Designing Serious Game Interventions for Individuals with Autism

The Need for Technology-Aided Instruction and Intervention Policy for Autistic Youth

This paper examines current technology-aided instruction and intervention (TAII) available for autistic transition-age youth (TAY) and existing policies that may support or hinder the delivery of these interventions. Specifically, we focus on policies that might influence the delivery of TAII to autistic TAY. After a careful review of the literature, we observed that postsecondary policy guiding the delivery of TAII designed to support autistic TAY is lacking. TAII have demonstrated effectiveness, usability, sustainability, and cost-effectiveness, particularly with this population. We suggest possibilities for future policies to support the development, implementation, and evaluation of TAII for autistic TAY.

Effectiveness of serious games in social skills training to autistic individuals: A systematic review

Autism Spectrum Disorder (ASD) is a complex neurological condition that significantly impacts individuals' daily lives and social interactions due to challenges in verbal and non-verbal communication. Game-based tools for psychological support and patient education are rapidly gaining traction. Among these tools, teaching social skills via serious games has emerged as a particularly promising educational strategy for addressing specific characteristics associated with autism. Unlike traditional games, serious games are designed with a dual purpose: to entertain and to fulfill a specific educational or therapeutic goal. This systematic review aims to identify and categorize serious computer games that have been used to teach social skills to autistic individuals and to assess their effectiveness. We conducted a comprehensive search across seven databases, resulting in the identification and analysis of 25 games within 26 studies. Out of the 104 criteria assessed across these studies, 57 demonstrated significant improvement in participants. Furthermore, 22 of these studies reported significant enhancements in at least one measured criterion, with 13 studies observing significant improvements in all assessed outcomes. These findings overwhelmingly support the positive impact of computer-based serious game interventions in teaching social skills to autistic individuals.

Engagnition: A multi-dimensional dataset for engagement recognition of children with autism spectrum disorder

Engagement plays a key role in improving the cognitive and motor development of children with autism spectrum disorder (ASD). Sensing and recognizing their engagement is crucial before sustaining and improving the engagement. Engaging technologies involving interactive and multi-sensory stimuli have improved engagement and alleviated hyperactive and stereotyped behaviors. However, due to the scarcity of data on engagement recognition for children with ASD, limited access to and small pools of participants, and the prohibitive application requirements such as robots, high cost, and expertise, implementation in real world is challenging. However, serious games have the potential to overcome those drawbacks and are suitable for practical use in the field. This study proposes Engagnition, a dataset for engagement recognition of children with ASD (N = 57) using a serious game, "Defeat the Monster," based on enhancing recognition and classification skills. The dataset consists of physiological and behavioral responses, annotated by experts. For technical validation, we report the distributions of engagement and intervention, and the signal-to-noise ratio of physiological signals.

Serious Games for Developing Social Skills in Children and Adolescents with Autism Spectrum Disorder: A Systematic Review

Serious games represent a promising avenue for intervention with children diagnosed with autism spectrum disorder, a neurodevelopmental disorder marked by persistent challenges in social communication and the presence of restricted, repetitive behaviors. Despite this potential, comprehensive reviews on this subject are scarce. This systematic review aims to evaluate the effectiveness of serious games and their specific characteristics in enhancing social skills among children and adolescents with autism. Employing PICO strategies and adhering to PRISMA guidelines, we screened 149 studies initially identified through PubMed and EBSCOhost databases. Nine studies met inclusion criteria and found a positive influence of serious games on social skills and related domains, encompassing emotion recognition/encoding/decoding, emotional regulation, eye gaze, joint attention, and behavioral skills. Nevertheless, despite these promising results, the limited available evidence underscores the need for rigorous study designs to consolidate findings and integrate evidence-based intervention strategies.

Social visual attention as a treatment outcome: evaluating the social games for autistic adolescents (SAGA) intervention

A core feature of autism involves difficulty perceiving and interpreting eye gaze shifts as nonverbal communicative signals. A hypothesis about the origins of this phenotype is that it emerges from developmentally different social visual attention (SVA). We developed Social Games for Autistic Adolescents (SAGA; Scherf et al. BMJ Open 8(9):e023682, 2018) as a serious game intervention for autistic individuals to discover the significance of eye gaze cues. Previously, we demonstrated the effectiveness of SAGA to improve the perception and understanding of eye gaze cues and social skills for autistic adolescents (Griffin et al. JCPP Adv 1(3):e12041, 2021). Here, we determine whether increases in social visual attention to faces and/or target gazed-at objects, as measured via eye tracking during the same Gaze Perception task in the same study sample, moderated this improvement. In contrast to predictions, SVA to faces did not differentially increase for the treatment group. Instead, both groups evinced a small increase in SVA to faces over time. Second, Prior to the SAGA intervention, attention to faces failed to predict performance in the Gaze Perception task for both the treatment and standard care control groups. However, at post-test, autistic adolescents in the treatment group were more likely to identify the object of directed gaze when they attended longer to faces and longer to target objects. Importantly, this is the first study to measure social visual attention via eye tracking as a treatment response in an RCT for autism. NCT02968225.

Co-Design of a Virtual Reality Multiplayer Adventure Game for Adolescents With Autism Spectrum Disorder: Mixed Methods Study

BACKGROUND

Virtual reality (VR) adventure games can offer ideal technological solutions for training social skills in adolescents with autism spectrum disorder (ASD), leveraging their support for multisensory and multiplayer interactions over distance, which may lower barriers to training access and increase user motivation. However, the design of VR-based game environments for social skills training is still understudied and deserves the deployment of an inclusive design approach to ensure its acceptability by target users.

OBJECTIVE

We aimed to present the inclusive design process that we had followed to develop the Zentastic VR adventure game to foster social skills training in adolescents with ASD and to investigate its feasibility as a training environment for adolescents.

METHODS

The VR game supports multiplayer training sessions involving small groups of adolescents and their therapists, who act as facilitators. Adolescents with ASD and their therapists were involved in the design and in an explorative acceptability study of an initial prototype of the gaming environment, as well as in a later feasibility multisession evaluation of the VR game final release.

RESULTS

The feasibility study demonstrated good acceptability of the VR game by adolescents and an enhancement of their social skills from baseline to posttraining.

CONCLUSIONS

The findings provide preliminary evidence of the benefits that VR-based games can bring to the training of adolescents with ASD and, potentially, other neurodevelopmental disorders.

