Who is a better teacher for children with autism? Comparison of learning outcomes between robot-based and human-based interventions in gestural production and recognition

Digital interventions for autism spectrum disorders: A systematic review and meta-analysis

Importance

Digital technology is now widely available for the interventions of autism, but its validity and feasibility remain to be proved.

Objective

This study aimed to investigate the effectiveness of digital health interventions (DHIs) in improving core symptoms or intelligence quotient in patients with autism spectrum disorder (ASD).

Methods

Three databases including PubMed, Cochrane, and Scopus, were searched on November 15, 2022. Randomized clinical trials that enrolled patients with ASD who received DHIs and a control group without DHI treatment were included. Cochrane risk of bias tool (RoB 2) was applied to assess the risk of bias.

Results

A total of 33 studies, involving 1285 participants (658 [51.2%] in DHI groups and 627 [48.8%] in control groups), were analyzed to investigate the differences between DHI groups and control groups. Significantly greater improvements in the overall performance of ASD were observed in the DHI groups compared to the control groups (including active, waitlist, treatment-as-usual, and no treatment) with an effect size of 1.89 (Cohen's d 95% confidence interval [CI]: 1.26-2.52). Studies with treatment-as-usual, waitlist, and no treatment control demonstrated large effect sizes of Cohen's d 3.41 (95% CI: 0.84-5.97), Cohen's d 4.27 (95% CI: 1.95-6.59), and Cohen's d 4.52 (95% CI: 2.98-6.06) respectively. In contrast, studies with active control revealed insignificant effect sizes (Cohen's d 0.73, 95% CI: 0.12-1.33).

Interpretation

This meta-analysis found significantly greater improvements in core symptoms or intelligence quotient in ASD patients receiving DHIs compared to those in control conditions. ASD patients may benefit from the DHIs and reduce the economic burden.

Interactive mirrOring Games wIth sOCial rObot (IOGIOCO): a pilot study on the use of intransitive gestures in a sample of Italian preschool children with autism spectrum disorder

Background

Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder characterized by persistent deficits in social communication, social interaction, and restricted behaviors. The importance of early intervention has been widely demonstrated, and developmental trajectories in ASD emphasize the importance of nonverbal communication, such as intransitive gesture production, as a possible positive prognostic factor for language development. The use of technological tools in the therapy of individuals with ASD has also become increasingly important due to their higher engagement and responsiveness to technological objects, such as robots.

Materials and methods

We developed a training protocol using the humanoid robot NAO, called IOGIOCO (Interactive mirroring Games wIth sOCial rObot), based on the use of intransitive gestures embedded in naturalistic dialogues, stimulating a triadic interaction between child, robot and therapist. The training was divided into six levels; the first 2 levels were called "familiarization levels," and the other 4 were "training levels". The technological setup includes different complexity levels, from mirroring tasks to building spontaneous interactions. We tested the protocol on 10 preschool children with ASD (aged 2-6 years) for 14 weeks. We assessed them at recruitment (T0), at the end of training (T1), and after 6 months (T2).

Results

We demonstrated the tolerability of the protocol. We found that one group (n=4, males and 2 females) reached the training level, while another and group (n=6 males) remained at a familiarization level (mirroring), we analyzed the results for the two groups. In the group that reached the training levels, we found promising results, such as an improvement in the Social Adaptive Domain of the ABAS-II questionnaire between T0 and T2.

Conclusion

While current results will need a Randomized Controlled Trial to be confirmed, the present work sets an important milestone in using social robots for ASD treatment, aimed at impacting social and communication skills in everyday life.

People with Autism Spectrum Disorder Could Interact More Easily with a Robot than with a Human: Reasons and Limits

Individuals with Autism Spectrum Disorder show deficits in communication and social interaction, as well as repetitive behaviors and restricted interests. Interacting with robots could bring benefits to this population, notably by fostering communication and social interaction. Studies even suggest that people with Autism Spectrum Disorder could interact more easily with a robot partner rather than a human partner. We will be looking at the benefits of robots and the reasons put forward to explain these results. The interest regarding robots would mainly be due to three of their characteristics: they can act as motivational tools, and they are simplified agents whose behavior is more predictable than that of a human. Nevertheless, there are still many challenges to be met in specifying the optimum conditions for using robots with individuals with Autism Spectrum Disorder.

Comparing the effectiveness of robot-based to human-based intervention in improving joint attention in autistic children

Background

Children with autism have impairments in initiation of joint attention (IJA) and response to joint attention (RJA).

Aims

The present study compared the learning effectiveness of robot-based intervention (RBI) with that of content-matched human-based intervention (HBI) in improving joint attention (JA). We examined whether RBI would enhance RJA, in comparison to HBI. We also examined whether RBI would increase IJA, in comparison to HBI.

