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

Gaming Platforms for People with ASD

Autism spectrum disorder (ASD) has a significant impact on a person's social, emotional, and communication functioning. According to research, individualized instruction can significantly improve these deficits. One of the most successful methods of achieving this outcome is by gaming platforms that provide serious games (SGs). This article is a systematic review study using the PRISMA diagram that delves into current research on the characteristics and design criteria of serious gaming platforms suitable for people with autism, presenting the benefits of using serious gaming platforms and highlighting the importance of differentiated strategy and planning, as well as disadvantages such as financial cost and complexity. According to the conclusions of this analysis, the bulk of these programs focus on prototyping and strengthening social and emotional abilities. It is also emphasized that platforms aiming at a bigger audience of persons with ASD, as well as a larger sample size, are required.

Feasibility and cross-cultural validation of an adapted social skills group training programme (KONTAKTTM CHILD) for Chinese autistic children: a waitlist RCT protocol

INTRODUCTION

School-age autistic children commonly experience social communication and interaction challenges in their everyday lives. While international evidence suggests that social skills group training (SSGT) programmes can support autistic children, improving their psychosocial functioning, to date there is no standardised evidence-based SSGT tailored towards the needs of autistic children aged 8-12 years living in the Chinese Mainland. Therefore, the primary objective of this study will be to evaluate the feasibility and acceptability of a culturally adapted 16-session version of the social skills programme KONTAKT in Chinese autistic children. Additionally, preliminary efficacy and cost-effectiveness will be assessed to inform a future definitive trial.

METHODS AND ANALYSIS

This study will employ a randomised, single-blinded, waitlist-controlled feasibility design with 36 Chinese autistic children aged 8-12 years with IQ over 70 referred to the Child Development and Behavior Center in Guangzhou, China. Participants will be randomly assigned to either the immediate training group or the delayed training group stratified by sex. Feasibility will be assessed using quantitative and qualitative data obtained from the KONTAKT CHILD participants, their parents and facilitators of the programme. Preliminary efficacy and cost-effectiveness are assessed via quantitative data obtained at five time points. The primary efficacy outcome is participants' improvement in social skills as measured by the Contextual Assessment of Social Skills. Other outcomes include parents and teachers' reports of participants' autistic traits and adaptive functioning, participants' self-report and projective tests for self-assertiveness and psychosocial functioning, and parent reports on parental reflective functioning and perceived school support. Common process factors and their effects on outcomes will also be explored. Cost-effectiveness will consider from both societal and healthcare perspectives.

ETHICS AND DISSEMINATION

The current study protocol has been reviewed and ethics approval has been obtained from the Ethical Board Committee at the Third Affiliated Hospital of Sun Yat-sen University (II2023-119-01). The trial was pre-registered in Chinese Clinical Trials (ChiCTR2300072136) on 5 June 2023. The results of this trial will be actively disseminated through peer-reviewed publications and conference presentations. Any identifiable personal information will be anonymised to protect confidentiality.

PROTOCOL VERSION

2.0, 31 July 2024.

TRIAL REGISTRATION NUMBER

ChiCTR2300072136.

A Serious Game to Train Rhythmic Abilities in Children With Dyslexia: Feasibility and Usability Study

BACKGROUND

Rhythm perception and production are related to phonological awareness and reading performance, and rhythmic deficits have been reported in dyslexia. In addition, rhythm-based interventions can improve cognitive function, and there is consistent evidence suggesting that they are an efficient tool for training reading skills in dyslexia.

OBJECTIVE

This paper describes a rhythmic training protocol for children with dyslexia provided through a serious game (SG) called Mila-Learn and the methodology used to test its usability.

METHODS

We computed Mila-Learn, an SG that makes training remotely accessible and consistently reproducible and follows an educative agenda using Unity (Unity Technologies). The SG's development was informed by 2 studies conducted during the French COVID-19 lockdowns. Study 1 was a feasibility study evaluating the autonomous use of Mila-Learn with 2500 children with reading deficits. Data were analyzed from a subsample of 525 children who spontaneously played at least 15 (median 42) games. Study 2, following the same real-life setting as study 1, evaluated the usability of an enhanced version of Mila-Learn over 6 months in a sample of 3337 children. The analysis was carried out in 98 children with available diagnoses.

RESULTS

Benefiting from study 1 feedback, we improved Mila-Learn to enhance motivation and learning by adding specific features, including customization, storylines, humor, and increasing difficulty. Linear mixed models showed that performance improved over time. The scores were better for older children (P<.001), children with attention-deficit/hyperactivity disorder (P<.001), and children with dyslexia (P<.001). Performance improved significantly faster in children with attention-deficit/hyperactivity disorder (β=.06; t3754=3.91; P<.001) and slower in children with dyslexia (β=-.06; t3816=-5.08; P<.001).

CONCLUSIONS

Given these encouraging results, future work will focus on the clinical evaluation of Mila-Learn through a large double-blind randomized controlled trial comparing Mila-Learn and a placebo game.

Gamified Environments and Serious Games for Students With Autistic Spectrum Disorder: Review of Research

The aim of this study is to review the available research (N = 70) derived from the use of Gamified Environments and Serious Games with people with Autistic Spectrum Disorder (ASD), identifying: authorship, nationality, publication period, topic, and design of the investigation. After that, the advantages and limitations observed are identified. Results indicate that most of them are focused on the design and testing of prototypes, (mostly) linked to the increase of social and emotional skills. The revision highlights that the game's mechanics and dynamics (feedback, rewards, missions, etc.) involve students from motivation. There is unanimous agreement to emphasize the positive impact of these resources to increment self-control, self-conscience, autonomy, and empathy.