Qualitative analysis of mental health conversational agents messages about autism spectrum disorder: a call for action

Background

Conversational agents (CA's) have shown promise in increasing accessibility to mental health resources. This study aimed to identify common themes of messages sent to a mental health CA (Wysa) related to ASD by general users and users that identify as having ASD.

Methods

This study utilized retrospective data. Two thematic analyses were conducted, one focusing on user messages including the keywords (e.g., ASD, autism, Asperger), and the second one with messages from users who self-identified as having ASD.

Results

For the sample of general users, the most frequent themes were "others having ASD," "ASD diagnosis," and "seeking help." For the users that self-identified as having ASD (n = 277), the most frequent themes were "ASD diagnosis or symptoms," "negative reaction from others," and "positive comments." There were 3,725 emotion words mentioned by users who self-identified as having ASD. The majority had negative valence (80.3%), and few were positive (14.8%) or ambivalent (4.9%).

Conclusion

Users shared their experiences and emotions surrounding ASD with a mental health CA. Users asked about the ASD diagnosis, sought help, and reported negative reactions from others. CA's have the potential to become a source of support for those interested in ASD and/or identify as having ASD.

A Scoping Review of the Serious Game-Based Rehabilitation of People with Cerebral Palsy

In a serious context, individuals with Cerebral Palsy (CP) have limited opportunities to engage in social interaction experiences. Through a review, this study provides an explanation and improved evidence of the methods for rehabilitation in games used in serious contexts for people with CP. Articles published from 2010 to 2022 focusing on serious game-based rehabilitation for people with CP are extracted from MEDILINE, Academic Search Ultimate, CINAHL, and the Web of Science. The articles were assessed based on the McMaster critical review form. This study analyzes the frequencies of goal and assessment tools according to the components using the International Classification of Functioning, Disability and Health (ICF). The evidence of all the studies is presented according to the principles of Population, Intervention, Comparison, Outcome (PICO) to organize the evidence. A total of 19 articles were selected. Five articles involved Randomized Controlled Trials (RCTs), six articles involved non-randomized one-group designs, three articles involved single experimental study designs, and five articles were case report designs. In the selected articles, the average score on the McMaster critical review form was 11.8 points. In the game-based rehabilitation for CP, more articles reported goals and assessment tools focusing on body function than goals and assessment tools focusing on activity and participation, according to the ICF. These findings provide a record of past work and identify the evidence to support the application of game-based rehabilitation for people with CP.

Research on the design of somatosensory interactive games for autistic children based on art therapy

There is no targeted drug treatment for autistic children. Educational intervention and rehabilitation are the main ways to improve the ability development of autistic children. However, there are great differences in the individual symptoms and abilities. It is an urgent need for educators, practitioners and parents of autistic children to find effective ways to improve their cognitive, social and motor abilities. The author cooperates with the therapist to study and design the somatosensory interaction game for autistic children, which is a formal attempt of art therapy on the treatment tool, with the purpose of studying an effective and safe art intervention method. In order to verify the effect, the author recruited 26 children with mild or moderate autism for a six-week empirical evaluation, and the participants were randomly assigned. Among them, 13 participants participated in the art therapy of the proposed somatosensory game group (the experimental group), and 13 participants participated the traditional picture book group (the control group) that improved the emotion, cognition and skills of children, and the design style was more popular with children. The aesthetic design in the picture book could have an intervention effect on the participants, and its artistic effect could serve as an effective reference for the interface design of the game group. The results showed that the two groups had a significant impact on the participants in different aspects. The game group improved not only in terms of concentration and special ability, but also in terms of physical coordination and activity enhancement, it is inferred that the core factors of game therapy are sub-intervention, interaction and feedback, icon design and color matching system; the picture book group has significant improvement in interpersonal relationship guidance and language learning and communication. The results show that it is necessary to take more comprehensive and richer preliminary research on the development of treatment products for autistic children. Because picture book education requires children's initial concentration, it is found that picture book therapy has high requirements for teachers' classroom control and relatively strict requirements for picture book content, and play therapy can be a good complement to these problems.

Iterative Design, Feasibility, and Preliminary Efficacy Testing for the Development of a Cooperative Card Game Intervention to Reduce Loneliness and Foster Social Connection

Objective: To present the design, development, and pilot testing of Connections, an empirically derived cooperative card game intervention to reduce loneliness and enhance connection. Materials and Methods: Theory and empirical evidence from domains such as self-disclosure, interpersonal closeness, and serious games informed the design of this game. Iterative design was used to develop the intervention, followed by feasibility and preliminary efficacy pilot testing. Results: Pilot testing showed that participants felt confident playing the game and found Connections to be enjoyable, interesting, and helpful in building connections with others, and would recommend the game to others. Preliminary evaluation found statistically significant benefits across multiple domains after playing the game. Participants reported decreases in loneliness, depressed mood, and anxiousness (ps < 0.02). Additionally, participants reported increases in looking forward to forming new connections with others in the future, the degree to which they felt like opening up and talking to others, and the amount they felt like they had in common with others (ps < 0.05). Conclusion: Pilot testing of Connections demonstrated feasibility and preliminary impact among a community sample. Future development plans include minor revisions to the game instructions followed by more rigorous testing of the feasibility, usability, and efficacy of Connections among various settings and populations, with large samples and controlled trials.

A randomized controlled trial on the digital socio-emotional competence training Zirkus Empathico for preschoolers

In this randomized controlled trial (RCT), the digital socio-emotional competence training Zirkus Empathico was tested in 74 Central European children (5.1 (0.9) years; 34 females) within a longitudinal design (three time points: T1 = pre-training; T2 = immediately following 6-week training, T3 = 3-month follow-up). The pre-registered primary outcome was empathy, secondary outcomes included emotion recognition, prosocial behavior, and behavioral problem reduction; furthermore, children's neural sensitivity to facial expressions quantified with event-related potentials. Compared to controls (N = 38), Zirkus Empathico participants (N = 36) showed increases in empathy (d = 0.28 [-0.17, 0.76]), emotion recognition (d = 0.57 [0.01, 1.06]), prosocial behavior (d = 0.51 [0.05, 0.99]) and reduced behavioral problems (d = 0.54 [0.08, 1.03]). They also showed larger P3 amplitudes to happy vs. angry and neutral facial expressions post-training. Thus, Zirkus Empathico may be a promising digital training for social competence in preschoolers.

