young children

BACKGROUND

A number of children experience difficulties with social communication and this has long-term deleterious effects on their mental health, social development and education. The E-PLAYS-2 study will test an intervention ('E-PLAYS') aimed at supporting such children. E-PLAYS uses a dyadic computer game to develop collaborative and communication skills. Preliminary studies by the authors show that E-PLAYS can produce improvements in children with social communication difficulties on communication test scores and observed collaborative behaviours. The study described here is a definitive trial to test the effectiveness and cost-effectiveness of E-PLAYS delivered by teaching assistants in schools.

METHODS

The aim of the E-PLAYS-2 trial is to establish the effectiveness and cost-effectiveness of care as usual plus the E-PLAYS programme, delivered in primary schools, compared to care as usual. Cluster-randomisation will take place at school level to avoid contamination. The E-PLAYS intervention will be delivered by schools' teaching assistants. Teachers will select suitable children (ages 5-7 years old) from their schools using guidelines provided by the research team. Assessments will include blinded language measures and observations (conducted by the research team), non-blinded teacher-reported measures of peer relations and classroom behaviour and parent-reported use of resources and quality of life. A process evaluation will also include interviews with parents, children and teaching assistants, observations of intervention delivery and a survey of care as usual. The primary analysis will compare pragmatic language scores for children who received the E-PLAYS intervention versus those who did not at 40 weeks post-randomisation. Secondary analyses will assess cost-effectiveness and a mixed methods process evaluation will provide richer data on the delivery of E-PLAYS.

DISCUSSION

The aim of this study is to undertake a final, definitive test of the effectiveness of E-PLAYS when delivered by teaching assistants within schools. The use of technology in game form is a novel approach in an area where there are currently few available interventions. Should E-PLAYS prove to be effective at the end of this trial, we believe it is likely to be welcomed by schools, parents and children.

TRIAL REGISTRATION

ISRCTN 17561417, registration date 19th December 2022.

PROTOCOL VERSION

v1.1 19th June 2023.

Aphantasia within the framework of neurodivergence: Some preliminary data and the curse of the confidence gap

Aphantasia is a neurocognitive phenomenon affecting voluntary visual imagery, such that it is either entirely absent, or markedly impaired. Using both the social and medical models of disability, this article discusses the extent to which aphantasia can be understood as a disorder or just a form of neutral neurodivergence, given that imagery plays a central role in thinking and memory for most other people. Preliminary school performance data are presented, showing that low imagery does not necessarily complicate life, especially given compensatory strategies and low societal barriers. In addition, we discuss the consequences of labelling aphantasia a disorder with regard to self- and public stigma, and we provide further data regarding a confidence gap, by which aphantasics perceive themselves as performing worse than they objectively do. We conclude that aphantasia should be understood as neutral neurodivergence and that labelling it a disorder is not only wrong, but potentially harmful.

Seeing and inviting participation in autistic interactions

What does it take to see how autistic people participate in social interactions? And what does it take to support and invite more participation? Western medicine and cognitive science tend to think of autism mainly in terms of social and communicative deficits. But research shows that autistic people can interact with a skill and sophistication that are hard to see when starting from a deficit idea. Research also shows that not only autistic people, but also their non-autistic interaction partners, can have difficulties interacting with each other. To do justice to these findings, we need a different approach to autistic interactions-one that helps everyone see, invite, and support better participation. I introduce such an approach, based on the enactive theory of participatory sense-making and supported by insights from indigenous epistemologies. This approach helps counteract the homogenizing tendencies of the "global mental health" movement, which attempts to erase rather than recognize difference, and often precludes respectful engagements. Based in the lived experiences of people in their socio-cultural-material and interactive contexts, I put forward an engaged-even engaging-epistemology for understanding how we interact across difference. From this perspective, we see participatory sense-making at work across the scientific, diagnostic, therapeutic, and everyday interactions of autistic and non-autistic people, and how everyone can invite and support more of it.