Methods and procedures

Thirty-eight Chinese-speaking children with autism aged 6 to 9 years were randomly assigned to RBI and HBI groups. Before intervention, their autism severity, cognitive abilities, and language skills were assessed. Each child received six 30-min training sessions over 3 weeks. During training, he/she watched one or two robot/human dramas twice where two robot/human actors demonstrated eye contact and RJA.

Outcomes and results

Children in the RBI (but not HBI) group produced more RJA and IJA behaviors in the delayed post-test than in the pre-test. Parents of the RBI children rated the program more positively than those of the HBI children.

Conclusions and implications

RBI may be more effective than HBI in promoting JA in autistic children with high support needs. Our findings shed light on the application of robot dramas in enhancing social communication skills.

Robot dramas may improve joint attention of Chinese-speaking low-functioning children with autism: stepped wedge trials

INTRODUCTION

Children with autism spectrum disorder (ASD), especially those with low cognitive functioning, have deficits in joint attention. Previous research has found that these children are interested in engaging with social robots.

PURPOSE

In the present study, we designed a robot drama intervention for promoting responses to joint attention abilities (RJA) of children with low-functioning autism (IQs < 70).

MATERIALS AND METHODS

Using a stepped wedge design, Chinese-speaking children aged six to eight were randomly assigned to three tiers (N = 18). Children of all three tiers had comparable autism severity, language and cognitive function, and joint attention abilities. Tier 1 first received intervention, followed by Tiers 2 and 3. They watched six dramas in which social robots demonstrated RJA behaviours.

RESULTS

The RJA of children of all tiers improved after intervention and such improvement was maintained over time. Despite initiation of joint attention (IJA) not being explicitly taught, IJA of all children was found to improve after intervention.

CONCLUSIONS

It was, therefore, concluded that a robot drama could enhance the joint attention of children with low-functioning ASD.Implications for rehabilitationIn comparison to typically developing children, children with autism spectrum disorder (ASD), especially those with low cognitive functioning, have deficits in joint attention.Robot-based drama intervention program was developed to promote responses to joint attention (RJA) abilities of children with low-functioning autism (IQs < 70).Modelling RJA in robot dramas can promote RJA abilities in these children.An improvement in RJA also yielded an increase in the initiation of joint attention (IJA) abilities.Children with low-functioning autism might be able to extract the initiation of joint attention skills from the drama, even though these behaviours were not explicitly taught.

The Design and Observed Effects of Robot-Performed Manual Gestures: A Systematic Review

Communication using manual (hand) gestures is considered a defining property of social robots, and their physical embodiment and presence, therefore we see a need for a comprehensive overview of the state of the art in social robots that use gestures. This systematic literature review aims to address this need by (1) describing the gesture production process of a social robot, including the design and planning steps, and (2) providing a survey of the effects of robot-performed gestures on human-robot interactions in a multitude of domains. We identify patterns and themes from the existing body of literature, resulting in nine outstanding questions for research on robot-performed gestures regarding: developments in sensor technology and AI, structuring the gesture design and evaluation process, the relationship between physical appearance and gestures, the effects of planning on the overall interaction, standardizing measurements of gesture ‘quality’, individual differences, gesture mirroring, whether human-likeness is desirable, and universal accessibility of robots. We also reflect on current methodological practices in studies of robot-performed gestures, and suggest improvements regarding replicability, external validity, measurement instruments used, and connections with other disciplines. These outstanding questions and methodological suggestions can guide future work in this field of research.

The use of social robots with children and young people on the autism spectrum: A systematic review and meta-analysis

BACKGROUND

Robot-mediated interventions show promise in supporting the development of children on the autism spectrum.

OBJECTIVES

In this systematic review and meta-analysis, we summarize key features of available evidence on robot-interventions for children and young people on the autism spectrum aged up to 18 years old, as well as consider their efficacy for specific domains of learning.

DATA SOURCES

PubMed, Scopus, EBSCOhost, Google Scholar, Cochrane Library, ACM Digital Library, and IEEE Xplore. Grey literature was also searched using PsycExtra, OpenGrey, British Library EThOS, and the British Library Catalogue. Databases were searched from inception until April (6th) 2021.

SYNTHESIS METHODS

Searches undertaken across seven databases yielded 2145 articles. Forty studies met our review inclusion criteria of which 17 were randomized control trials. The methodological quality of studies was conducted with the Quality Assessment Tool for Quantitative Studies. A narrative synthesis summarised the findings. A meta-analysis was conducted with 12 RCTs.