The Use of Serious Gaming to Improve Sensorimotor Function and Motivation in People with Cerebral Palsy: A Systematic Review

The aim of this systematic review was to review the evidence for serious gaming interventions in improving sensorimotor function in children and adults with cerebral palsy (CP). Seven databases were searched with terms related to serious gaming and CP. Articles were evaluated according to the Downs and Black rating scale and important principles of serious gaming defined by Whyte et al. Extracted data included the population, intervention, serious gaming elements, outcomes, and authors' conclusions. Fifty-seven articles were identified for inclusion. Participants' ages ranged from 3 to 57 years. Interventions tested included commercial videogames as well as specially designed games. Most interventions had themed content, short-term goals, rewards, feedback, and multiple games. Outcome measures and study designs were inconsistent between studies. Sensorimotor function results of noncomparative studies were positive or neutral overall, but results of comparative studies were more mixed. We concluded that serious gaming interventions may be a useful adjunct to treatment as they are noninvasive, were not associated with deterioration in most cases, and may improve compliance. More comparative studies need to be completed to assess compliance and treatment outcomes. Future games should also aim to adhere more closely to the principles of serious gaming.

Serious Games in the new era of digital-health interventions: A narrative review of their therapeutic applications to manage neurobehavior in neurodevelopmental disorders

Children and adolescents with neurodevelopmental disorders generally show adaptive, cognitive and motor skills impairments associated with behavioral problems, i.e., alterations in attention, anxiety and stress regulation, emotional and social relationships, which strongly limit their quality of life. This narrative review aims at providing a critical overview of the current knowledge in the field of serious games (SGs), known as digital instructional interactive videogames, applied to neurodevelopmental disorders. Indeed, a growing number of studies is drawing attention to SGs as innovative and promising interventions in managing neurobehavioral and cognitive disturbs in children with neurodevelopmental disorders. Accordingly, we provide a literature overview of the current evidence regarding the actions and the effects of SGs. In addition, we describe neurobehavioral alterations occurring in some specific neurodevelopmental disorders for which a possible therapeutic use of SGs has been suggested. Finally, we discuss findings obtained in clinical trials using SGs as digital therapeutics in neurodevelopment disorders and suggest new directions and hypotheses for future studies to bridge the gaps between clinical research and clinical practice.

Mixed methods implementation evaluation of virtual interview training for transition-age autistic youth in pre-employment transition services

BACKGROUND

Autistic transition-age youth are employed at rates far lower than their non-disabled peers as well as youth with other disabilities. Meanwhile, very few studies have evaluated the implementation of job interviewing practices within pre-employment transition services.

OBJECTIVE

We conducted an initial implementation evaluation as part of a Type I hybrid randomized controlled effectiveness-implementation trial where we trained teachers to deliver Virtual Interview Training for Transition-Age Youth (VIT-TAY) within five pre-employment transition services programs.

METHODS

We used mixed methods to evaluate leader (n=5), teacher (n=15) and autistic transition age youth (n=48) perceptions of VIT-TAY. We used descriptive statistics and thematic network analysis to evaluate survey data. Mixed methods integration was then performed to make comparisons between quantitative and qualitative results.

RESULTS

Quantitative survey data revealed that leaders and teachers found VIT-TAY to be highly acceptable and appropriate for pre-employment transition services; findings which were confirmed via thematic network analysis of qualitative interview data. Autistic students reported via quantitative surveys that VIT-TAY was acceptable and usable, which was confirmed via thematic network analysis of open-ended survey data.

CONCLUSIONS

This initial implementation evaluation can be used to inform a larger scale implementation evaluation of VIT-TAY in schools.

Evaluation of the Effect of a Serious Game on the Performance of Daily Routines by Autistic and ADHD Children

Objectives

Learning and performing new routines are difficult for children with neurodevelopmental disorders. Studies have shown that consistency in child reinforcement and parental support are effective. For example, digital solutions such as serious games can be used to support parents and children in developing these life skills. The objective of this study was to evaluate the effect of a serious game on the performance of daily routines by autistic and ADHD children.

Methods

A total of 201 families (parents and children) participated in the study. The study used a combined 3 (intervention) × 3 (diagnosis) × 3 (time) research design with repeated measures. Participants were randomly assigned to three intervention groups (serious game, parental support, and a combination of serious game and parental support) based on their diagnosis (ASD, ADHD, neurotypical). Latent growth modeling and repeated ANOVAS were performed to analyze routine scores collected at three moments (baseline, midpoint, persistence) over an 8-week period.

Results

Results show a moderating effect of diagnosis on child routine trajectory. For ADHD participants, we observed a very important significant clinical effect for two interventions (parental support alone and combination of serious game and parental support) where for ASD children, this effect is observed for only one treatment (combination of serious game and parental support). For neurotypical children, results indicate a very important and significant clinical effect when they use the serious game alone.

Conclusions

Results show that the serious game can improve children's routines. However, for some neurodevelopmental profiles (ASD or ADHD), the addition of parental support produces greater clinical improvements.

Use of a serious game simulation to build early childhood staff capacity for reducing unintentional childhood injuries

INTRODUCTION

Unintentional home injuries are common and costly, with over 1.6 million occurring among U.S. children ages 0-4 in 2018. Home visitors and other early childhood professionals can provide valuable prevention education and intervention to reduce unintentional injury risk for children. This proof-of-concept study aimed to test the feasibility of the first phase of Home Safety Hero, a software-based serious game simulation that trains users in identification of home safety risks, as a capacity building tool for early childhood professionals.

METHODS

The game simulation's potential for knowledge promotion and engagement in a sample of home visitors was explored based on play of the first phase. Repeated measures ANOVAs were used to assess learning via reaction time, and engagement was measured via the User Engagement Scale (UES).

RESULTS

Reaction time (i.e., average time to identify hazards) improved from the first to last levels in both single and mixed category levels in this trial. Participant indicated agreement with four subscales of engagement measured by the UES, and neutral to agree on a fifth subscale, focused attention.

CONCLUSIONS

We propose that this game simulation can meet the unique training needs of early childhood professionals while promoting home safety knowledge that can improve prevention work with families. Participant feedback was largely positive, and results suggest that the game simulation is engaging and contributes to knowledge.

PRACTICAL APPLICATIONS

The Home Safety Hero serious game simulation is a flexible training option that appeared to be feasible for reducing time to hazard identification among home visitors in this proof-of-concept study. The design of the game simulation has utility in meeting the specialized training needs of early childhood professionals and potential to build their capacity to provide direct intervention around home safety, reducing risk for unintentional injury among children.