Assistive Technology to Improve Collaboration in Children with ASD: State-of-the-Art and Future Challenges in the Smart Products Sector

Within the field of products for autism spectrum disorder, one of the main research areas is focused on the development of assistive technology. Mid and high-tech products integrate interactive and smart functions with multisensory reinforcements, making the user experience more intuitive, adaptable, and dynamic. These products have a very significant impact on improving the skills of children with autism, including collaboration and social skills, which are essential for the integration of these children into society and, therefore, their well-being. This work carried out an exhaustive analysis of the scientific literature, as well as market research and trends, and patent analysis to explore the state-of-the-art of assistive technology and smart products for children with ASD, specifically those aimed at improving social and communication skills. The results show a reduced availability of products that act as facilitators of the special needs of children with ASD, which is even more evident for products aimed at improving collaboration skills. Products that allow the participation of several users simultaneously through multi-user interfaces are required. On top of this, the trend toward virtual environments is leading to a loss of material aspects in the design that are essential for the development of these children.

Acting with shared intentions: A systematic review on joint action coordination in Autism Spectrum Disorder

BACKGROUND

Joint actions, described as a form of social interaction in which individuals coordinate their actions in space and time to bring about a change in the environment, rely on sensory-motor processes that play a role in the development of social skills. Two brain networks, associated with "mirroring" and "mentalizing", are engaged during these actions: the mirror neuron and the theory of mind systems. People with autism spectrum disorder (ASD) showed impairment in interpersonal coordination during joint actions. Studying joint action coordination in ASD will contribute to clarify the interplay between sensory-motor and social processes throughout development and the interactions between the brain and the behavior.

METHOD

This review focused on empirical studies that reported behavioral and kinematic findings related to joint action coordination in people with ASD.

RESULTS

Literature on mechanisms involved in the joint action coordination impairment in ASD is still limited. Data are controversial. Different key-components of joint action coordination may be impaired, such as cooperative behavior, temporal coordination, and motor planning.

CONCLUSIONS

Interpersonal coordination during joint actions relies on early sensory-motor processes that have a key role in guiding social development. Early intervention targeting the sensory-motor processes involved in the development of joint action coordination could positively support social skills.

Evaluating 'Enhancing Pragmatic Language skills for Young children with Social communication impairments' (E-PLAYS): a feasibility cluster-randomised controlled trial

BACKGROUND

This article reports the results from a feasibility study of an intervention ('E-PLAYS') aimed at supporting children who experience difficulties with social communication. E-PLAYS is based around a dyadic computer game, which aims to develop collaborative and communication skills. A pilot study found that when E-PLAYS was delivered by researchers, improvements on communication test scores and on collaborative behaviours were observed. The aim of this study was to ascertain the feasibility of running a full-scale trial to test the effectiveness of E-PLAYS in a National Health Service (NHS) setting with delivery by speech and language therapists and teaching assistants.

METHODS

The study was a two-arm feasibility cluster-randomised controlled trial of the E-PLAYS intervention with a treatment as usual control arm. Data relating to recruitment and retention, treatment fidelity, acceptability to participants, suitability of outcomes and feasibility of collecting health economic measures and of determining cost-effectiveness were collected. Speech and language therapists selected suitable children (ages 4-7 years old) from their caseload. E-PLAYS intervention (experimental group) was then delivered by teaching assistants overseen by speech and language therapists. The control group received usual care. Assessments included blinded language measures and observations, non-blinded teacher-reported measures of peer relations and classroom behaviour and non-blinded parent-reported use of health and education resources and quality of life.

RESULTS

Planned recruitment was for 70 children, in the event, 50 children were recruited which was sufficient for feasibility purposes. E-PLAYS was very highly rated by children, teaching assistants and speech and language therapists and treatment fidelity did not pose any issues. We were able to collect health economic data which suggests that E-PLAYS would be a low-cost intervention.

CONCLUSION

Based on recruitment, retention and adherence rates and our outcome measures, a full-scale randomised controlled trial estimated appears feasible and warranted to assess the effectiveness of E-PLAYS for use by the NHS and schools.

TRIAL REGISTRATION

ISRCTN 14818949 (retrospectively registered).

Evaluating 'enhancing pragmatic language skills for young children with social communication impairments' (E-PLAYS): protocol for a feasibility randomised controlled trial study

Background

A number of children experience difficulties with social communication and this has long-term deleterious effects on their mental health, social development and education. The proposal presented in this article describes a feasibility study for a trial to test an intervention (‘E-PLAYS’) aimed at supporting children with social communication impairments. E-PLAYS harnesses technology in the form of a novel computer game in order to develop collaborative and communication skills. Preliminary studies by the authors show that when E-PLAYS was administered by the research team, children with social communication impairments showed improvements on communication test scores and on observed collaborative behaviours. The study described here is a pragmatic trial to test the application of E-PLAYS delivered by NHS speech and language therapists together with schools.