RESULTS

Most interventions used humanoid (67%) robotic platforms, were predominantly based in clinics (37%) followed home, schools and laboratory (17% respectively) environments and targeted at improving social and communication skills (77%). Focusing on the most common outcomes, a random effects meta-analysis of RCTs showed that robot-mediated interventions significantly improved social functioning (g = 0.35 [95%CI 0.09 to 0.61; k = 7). By contrast, robots did not improve emotional (g = 0.63 [95%CI -1.43 to 2.69]; k = 2) or motor outcomes (g = -0.10 [95%CI -1.08 to 0.89]; k = 3), but the numbers of trials were very small. Meta-regression revealed that age accounted for almost one-third of the variance in effect sizes, with greater benefits being found in younger children.

CONCLUSIONS

Overall, our findings support the use of robot-mediated interventions for autistic children and youth, and we propose several recommendations for future research to aid learning and enhance implementation in everyday settings.

PROSPERO REGISTRATION

Our methods were preregistered in the PROSPERO database (CRD42019148981).

Parental Influence in Disengagement during Robot-Assisted Activities: A Case Study of a Parent and Child with Autism Spectrum Disorder

We examined the influence of a parent on robot-assisted activities for a child with Autism Spectrum Disorder. We observed the interactions between a robot and the child wearing a wearable device during free play sessions. The child participated in four sessions with the parent and interacted willingly with the robot, therapist, and parent. The parent intervened when the child did not interact with the robot, considered “disengagement with the robot”. The number and method of intervention were decided solely by the parent. This study adopted video recording for behavioral observations and specifically observed the situations before the disengagement with the robot, the child’s behaviors during disengagement, and the parent’s intervention. The results showed that mostly the child abruptly discontinued the interactions with the robot without being stimulated by the surrounding environment. The second most common reason was being distracted by various devices in the play sessions, such as the wearable device, a video camera, and a laptop. Once he was disengaged with the robot, he primarily exhibited inappropriate and repetitive behaviors accentuating the symptoms of autism spectrum disorder. The child could re-initiate the interaction with the robot with an 80% chance through the parent’s intervention. This suggests that engagement with a robot may differ depending on the parent’s participation. Moreover, we must consider types of parental feedback to re-initiate engagement with a robot to benefit from the therapy adequately. In addition, environmental distractions must be considered, especially when using multiple devices for therapy.

Emotional Expression in Children With ASD: A Pre-Study on a Two-Group Pre-Post-Test Design Comparing Robot-Based and Computer-Based Training

Several studies have found a delay in the development of facial emotion recognition and expression in children with an autism spectrum condition (ASC). Several interventions have been designed to help children to fill this gap. Most of them adopt technological devices (i.e., robots, computers, and avatars) as social mediators and reported evidence of improvement. Few interventions have aimed at promoting emotion recognition and expression abilities and, among these, most have focused on emotion recognition. Moreover, a crucial point is the generalization of the ability acquired during treatment to naturalistic interactions. This study aimed to evaluate the effectiveness of two technological-based interventions focused on the expression of basic emotions comparing a robot-based type of training with a "hybrid" computer-based one. Furthermore, we explored the engagement of the hybrid technological device introduced in the study as an intermediate step to facilitate the generalization of the acquired competencies in naturalistic settings. A two-group pre-post-test design was applied to a sample of 12 children (M = 9.33; ds = 2.19) with autism. The children were included in one of the two groups: group 1 received a robot-based type of training (n = 6); and group 2 received a computer-based type of training (n = 6). Pre- and post-intervention evaluations (i.e., time) of facial expression and production of four basic emotions (happiness, sadness, fear, and anger) were performed. Non-parametric ANOVAs found significant time effects between pre- and post-interventions on the ability to recognize sadness [t ₍₁₎ = 7.35, p = 0.006; pre: M (ds) = 4.58 (0.51); post: M (ds) = 5], and to express happiness [t ₍₁₎ = 5.72, p = 0.016; pre: M (ds) = 3.25 (1.81); post: M (ds) = 4.25 (1.76)], and sadness [t ₍₁₎ = 10.89, p < 0; pre: M (ds) = 1.5 (1.32); post: M (ds) = 3.42 (1.78)]. The group^*time interactions were significant for fear [t ₍₁₎ = 1.019, p = 0.03] and anger expression [t ₍₁₎ = 1.039, p = 0.03]. However, Mann-Whitney comparisons did not show significant differences between robot-based and computer-based training. Finally, no difference was found in the levels of engagement comparing the two groups in terms of the number of voice prompts given during interventions. Albeit the results are preliminary and should be interpreted with caution, this study suggests that two types of technology-based training, one mediated via a humanoid robot and the other via a pre-settled video of a peer, perform similarly in promoting facial recognition and expression of basic emotions in children with an ASC. The findings represent the first step to generalize the abilities acquired in a laboratory-trained situation to naturalistic interactions.