Digital Interventions for Emotion Regulation in Children and Early Adolescents: Systematic Review and Meta-analysis

Background

Difficulties in emotion regulation are common in adolescence and are associated with poor social and mental health outcomes. However, psychological therapies that promote adaptive emotion regulation may be inaccessible and unattractive to youth. Digital interventions may help address this need.

Objective

The aim of this systematic review and meta-analysis was to synthesize evidence on the efficacy, feasibility, and acceptability of emotion regulation digital interventions in children and early adolescents aged 8 to 14 years.

Methods

Systematic searches of Web of Science, MEDLINE, PsycINFO, EMBASE, Education Resources Information Centre, ACM Digital Library, and IEEE Xplore up to July 2020 identified 39 studies, of which 11 (28%) were included in the meta-analyses (n=2476 participants). A bespoke tool was used to assess risk of bias.

Results

The studies evaluated digital games (27/39, 69%), biofeedback (4/39, 10%), virtual or augmented reality (4/39, 10%), and program or multimedia (4/39, 10%) digital interventions in samples classified as diagnosed, at risk, healthy, and universal. The most consistent evidence came from digital games, which reduced negative emotional experience with a small significant effect, largely in youth at risk of anxiety (Hedges g=–0.19, 95% CI –0.34 to –0.04). In general, digital interventions tended to improve emotion regulation, but this effect was not significant (Hedges g=0.19, 95% CI –0.16 to 0.54).

Conclusions

Most feasibility issues were identified in diagnosed youth, and acceptability was generally high across intervention types and samples. Although there is cause to be optimistic about digital interventions supporting the difficulties that youth experience in emotion regulation, the predominance of early-stage development studies highlights the need for more work in this area.

Application of Serious Games in Health Care: Scoping Review and Bibliometric Analysis

Background

Serious games (SGs) as one kind of intervention that can improve the level of knowledge and change behavior to affect health outcomes has been increasingly applied in health care.

Objective

Analyze hotspots and trends of the application of SGs in health care and provide reference and direction for further research in the future.

Methods

The Web of Science (WoS) Core Collection database was used for extracting the literature on SGs in health care for the period from the database established to 11 October, 2021. Scoping review and bibliometric analysis were used to deeply analyze and visualize countries, categories of studies, annual study output, cited authors, cited journals, cited articles, and keywords of healthcare field.

Results

A total of 1,322 articles were retrieved, then every articles' title and abstract were read one by one, and 795 articles were included after screening with an exponential increase in publication volume. The United States of America made the greatest contribution to global publications regarding SGs in health care. From the total, 20.8% of articles fall under the category of health care sciences services. The target groups were mainly concentrated in children (18.0%), youth (13.8%), the elderly (10.9%), adolescents (9.1%), and adults (3.4%). Baranowski T (n = 103 citations) is the most influential author, followed by Kato PM (n = 73 citations) and Desmet A (n = 58 citations). The top three cited journals were "Plos One" (n = 268 citations), "Games for Health Journal" (n = 209 citations), and "Journal of Medical Internet Research" (n = 197 citations), and the top three cited articles were "A meta-analysis of serious digital games for healthy lifestyle promotion," "A Systematic Review of Serious Games in Training Health Care Professionals," and "Video game training enhances cognitive control in older adults." More and more studies focus on specific age groups, such as children, adolescents, and the elderly. The research hotspots and trends included "rehabilitation," "medical education," and "design."

Conclusions

The application of SGs in health care remains important areas for future research. "Rehabilitation," "medical education," and "design" reflected the latest research hotpots and future trends.

Extended Reality Guidelines for Supporting Autism Interventions Based on Stakeholders' Needs

While Extended Reality (XR) autism research, ranging from Augmented to Virtual Reality, focuses on socio-emotional abilities and autistic children requiring low support, common interventions address the entire spectrum and focus on other abilities, including perceptual abilities. Based on these observations, this paper first addresses common practitioners' interventions, and then suggests XR use cases and guidelines to better support them. To do so, 34 interviews were conducted with stakeholders, mainly including practitioners, and then analyzed. Emerging XR use cases were compared with the findings from two former systematic literature reviews, and emerging design guidelines were compared with the findings from a literature survey that we conducted. Findings suggest that collaborative XR sensory-based and mediation approaches could benefit the entire spectrum.

Personalized Training via Serious Game to Improve Daily Living Skills in Pediatric Patients with Autism Spectrum Disorder

The majority of people with Autism Spectrum Disorder (ASD) exhibit difficulties in social communication and behavior, which hinder their learning capability, amid others. Among technological solutions for people with ASD, serious games are frequently used to enhance learning of specific skills and instructional contents. However, because of heterogeneity in applications and game design, few studies have investigated their use in training daily activities. This paper presents a 3D personalized serious game we developed and validated to help ASD patients practice with shopping activities. Personalized training is paramount in people with ASD, thus several elements of this game were personalized to improve engagement and therefore the effectiveness of the virtual training. In order to assess the validity of the game, ten subjects (age 11.9 2.7, 20% female) with ASD played ten sessions of the serious game, once per week. The participants underwent a real-life experience pre- and post-training in a real-life supermarket. Changes in daily living skills among participants were evaluated through specific tools: a form based on the International Classification of Functioning, Disability and Health for Children and Youth; and the Vineland Adaptive Behavior Scale II. Significant improvements (p<0.05) were detected in the main skills trained with the serious game, especially in learning the shopping procedure, directing attention, and problem-solving skills. These findings suggest that personalized serious games can represent a prominent tool to enhance daily living skills, but future work should clinically validate their efficacy.

Opportunities and Challenges in Developing Technology-Based Social Skills Interventions for Adolescents with Autism Spectrum Disorder: A Qualitative Analysis of Parent Perspectives

Interest continues to be high in technology-based interventions for individuals with autism spectrum disorder (ASD). Understanding the preferences and challenges of technology use among individuals with ASD can inform the design of such interventions. Through 18 interviews with parents, we used an iterative inductive-deductive approach to qualitative analysis and explored uses of technology for social skills development among adolescents with ASD. Our findings include parents’ observations about their adolescent’s preferences in types of technology devices and digital content, as well as both positive and negative effects of technology use on mood and behavior. Parents highlighted several avenues of technological preferences and risks that may inform intervention design, enhance user engagement, and capitalize on users’ strengths while buttressing areas for growth.