Methods

This protocol outlines a two-arm feasibility cluster-randomised controlled trial of the E-PLAYS intervention with treatment as usual control arm, with randomisation at the level of the speech and language therapist. The aim of this study is to ascertain whether it will be feasible to progress to running a full-scale definitive trial to test the effectiveness of E-PLAYS in an NHS setting. Data relating to recruitment and retention, the appropriateness of outcomes and the acceptability of E-PLAYS to participants will be collected.

Speech and language therapists will select suitable children (ages 4–7 years old) from their caseloads and deliver either the E-PLAYS intervention (experimental group) or treatment as usual (control group). Assessments will include blinded language measures and observations, non-blinded teacher-reported measures of peer relations and classroom behaviour and parent-reported use of resources and quality of life. There will also be a qualitative process evaluation.

Discussion

The findings of this study will inform the decision as to whether to progress to a full-scale definitive randomised controlled trial to test the effectiveness of E-PLAYS when delivered by speech and language therapists and teaching assistants within schools. The use of technology in game form is a novel approach in an area where there are currently few available interventions.

Trial registration

ISRCTN 14818949 (retrospectively registered).

Beyond autism and technology: lessons from neurodiverse populations

Purpose

The purpose of this paper is to report on the sixth seminar in a seven-seminar series entitled, Innovative Technologies for Autism: Critical Reflections on Digital Bubbles, funded by the UK Economic and Social Research Council. The aim of this particular seminar was to reflect upon the implications from neurodiverse communities for the development of technology for autism.

Design/methodology/approach

Presentations from key researchers and parental perspectives are reviewed, highlighting contemporary issues in neurodiverse populations that have important implications for autism.

Findings

Whilst there are many conditions associated with autism, most commonly intellectual disability (learning difficulties), this is not reflected in research. In addition, for child-based research, researchers are at least a generation older than participants and have had different digital-childhoods. Involving neurodiverse populations within participatory design sessions can address both of these issues. Understanding the context of the issues that the participatory design sessions address is crucial for developing participatory design principles that extend from one condition to another. This includes understanding when findings based upon verbal populations can be extended to non-verbal populations.

Originality/value

This paper offers up-to-date insights into how design principles from one condition extend to different conditions. Universal interaction and neurodiversity HCI are considered. This is important within neurodiverse populations, especially given the high rates of additional conditions that are associated with autism. Whilst the majority of autism research has involved verbal populations, the benefits of technology can extend to non-verbal populations.

Autism in Action: Reduced Bodily Connectedness during Social Interactions?

Autism is a lifelong disorder, defined by deficits in social interactions and flexibility. To date, diagnostic markers for autism primarily include limitations in social behavior and cognition. However, such tests have often shown to be inadequate for individuals with autism who are either more cognitively able or intellectually disabled. The assessment of the social limitations of autism would benefit from new tests that capture the dynamics of social initiative and reciprocity in interaction processes, and that are not dependent on intellectual or verbal skills. New entry points for the development of such assessments may be found in ‘bodily connectedness’, the attunement of bodily movement between two individuals. In typical development, bodily connectedness is related to psychological connectedness, including social skills and relation quality. Limitations in bodily connectedness could be a central mechanism underlying the social impairment in autism. While bodily connectedness can be minutely assessed with advanced techniques, our understanding of these skills in autism is limited. This Perspective provides examples of how the potential relation between bodily connectedness and specific characteristics of autism can be examined using methods from the coordination dynamics approach. Uncovering this relation is particularly important for developing sensitive tools to assess the tendency to initiate social interactions and the dynamics of mutual adjustments during social interactions, as current assessments are not suited to grasp ongoing dynamics and reciprocity in behavior. The outcomes of such research may yield valuable openings for the development of diagnostic markers for autism that can be applied across the lifespan.

Innovative technologies for autism: critical reflections on digital bubbles

Purpose

– There is increasing interest from researchers, teachers and other professionals, individuals with autism, and families about the potential for innovative technologies to transform learning experiences and facilitate friendships and social networks. Media accounts have highlighted both the apparently miraculous impacts of technology on supporting communication and learning for people with autism, as well as significant concerns about whether technology use is healthy, safe and socially appropriate for children and young people. Rarely, however, is any evidence reported to support either set of claims. The paper aims to discuss these issues.