Are social robots ready yet to be used in care and therapy of autism spectrum disorder: A systematic review of randomized controlled trials

Autism is a neurodevelopmental disorder that affects the everyday life of people who have this lifelong condition. Robots hold great promise for uplifting therapy and care of the affected population. We searched Scopus, Medline, ScienceDirect, Web of Science, and PubMed databases for randomized controlled trials that had evaluated robot use in the therapy of people with autism, to see how effective social robots have been incorporated in autism care. Out of 240 papers initially identified, 19 satisfied the inclusion criteria and were fully evaluated. Overall, 10 different robots were utilized in the trials, out of which, four were non-humanoids. The number of papers with positive results for using robots on the main and secondary parameters was 11 and 5, respectively. Three papers reported that robot groups did not achieve better results than others. Robots in the papers included here were mainly added as the "entertainment agent" to elicit greater engagement from the participants, which is understandable, as robots at this stage might not be ready yet to deliver high-end care.

Robot-based play-drama intervention may improve the narrative abilities of Chinese-speaking preschoolers with autism spectrum disorder

BACKGROUND

Children with autism spectrum disorder (ASD) have deficits in their narrative skills and gestural communication. Very few intervention studies have been conducted with the aim of improving these skills.

AIMS

We examined whether children with ASD who received the robot-based drama intervention had better narrative abilities and gestured more often than their peers who did not receive the intervention.

METHODS AND PROCEDURES

Preschool children were randomly assigned to the intervention group (N = 13) and waitlist control group (N = 13). Children in the intervention group watched three robot dramas and engaged in roleplays with both robots and human experimenters. Children in both groups took the pre-tests, immediate post-tests, and, two week later, delayed post-tests, in which they narrated three stories.

OUTCOMES AND RESULTS

There were significant improvements in various narrative measures, including narrative length, syntactic complexity, narrative structure, and cognitive inferences, in the intervention group. There was also an improvement in the average number of overall gestures per clause in this condition. These learning outcomes were maintained in the delayed post-test. These patterns were not found in the waitlist control group.

CONCLUSIONS AND IMPLICATIONS

A robot-based play-drama intervention can enhance the narrative abilities and gestural communication of children with ASD.

The Attitudes of Therapists and Physicians on the Use of Sex Robots in Sexual Therapy: Online Survey and Interview Study

Background

Various types of robots have already been successfully used in medical care, and the use of new technologies is also playing an increasing role in the area of sexuality. Sex robots are marketed as advanced sex toys and sex dolls with artificial intelligence. Only a few considerations about the therapeutic use of sex robots in sexual therapy are debated in expert discussions.

Objective

The aim of this study was to conduct a first exploratory survey on the attitudes of sex therapists and physicians toward the therapeutic benefits of sex robots.

Methods

This study comprised a quantitative online survey and a qualitative interview study. A self-constructed questionnaire was used to survey the general attitudes of sex therapists and physicians regarding the benefits of sex robots in therapy. The qualitative study was designed to gain in-depth insight into the participants’ beliefs and attitudes. Therefore, semistructured interviews were conducted. The quantitative data were evaluated by statistical analysis, and the interviews were transcribed and analyzed by using a grounded theory approach.

Results

A total of 72 sex therapists and physicians completed our self-constructed questionnaire (response rate 15%, 72/480). Only a few respondents (11%, 8/72) said that the use of sex robots was not conceivable for them, and almost half of all therapists and physicians could imagine recommending sex robots in therapy (45%, 33/72). The attitude toward sex robots as a therapeutic tool was very heterogeneous, with gender (P=.006), age (P=.03), and occupational differences (P=.05); female therapists, older therapists, and psychologists (in contrast to physicians) were more critical toward the therapeutic use of sex robots. The analysis of the 5 interviews identified 3 high-level core themes that were representative of the participants’ responses: (1) the importance of the personal definition of sex robots for the assessment of their therapeutic benefits, (2) therapeutic benefits and dangers of sex robots, and (3) considerations on the quality of human-robot sexuality. Initial insights into the possible therapeutic use of sex robots in different disorders (eg, sexual dysfunction or pedophilia) and situations were gained from the perspective of sex therapists.

Conclusions

The results of this study provide a first overview of the potential therapeutic use of sex robots. Moral, ethical, and treatment-related issues in this context are still unresolved and need to be further researched. We suggest integrating the topic into the training of sex therapists to form opinions beyond media images and to show therapy possibilities. Scientists engaged in sexual research should be involved in the development of sex robots to design robots with positive effects on sexual education, sexual therapy, sexual counseling, and sexual well-being for interested groups.