Improving sensitivity to eye gaze cues in adolescents on the autism spectrum using serious game technology: A randomized controlled trial

Background

Perceiving and interpreting eye gaze cues is foundational for social cognition and social interactions because it involves the ability to use eye gaze direction to predict the actions and intentions of others. Autism is a disability that impacts social interactions. A diagnostic symptom of autism is difficulty understanding eye gaze cues as social signals. This deficit has long-term consequences for understanding goal-directed behavior, language learning, and social communication. We hypothesize that targeted intervention methods designed to improve sensitivity to eye gaze cues may begin to treat core symptoms of autism and potentially alter multiple aspects of social functioning. Social Games for Autistic Adolescents (SAGA) is a serious computer game intervention designed to improve sensitivity to eye gaze cues. Serious games improve targeted skills with the goal of enhancing real life outcomes. In SAGA, participants progress through a narrative storyline and interact with animated characters. In so doing, they implicitly discover that eye gaze cues are useful for guiding their own goal-directed behavior to solve problems in the game.

Methods

We evaluated the feasibility and effectiveness of SAGA in a hybrid phase 1/2, randomized controlled trial. Forty adolescents on the autism spectrum were randomized to either the treatment or standard care control group. Adolescents in the treatment group were asked to play SAGA for 30-minute sessions at home 3 times a week over 10 weeks.

Results

A group × time interaction revealed that the treatment group developed increasing sensitivity to human eye gaze cues, whereas the standard care group did not. Participants who experienced a sufficient dose of gameplay showed larger treatment-related improvements. Critically, increases in sensitivity to human eye gaze cues were associated with improvements in social skills.

Conclusions

This accessible, scalable, and affordable intervention shows promise as an effective tool for improving the ability to interpret and understand eye gaze cues and social skills in adolescents on the autism spectrum.

Pilot Study of an Attention and Executive Function Cognitive Intervention in Children with Autism Spectrum Disorders

This pilot study investigated the efficacy of a game-based cognitive training program (Caribbean Quest; CQ) for improving attention and executive function (EF) in school-aged children with Autism Spectrum Disorder (ASD). CQ is a 'serious game' that uses a hybrid process-specific/compensatory approach to remediate attention and EF abilities through repetitive, hierarchically graded exercises delivered in an adaptive format. Game-play is accompanied by instruction in metacognitive strategies delivered by an adult trainer. Twenty children diagnosed with ASD (ages 6-12 years) completed 12 h of intervention in schools over 8-10 weeks that was facilitated by a trained Research Assistant. Pre-post testing indicated near transfer gains for visual working memory and selective attention and far transfer effects for math fluency. Exit interviews with parents and school staff indicated anecdotal gains in attention, EF, emotion-regulation, flexibility, communication, and social skills. Overall, this study provides preliminary support for the feasibility and potential efficacy of the CQ when delivered in schools to children with ASD.

Dartanan: Prototype evaluations of a serious game to engage children in the calibration of their hearing aid functionalities

Introduction

It is notoriously difficult to obtain a perfect fitting of hearing aids (HAs) for children as they often struggle to understand their hearing loss well enough to discuss the fitting adequately with their audiologist. Dartanan is an ‘edutainment’ game developed to help children understand the functions of their HA in different sound contexts. Dartanan also has elements of a leisure game for all children, in order to create an inclusive activity.

Methods

Game prototypes were evaluated during two formative evaluations and a summative evaluation. In total 106 children with and without hearing loss in Italy, Spain and the UK played Dartanan. A built-in virtual HA enabled children with hearing loss to use headphones to play.

Results and conclusions: During the formative stages, feedback was discussed during focus groups on factors such as the audiological aspects, the extent to which children learned about HA functions, accessibility and usability, and this feedback was presented to the developers. After redevelopment, a summative evaluation was performed using an online survey. It was concluded that the game had met the goals of helping children understand their HA functionalities and providing an inclusive activity. User-evaluations were crucial in the development of the app into a useful and useable service.

Development and Feasibility of MindChip™: A Social Emotional Telehealth Intervention for Autistic Adults

The study aims to develop and pilot a telehealth social emotional program, MindChip™ delivered with a computer based interventions (CBI) (Mind Reading^©) for autistic adults. MindChip™ combined four theoretical perspectives and community feedback underpinning the essential mechanisms for targeting the social emotional understanding of autistic adults. A randomised pragmatic pilot trial (N = 25) was conducted to explore the feasibility of MindChip™ (n = 11) and to understand the preliminary efficacy of combining it with CBI compared to CBI only (n = 14). The use of MindChip™ and CBI combined demonstrated partial feasibility, with preliminary efficacy findings revealing increased emotion recognition generalisation outcomes compared to CBI only. Further research is required to improve the engagement and personalisation of the intervention for autistic adults.

Stakeholder Perspectives to Support Graphical User Interface Design for Children with Autism Spectrum Disorder: A Qualitative Study

The development of digital supports for people with autism has increased considerably in recent years. Technology designers and developers have interpreted the needs and learning styles of people with autism in different ways. As a result, there are generic, non-specific or heterogeneous guidelines for the design and development of technology for people with autism. This study aims to identify and describe the recommended elements to support graphical user interface design for children with Autism Spectrum Disorder (ASD), considering the stakeholders' perspective, engaged in a computer application development. A qualitative, longitudinal, multicentre study was carried out. A sample of 39 participants belonging to four groups of stakeholders participated: children with autism, family members, professionals with experience in the intervention with children with autism, and professionals with expertise in the design and development of assistive technology. The techniques used to formalise the collection of information from participants were semi-structured interviews and observation. MAXQDA 2020 software (Verbi Software, Berlin, Germany) was used to analyse the data. The result is a guide with suggestions to support an interface design that emerges from the stakeholder perspectives. This study provides useful information to offer alternatives for children with ASD and facilitate the understanding of daily life.

Quality Criteria for Serious Games: Serious Part, Game Part, and Balance

Serious games are digital games that have an additional goal beyond entertainment. Recently, many studies have explored different quality criteria for serious games, including effectiveness and attractiveness. Unfortunately, the double mission of serious games, that is, simultaneous achievement of intended effects (serious part) and entertainment (game part), is not adequately considered in these studies. This paper aims to identify essential quality criteria for serious games. The fundamental goal of our research is to identify important factors of serious games and to adapt the existing principles and requirements from game-related literature to effective and attractive serious games. In addition to the review of the relevant literature, we also include workshop results. Furthermore, we analyzed and summarized 22 state-of-the-art serious games for education and health. The selected best-practice serious games either prove their effectiveness through scientific studies or by winning game awards. For the analysis of these games, we refer to "DIN SPEC 91380 Serious Games Metadata Format." A summarized text states quality criteria for both the serious and the game part, and especially the balance between them. We provide guidelines for high-quality serious games drawn from literature analysis and in close cooperation with domain experts.