Design/methodology/approach

– This short paper reports on an Economic and Social Research Council-funded seminar series in the UK that is critically reviewing and discussing the field with respect to the research evidence base but also the assumptions that are made about where, how and whether innovative technologies may be useful for people with autism and their families.

Findings

– The first seminar in the series focused on whether technologies create a social bubble for people with autism and presented research demonstrating that technology use can be positive, supportive and rewarding.

Originality/value

– This paper offers an up-to-date insight into some of key debates about the benefits and limitations of social technologies for people with autism. Its value lies in raising questions about, and discussing evidence that challenges, some of the negative assumptions that are often perpetuated by the media about the potentially harmful effects of technologies.

Intersections between the autism spectrum and the internet: perceived benefits and preferred functions of computer-mediated communication

An online survey compared the perceived benefits and preferred functions of computer-mediated communication of participants with (N  =  291) and without ASD (N  =  311). Participants with autism spectrum disorder (ASD) perceived benefits of computer-mediated communication in terms of increased comprehension and control over communication, access to similar others, and the opportunity to express their true selves. They enjoyed using the Internet to meet others more, and to maintain connections with friends and family less, than did participants without ASD. People with ASD enjoyed aspects of computer-mediated communication that may be associated with special interests or advocacy, such as blogging, more than did participants without ASD. This study suggests that people with ASD may use the Internet in qualitatively different ways from those without ASD. Suggestions for interventions are discussed.

A randomised controlled trial of a computerised intervention for children with social communication difficulties to support peer collaboration

An intervention aiming to support children with social communication difficulties was tested using a randomised controlled design. Children aged 5-6 years old (n=32) were tested and selected for participation on the basis of their scores on the Test of Pragmatic Skills (TPS) and were then randomly assigned to the intervention arm or to the delayed intervention control group. Following previous research which suggested that computer technology may be particularly useful for this group of children, the intervention included a collaborative computer game which the children played with an adult. Subsequently, children's performance as they played the game with a classmate was observed. Micro-analytic observational methods were used to analyse the audio-recorded interaction of the children as they played. Pre- and post-intervention measures comprised the Test of Pragmatic Skills, children's performance on the computer game and verbal communication measures that the children used during the game. This evaluation of the intervention shows promise. At post-test, the children who had received the intervention, by comparison to the control group who had not, showed significant gains in their scores on the Test of Pragmatic Skills (p=.009, effect size r=-.42), a significant improvement in their performance on the computer game (p=.03, r=-.32) and significantly greater use of high-quality questioning during collaboration (p<.001, r=-.60). Furthermore, the children who received the intervention made significantly more positive statements about the game and about their partners (p=.02, r=-.34) suggesting that the intervention increased their confidence and enjoyment.

We can work it out: an enactive look at cooperation

The past years have seen an increasing debate on cooperation and its unique human character. Philosophers and psychologists have proposed that cooperative activities are characterized by shared goals to which participants are committed through the ability to understand each other's intentions. Despite its popularity, some serious issues arise with this approach to cooperation. First, one may challenge the assumption that high-level mental processes are necessary for engaging in acting cooperatively. If they are, then how do agents that do not possess such ability (preverbal children, or children with autism who are often claimed to be mind-blind) engage in cooperative exchanges, as the evidence suggests? Secondly, to define cooperation as the result of two de-contextualized minds reading each other's intentions may fail to fully acknowledge the complexity of situated, interactional dynamics and the interplay of variables such as the participants' relational and personal history and experience. In this paper we challenge such accounts of cooperation, calling for an embodied approach that sees cooperation not only as an individual attitude toward the other, but also as a property of interaction processes. Taking an enactive perspective, we argue that cooperation is an intrinsic part of any interaction, and that there can be cooperative interaction before complex communicative abilities are achieved. The issue then is not whether one is able or not to read the other's intentions, but what it takes to participate in joint action. From this basic account, it should be possible to build up more complex forms of cooperation as needed. Addressing the study of cooperation in these terms may enhance our understanding of human social development, and foster our knowledge of different ways of engaging with others, as in the case of autism.