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.

Telehealth Interventions to Promote Health and Behavior-Related Outcomes in Adolescents with Autism Spectrum Disorder

This systematic review examined the effectiveness in a hybrid telehealth model for adolescents with autism spectrum disorder (ASD), exploring the evidence base, methodology, and outcomes of health and behavior-related interventions for adolescents with ASD. The 11 included studies (a) were quantitative, (b) evaluated interventions delivered through a hybrid telehealth model (i.e., combined remote intervention with minimal in-person procedures), (c) measured health and behavior-related outcomes, and (d) considered adolescence as ages 12 through 25 years. The studies were a mixture of designs, methods, and outcome measures, and participant numbers were extremely low. Results demonstrated an overall lack of empirical evidence on the efficacy of hybrid-delivered interventions for adolescents with ASD, and more studies are needed to explore their effectiveness.

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.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine "Google Scholar," and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (P=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (P=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (P=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969.

The Effectiveness of Serious Games for Alleviating Depression: Systematic Review and Meta-analysis (Preprint).. [DOI: 10.2196/preprints.32331]

BACKGROUND

Depression is a common mental disorder characterized by disturbances in mood, thoughts, or behaviors. Serious games, which are games that have a purpose other than entertainment, have been used as a nonpharmacological therapeutic intervention for depression. Previous systematic reviews have summarized evidence of effectiveness of serious games in reducing depression symptoms; however, they are limited by design and methodological shortcomings.

OBJECTIVE

This study aimed to assess the effectiveness of serious games in alleviating depression by summarizing and pooling the results of previous studies.

METHODS

A systematic review of randomized controlled trials (RCTs) was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The search sources included 6 bibliographic databases (eg, MEDLINE, PsycINFO, IEEE Xplore), the search engine “Google Scholar,” and backward and forward reference list checking of the included studies and relevant reviews. Two reviewers independently carried out the study selection, data extraction, risk of bias assessment, and quality of evidence appraisal. Results of the included studies were synthesized narratively and statistically, as appropriate, according to the type of serious games (ie, exergames or computerized cognitive behavioral therapy [CBT] games).

RESULTS

From an initial 966 citations retrieved, 27 studies met the eligibility criteria, and 16 studies were eventually included in meta-analyses. Very low-quality evidence from 7 RCTs showed no statistically significant effect of exergames on the severity of depressive symptoms as compared with conventional exercises (<i>P</i>=.12). Very low-quality evidence from 5 RCTs showed a statistically and clinically significant difference in the severity of depressive symptoms (<i>P</i>=.004) between exergame and control groups, favoring exergames over no intervention. Very low-quality evidence from 7 RCTs showed a statistically and clinically significant effect of computerized CBT games on the severity of depressive symptoms in comparison with no intervention (<i>P</i>=.003).

CONCLUSIONS

Serious games have the potential to alleviate depression as other active interventions do. However, we could not draw definitive conclusions regarding the effectiveness of serious games due to the high risk of bias in the individual studies examined and the low quality of meta-analyzed evidence. Therefore, we recommend that health care providers consider offering serious games as an adjunct to existing interventions until further, more robust evidence is available. Future studies should assess the effectiveness of serious games that are designed specifically to alleviate depression and deliver other therapeutic modalities, recruit participants with depression, and avoid biases by following recommended guidelines for conducting and reporting RCTs.

CLINICALTRIAL

PROSPERO International Prospective Register of Systematic Reviews CRD42021232969; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=232969

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.

Comparing Effectiveness Between a Mobile App Program and Traditional Cognitive Behavior Therapy in Obsessive-Compulsive Disorder: Evaluation Study

BACKGROUND

This study proposes a digital program for the treatment of mental illness that could increase motivation and improve learning outcomes for patients. Several studies have already applied this method by using an exposure and response prevention-inspired serious game to treat patients with obsessive-compulsive disorder (OCD).

OBJECTIVE

We hypothesized that a mobile cognitive behavior therapy (CBT) program would be as effective in treating OCD as traditional offline CBT. In addition, the treatment efficacy in response to mobile CBT for OCD might be associated with increased brain activity within the cortico-striato-thalamo-cortical (CSTC) tract.

METHODS

The digital CBT treatment program for OCD, OCfree, consists of 6 education sessions, 10 quests, and 7 casual games. Information was gathered from 27 patients with OCD (15 offline CBT and 12 OCfree CBT). During the 6-week intervention period, changes in clinical symptoms and brain function activity were analyzed.

RESULTS

There was no significant difference in the change in OCD symptoms and depressive symptoms between the two groups. However, the OCfree group showed greater improvement in anxiety symptoms compared to the offline CBT group. Both offline CBT and OCfree CBT increased the functional connectivity within the CSTC tract in all patients with OCD. However, CBT using OCfree showed greater changes in brain connectivity within the thalamus and insula, compared to offline CBT.

CONCLUSIONS

OCfree, an OCD treatment app program, was effective in the treatment of drug-naïve patients with OCD. The treatment effects of OCfree are associated with increased brain connectivity within the CSTC tract. Multisensory stimulation by education, quests, and games in OCfree increases the activity within the thalamus and insula in patients with OCD.

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.

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.