SoundFields: A Virtual Reality Game Designed to Address Auditory Hypersensitivity in Individuals with Autism Spectrum Disorder

Individuals with autism spectrum disorder (ASD) are characterised as having impairments in social-emotional interaction and communication, alongside displaying repetitive behaviours and interests. Additionally, they can frequently experience difficulties in processing sensory information with particular prevalence in the auditory domain. Often triggered by everyday environmental sounds, auditory hypersensitivity can provoke self-regulatory fear responses such as crying and isolation from sounds. This paper presents SoundFields, an interactive virtual reality game designed to address this area by integrating exposure based therapy techniques into game mechanics and delivering target auditory stimuli to the player rendered via binaural based spatial audio. A pilot study was conducted with six participants diagnosed with ASD who displayed hypersensitivity to specific sounds to evaluate the use of SoundFields as a tool to reduce levels of anxiety associated with identified problematic sounds. During the course of the investigation participants played the game weekly over four weeks and all participants actively engaged with the virtual reality (VR) environment and enjoyed playing the game. Following this period, a comparison of pre- and post-study measurements showed a significant decrease in anxiety linked to target auditory stimuli. The study results therefore suggest that SoundFields could be an effective tool for helping individuals with autism manage auditory hypersensitivity.

Using community-engaged methods to adapt virtual reality job-interview training for transition-age youth on the autism spectrum

BACKGROUND

Virtual Reality Job-Interview Training (VR-JIT) is an efficacious Internet-based intervention for adults with severe mental illness (SMI). Evaluations of VR-JIT have shown improved interview skill and access to employment in several cohorts of adults with SMI and with autism spectrum disorders (ASD). VR-JIT trains participants how to fill out job applications and handle job interviews through e-learning content and applied practice. Trainees receive feedback through in-the-moment nonverbal cues, critiques, and recommendations for improving performance. Our study sought to adapt VR-JIT for transition-age youth with ASD (TAY-ASD).

METHODS

We recruited TAY-ASD and adult stakeholders from public and charter schools, transition programs, and community service providers. Participants provided feedback on VR-JIT to enhance its applicability to TAY-ASD. We used community-engaged methods to process and analyze data from TAY-ASD and stakeholders, presented their quantitative and qualitative responses to community and scientific advisory boards for review and recommendations, and adapted the intervention design and content.

RESULTS

Our adaptations included adding diversity (gender; race/ethnicity) to the virtual hiring manager; shortening the interview by reducing response options; increasing social storytelling to enhance engagement with VR-JIT core components; adding employment opportunities more relevant to younger workers; reducing the reading level; and making the e-learning content more accessible by adding bullet points, voiceover, and imagery/video; and adding new learning goals.

CONCLUSIONS

This study presents a rigorous and innovative community-engaged methodology for adapting VR-JIT to meet the needs of TAY-ASD. We review our engagement with TAY-ASD and stakeholders, and discuss the standardized coding scheme we used to adapt VR-JIT and the usefulness and limitations of employing this methodology in adapting other behavioral interventions.

Effectiveness of Computerized Cognitive Training Programs (CCTP) with Game-like Features in Children with or without Neuropsychological Disorders: a Meta-Analytic Investigation

Computerized cognitive training programs (CCTP) are based on the assumption that cognitive abilities may be boosted by repetitively performing challenging tasks. The integration of game-like features in these programs, associated with the goal of amusing or rewarding participants, may contribute to generate cognitive benefits. Indeed, reinforcement contingencies have been reported to produce positive effects on performance and motivation, especially in children. This meta-analysis was aimed at providing a quantitative summary of the effectiveness of CCTP with game-like features in school-aged children with typical and atypical development. A total of 24 studies, with the cognitive and behavioral outcome data of 1547 participants, were selected for inclusion in the meta-analysis. Subgroup analyses were performed to identify the sources of the observed methodological heterogeneity. A robust variance estimation model, after removal of study outliers, yielded a small-to-moderate significant effect size. Final results pointed out smaller but more precise estimate effect sizes according to methodological aspects related to cognitive domain of outcomes, standardization of measures and type of control applied. Alongside supporting the use of CCTP for rehabilitating cognitive functions, the present results shed light on how different methodological choices are able to shape research findings in the field of children's cognitive rehabilitation.

Empowering Children with ASD and Their Parents: Design of a Serious Game for Anxiety and Stress Reduction

Autism Spectrum Disorder (ASD) is characterized by social interaction difficulties and communication difficulties. Moreover, children with ASD often suffer from other co-morbidities, such as anxiety and depression. Finding appropriate treatment can be difficult as symptoms of ASD and co-morbidities often overlap. Due to these challenges, parents of children with ASD often suffer from higher levels of stress. This research aims to investigate the feasibility of empowering children with ASD and their parents through the use of a serious game to reduce stress and anxiety and a supporting parent application. The New Horizon game and the SpaceControl application were developed together with therapists and according to guidelines for e-health patient empowerment. The game incorporates two mini-games with relaxation techniques. The performance of the game was analyzed and usability studies with three families were conducted. Parents and children were asked to fill in the Spence’s Children Anxiety Scale (SCAS) and Spence Children Anxiety Scale-Parents (SCAS-P) anxiety scale. The game shows potential for stress and anxiety reduction in children with ASD.

New technologies and future trends

Numerous technologies have been introduced for the diagnosis, treatment, and management of patients with neurologic disorders, offering the promise of early diagnosis, tailored and individualized interventions, improvement in quality of life, and restoration of neurologic function. Many of these technologies have become available commercially without having been evaluated by rigorous clinical trials and regulatory reviews, or at the least by peer review of results submitted for publication. A subset is intended to assess, assist, and monitor cognitive functions, motor skills, and autonomic functions and as such may be applicable to persons with developmental disabilities. Barriers that have previously limited the use of technologies by persons with neurodevelopmental disabilities are disappearing as new technologies that have the potential to substantially augment diagnosis and interventions to enhance the daily lives of persons with these disorders are emerging. While recent and future advances in technology have the potential to transform their lives, cautious and thoughtful evaluation is needed to ensure the technologies provide maximal value. As such, further work is needed to demonstrate feasibility, efficacy, and cost-effectiveness, and technologies should be designed to be optimized for individual use.

Therapeutic and Preventive Use of Video Games in Child and Adolescent Psychiatry: A Systematic Review

BACKGROUND

Over the past decade, the use of commercial video games and serious games has developed in child and adolescent psychiatry. These games may become relevant alternatives or adjuncts to traditional psychotherapy, providing that their effectiveness is properly established. The purpose of this literature review was to evaluate the effectiveness of serious games and commercial video games in the treatment or prevention of psychiatric disorders in children and adolescents.

METHODS

Medline's database was used to search articles published between January 2012 and July 2019. The following keywords were used for this search: "Video games" OR "Active video game" OR "serious gaming" OR "Serious game" OR "Exergame" AND "Child mental disorder" OR "Adolescent" OR "Child" AND "Therapy" OR "Prevention". Only comparative studies which targeted interventions on children and adolescents suffering from psychiatric disorders were included.

RESULTS

Twenty-two studies, focusing on a wide range of psychiatric conditions, met our inclusion criteria's: 14 evaluated serious games and 8 commercial games. All studies were randomized controlled trials but only two studies compared the intervention game to psychotherapeutic gold standard; other studies used a no-intervention control group or an alternative game as the control group. Eighteen studies reported significant improvements on the symptoms and test scores targeted.

CONCLUSION

Serious games and commercially available video games can be an effective trajectory for psychotherapy in child and adolescent psychiatry. However, there is a lack of longitudinal studies which assess the sustained effects of these games, and standards for proper evaluation of their effectiveness are missing.

Appropriateness of the TOBY Application, an iPad Intervention for Children with Autism Spectrum Disorder: A Thematic Approach

This study aimed to explore the appropriateness of an ICT intervention, the Therapeutic Outcomes by You application (TOBY app), from the perspectives of the parents. Parental experiences of twenty-four parents of a child with ASD who had participated in a three-month trial using the TOBY app were collected using semi-structured interviews. Thematic analysis was conducted and themes were mapped against an appropriateness framework. Collectively, parents felt the TOBY app was relevant and important to them and their children's needs, while expressing partial support of the TOBY app as: a positive experience for them and their children, beneficial for them and their children, a socially and ecological valid intervention, and an intervention that supported change and continuation in the skills learnt.

Design Elements During Development of Videogame Programs for Children with Autism Spectrum Disorder: Stakeholders' Viewpoints

Introduction: Research has demonstrated that videogame programs can be an effective intervention targeting social challenges among children with autism spectrum disorder (ASD). Despite the rapid growth in developing videogame programs, incorporation of stakeholders' views has been limited. Objective: This project aimed to identify the design elements that should be considered during development of videogame programs for children with ASD, from the perspectives of stakeholders. Materials and Methods: We involved 26 stakeholders, including parents of children with ASD, youth with ASD, and clinicians working with individuals with ASD in focus groups and interviews. Results: Thematic analysis yielded three themes: (1) addressing heterogeneity and diverse needs; (2) mirroring real world; and (3) teaching strategies. Conclusion: Incorporating these elements during development of videogame programs can help enhance the outcomes for children with ASD. By including stakeholders' voices, it is assumed that the developed videogame programs may serve as user-friendly and engaging tools to potentially complement traditional interventions when overcoming social difficulties in individuals with ASD.

Educators' Views on Using Humanoid Robots With Autistic Learners in Special Education Settings in England

Researchers, industry, and practitioners are increasingly interested in the potential of social robots in education for learners on the autism spectrum. In this study, we conducted semi-structured interviews and focus groups with educators in England to gain their perspectives on the potential use of humanoid robots with autistic pupils, eliciting ideas, and specific examples of potential use. Understanding educator views is essential, because they are key decision-makers for the adoption of robots and would directly facilitate future use with pupils. Educators were provided with several example images (e.g., NAO, KASPAR, Milo), but did not directly interact with robots or receive information on current technical capabilities. The goal was for educators to respond to the general concept of humanoid robots as an educational tool, rather than to focus on the existing uses or behaviour of a particular robot. Thirty-one autism education staff participated, representing a range of special education settings and age groups as well as multiple professional roles (e.g., teachers, teaching assistants, speech, and language therapists). Thematic analysis of the interview transcripts identified four themes: Engagingness of robots, Predictability and consistency, Roles of robots in autism education, and Need for children to interact with people, not robots. Although almost all interviewees were receptive toward using humanoid robots in the classroom, they were not uncritically approving. Rather, they perceived future robot use as likely posing a series of complex cost-benefit trade-offs over time. For example, they felt that a highly motivating, predictable social robot might increase children's readiness to learn in the classroom, but it could also prevent children from engaging fully with other people or activities. Educator views also assumed that skills learned with a robot would generalise, and that robots' predictability is beneficial for autistic children—claims that need further supporting evidence. These interview results offer many points of guidance to the HRI research community about how humanoid robots could meet the specific needs of autistic learners, as well as identifying issues that will need to be resolved for robots to be both acceptable and successfully deployed in special education contexts.

A Demonstration Project for the Utility of Kinect-Based Educational Games to Benefit Motor Skills of Children with ASD

Motor disorders often accompany autism spectrum disorder (ASD), although they are not included in its diagnostic criteria. Slower motor development is evident in early childhood in this population, making early motor skills intervention advisable. As educational games and modern technology can represent new forms of treatment, this study evaluated four Kinect-based visuo-motor games called Fruits that were specially designed for this research. We sought to test whether children with ASD would show behavior changes during their game play and whether any effects would generalize to another game called Rackets. The study included 10 elementary school children with ASD, aged 9-13 years, who were divided into (a) an experimental group ( n = 5) who, in addition to standard treatment, played Fruits once a week for a 5-week period and Rackets both before and after the 5-week period and (b) a control group ( n = 5) who received only standard treatment during this period and also played Rackets before and after it. We found significant improvements in gross motor skills and successful generalization of acquired skills among children in the experimental group relative to the control group. The experimental group also showed an increase in positive emotions and a decrease in loss of attention while playing the games. These preliminary findings indicate a motor skill benefit for children with ASD who play Kinect-based educational games, but further research is needed to replicate and expand these findings with larger participant samples.

Designing a Serious Game for Youth with ASD: Perspectives from End-Users and Professionals

Recent years have seen an emergence of social emotional computer games for individuals with Autism Spectrum Disorder (ASD). These games are heterogeneous in design with few underpinned by theoretically informed approaches to computer-based interventions. Guided by the serious game framework outlined by Whyte et al. (Journal of Autism and Developmental Disorders 45(12):1-12, 2014), this study aimed to identify the key motivating and learning features for serious games targeting emotion recognition skills from the perspectives of 11 youth with ASD and 11 experienced professionals. Results demonstrated that youth emphasised the motivating aspects of game design, while the professionals stressed embedding elements facilitating the generalisation of acquired skills. Both complementary and differing views provide suggestions for the application of serious game principles in a potential serious game.

Process Evaluation of the BOOST-A™ Transition Planning Program for Adolescents on the Autism Spectrum: A Strengths-Based Approach

A process evaluation was conducted to determine the effectiveness, usability, and barriers and facilitators related to the Better OutcOmes & Successful Transitions for Autism (BOOST-A™), an online transition planning program. Adolescents on the autism spectrum (n = 33) and their parents (n = 39) provided feedback via an online questionnaire. Of these, 13 participants were interviewed to gain in-depth information about their experiences. Data were analyzed using descriptive statistics and thematic analysis. Four themes were identified: (i) taking action to overcome inertia, (ii) new insights that led to clear plans for the future, (iii) adolescent empowerment through strengths focus, and (iv) having a champion to guide the way. The process evaluation revealed why BOOST-A™ was beneficial to some participants more than others. Trial registration #ACTRN12615000119594.

Brief social attention bias modification for children with autism spectrum disorder

Reduced social attention is a hallmark feature in autism spectrum disorder (ASD), emerging as early as the first year of life. This difference represents a possible mechanism impacting upon the development of more complex social-communicative behaviors. The aim of this study was to develop and test the efficacy of a novel attention bias modification paradigm to alter social attention, specifically orienting to faces. Children with ASD (n = 66), aged between 5 and 12 years, were randomized to play either a social attention training or control game for 15 min. Children playing the training game were reinforced for attending to and engaging with social characters, whereas children in the control group were equally rewarded for attending to both social and non-social characters. Eye-tracking measures were obtained before and after gameplay. There was a significant increase in the percentage of first fixations to faces, relative to objects, after social attention training compared to a control group, associated with a medium effect size (partial η = 0.15). The degree of social attention change in the training group was inversely associated with restricted and repetitive behaviors and moderated by comorbid attention deficit hyperactivity disorder diagnoses, suggestive of differential training effects based on individual symptom profiles. By using the principles of attention bias modification, we demonstrated that social attention can be acutely modified in children with ASD, with an increased tendency to orient attention toward faces after brief social attention training. Modifying attentional biases may therefore represent a potential novel mechanism to alter the development of social communication trajectories. Autism Res 2019, 12: 527-535 © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: Some children with autism spectrum disorder (ASD) do not look at faces or eyes as much as their non-ASD peers do. Using a game where players have to pay attention to characters with faces to score points, we found that children playing the game began to look more at faces, even outside of the game. Looking at faces is an important prerequisite to many social interactions, telling us about others' emotions and states of attention-things that become harder to understand when they are not seen. If children with ASD could use games to help train looking at faces in real life, then they may be in a better position to understand and participate in social exchanges.

Emotion-in-Motion, a Novel Approach for the Modification of Attentional Bias: An Experimental Proof-of-Concept Study

Background

Individuals with heightened anxiety vulnerability tend to preferentially attend to emotionally negative information, with evidence suggesting that this attentional bias makes a causal contribution to anxiety vulnerability. Recent years have seen an increase in the use of attentional bias modification (ABM) procedures to modify patterns of attentional bias; however, often this change in bias is not successfully achieved.

Objective

This study presents a novel ABM procedure, Emotion-in-Motion, requiring individuals to engage in patterns of attentional scanning and tracking within a gamified, complex, and dynamic environment. We aimed to examine the capacity of this novel procedure, as compared with the traditional probe-based ABM procedure, to produce a change in attentional bias and result in a change in anxiety vulnerability.

Methods

We administered either an attend-positive or attend-negative version of our novel ABM task or the conventional probe-based ABM task to undergraduate students (N=110). Subsequently, participants underwent an anagram stressor task, with state anxiety assessed before and following this stressor.

Results

Although the conventional ABM task failed to induce differential patterns of attentional bias or affect anxiety vulnerability, the Emotion-in-Motion training did induce a greater attentional bias to negative faces in the attend-negative training condition than in the attend-positive training condition (P=.003, Cohen d=0.87) and led to a greater increase in stressor-induced state anxiety faces in the attend-negative training condition than in the attend-positive training condition (P=.03, Cohen d=0.60).

Conclusions

Our novel, gamified Emotion-in-Motion ABM task appears more effective in modifying patterns of attentional bias and anxiety vulnerability. Candidate mechanisms contributing to these findings are discussed, including the increased stimulus complexity, dynamic nature of the stimulus presentation, and enriched performance feedback.

Improving sensitivity to eye gaze cues in autism using serious game technology: study protocol for a phase I randomised controlled trial

INTRODUCTION

Autism spectrum disorder (ASD) is characterised by impairments in social communication. Core symptoms are deficits in social looking behaviours, including limited visual attention to faces and sensitivity to eye gaze cues. We designed an intervention game using serious game mechanics for adolescents with ASD. It is designed to train individuals with ASD to discover that the eyes, and shifts in gaze specifically, provide information about the external world. We predict that the game will increase understanding of gaze cues and attention to faces.

METHODS AND ANALYSIS

The Social Games for Adolescents with Autism (SAGA) trial is a preliminary, randomised controlled trial comparing the intervention game with a waitlist control condition. 34 adolescents (10-18 years) with ASD with a Full-Scale IQ between 70 and 130 and a minimum second grade reading level, and their parents, will be randomly assigned (equally to intervention or the control condition) following baseline assessments. Intervention participants will be instructed to play the computer game at home on a computer for ~30 min, three times a week. All families are tested in the lab at baseline and approximately 2 months following randomisation in all measures. Primary outcomes are assessed with eye tracking to measure sensitivity to eye gaze cues and social visual attention to faces; secondary outcomes are assessed with questionnaires to measure social skills and autism-like behaviours. The analyses will focus on evaluating the feasibility, safety and preliminary effectiveness of the intervention.

ETHICS AND DISSEMINATION

SAGA is approved by the Institutional Review Board at Pennsylvania State University (00005097). Findings will be disseminated via scientific conferences and peer-reviewed journals and to participants via newsletter. The intervention game will be available to families in the control condition after the full data are collected and if analyses indicate that it is effective.

TRIAL REGISTRATION NUMBER

NCT02968225.