A framework of evidence-based practice for digital support, co-developed with and for the autism community

Apps and Digital Resources for Child Neurodevelopment, Mental Health, and Well-Being: Review, Evaluation, and Reflection on Current Resources

BACKGROUND

An increase in the prevalence of neurodevelopmental conditions worldwide, alongside resource constraints within clinical services, has led to increased interest in health information technologies, such as apps and digital resources. Digital tools are often viewed as a solution to bridge this divide and to increase supports for families. There is, however, a paucity of research that has evaluated digital health tools, their potential benefits for child neurodevelopment and associated concerns (eg, mental health, well-being), and their benefit for families.

OBJECTIVE

This study conducted the first review of existing mobile apps and digital resources targeted at supporting the needs of children with developmental concerns or neurodevelopmental conditions.

METHODS

We identified 3435 separate resources, of which 112 (43 apps and 69 digital resources) met the criteria. These resources were categorized according to their purpose or target and were then reviewed based on their engagement, information quality, and evidence base using the Adapted Mobile App Rating Scale.

RESULTS

The most common condition of concern targeted by apps and digital resources was autism (19/112, 17% resources), with retrieved resources focusing on supporting challenging behaviors, promoting speech, language, and social development, and providing options for alternative and assistive communication. Other common areas of concern targeted by apps and digital resources included language and communication (16/112, 14.3%) and attention-deficit/hyperactivity disorder (11/112, 9.8%). Results showed that reviewed resources were engaging, with high levels of accessibility and functionality. Resources had various functions, including developmental or behavioral tasks targeted at children, assistive communication support, scheduling support, journaling, and advice, activities, and strategies for parents. The information quality of resources, such as credibility of source and evidence base was, however, mostly low. Apps and digital resources with good credibility and an existing evidence base were largely developed in partnership with research, health, or government institutions, and were rated significantly higher on overall quality compared with apps and digital resources not developed in partnership with such institutions (apps; t41=-4.35, P<.001; digital resources; t67=-4.95, P<.001).

CONCLUSIONS

The lack of evidence base across resources means that it is extremely difficult to provide recommendations to families with respect to apps or digital resources that may support their needs. Frameworks for the development of new tools are discussed, highlighting the novel approaches required to demonstrate the efficacy of tools for improving outcomes for children and families. Such a framework requires collaboration with multiple stakeholders (software developers, researchers, regulatory bodies, clinicians, children, and families) and engagement across multiple levels of expertise (app development, implementation, and dissemination within services, policy, and clinical regulations), to harness the potential of digital health for improving outcomes and promoting support in child neurodevelopment, which at this juncture remains largely underdeveloped.

Hybrid Service Delivery for voluntary, community and social enterprise organisations working with adults with learning disabilities and/or autism: a realist review protocol

BACKGROUND

Delivery of health and care services using a combination of remote and/or in-person channels and digital and/or traditional tools (Hybrid Service Delivery, HSD) is increasingly seen as a way of improving quality and affordability, improving access, personalisation and sustainability, and reducing inequalities. Across the voluntary, community and social enterprise sector (VCSE), using a combination of remote and/or in-person channels and digital and/or traditional tools (HSD) has enabled the essential provision of services for people who have learning disabilities and/or autistic (LDA). However, it is unclear how different tools and channels have been used, what worked well or not well, for whom, and in what circumstances. The aim of this realist review is to explore how VCSE organisations can effectively use digital technologies alongside or instead of in-person activity to provide social care services to adults with learning disabilities and/or autism. This review protocol is presented in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P).

METHODS

We will conduct a participatory realist review. Following realist review methodology, and involving people with LDA and organisations who deliver services to them, we will define the scope of the review/theory development, search for and appraise evidence, extract and synthesise findings, and develop the narrative. Using a developed strategy, electronic databases (Academic Search Complete, CINAHL, MEDLINE, PsycInfo, SCOPUS, Social Science Citation Index and Social Policy and Practice) will be searched. A data extraction table will be used to assist in sifting, sorting and organising relevant information from identified studies. For each proposition statement, relevant data from the identified literature will be synthesised and compared with the proposed theory to develop an understanding of how, why and when hybrid delivery works in different settings with different populations.

DISCUSSION

This review aims to collate and synthesise evidence relating to hybrid service delivery in VCSE organisations to provide social care services to LDA adults. By conducting a participatory realist review, we anticipate that the findings will lead to a greater understanding of contextual factors and therefore more relevant recommendations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42024457161.

Learning Experience Design and Unpacking Sociocultural, Technological, and Pedagogical Design Considerations of Spherical Video-Based Virtual Reality Systems for Autistic Learners: A Systematic Literature Review

This systematic literature review discusses the use of spherical video-based virtual reality (SVVR) as a training and therapy intervention for autistic individuals. The authors emphasize the need for an evidence-based framework with guidelines and design considerations to help developers and educators tailor SVVR to the diverse needs of autistic learners. The paper highlights the unique benefits of SVVR, such as being relatively easier to develop compared to other VR technologies and high compatibility with various devices, making it more affordable for educational settings. The authors also discuss the importance of the STP (Sociotechnical-Pedagogical) framework for evaluating and designing social aspects of SVVR interventions for autistic individuals.

Development of oral health resources and a mobile app for caregivers and autistic children through consensus building

LAY ABSTRACT

Caregivers of autistic children often lack knowledge regarding oral homecare and when and where to see the dentist. To address this need, we developed a series of information on oral health. An autistic child assisted in developing two social stories to showcase a dental visit. A mobile app was developed to deliver the above mentioned. Other features include creation of customised social stories and visual schedule and an inbox to allow dentists to send messages to parents. The developed information and social stories were reviewed by experts and parents. The app also underwent anonymous and independent testing by parents. Overall the information and app were well received by the experts and parents.

Understanding the post-diagnostic support priorities of autistic adults in the United Kingdom: A co-produced modified Delphi study

LAY ABSTRACT

Autistic adults in the United Kingdom report that support for themselves and their peers is not suitable for their needs. There has been an increase in adults receiving an autism diagnosis, which many have reported as having a positive impact on their lives. However, the lack of support and understanding after diagnosis, combined with long wait times for an assessment to obtain a diagnosis and to access follow-on support, is having a negative impact on people's lives. This study took place to find out what support autistic people need and want after receiving their diagnosis. It was co-designed with a group of 10 autistic adults which means that the researchers and group members collaboratively designed the research. For the study, 43 autistic adults, diagnosed aged 18 or older, completed three questionnaires. A fourth questionnaire followed that was completed by 139 autistic people who received their diagnosis in adulthood. These questionnaires aimed to help people identify their own priorities when it came to the support they would have liked to receive after being given their autism diagnosis. Participants ranked access to support where they live, training of professionals, support to process the impact of a late diagnosis, use of their preferred mode of contact and a personalised support plan as their top priorities. This demonstrates that local support is highly valued by autistic adults, as are well-trained professionals who offer a range of contact options, support to process a late-in-life autism diagnosis and help to develop and implement support plans.

Involving autism stakeholders in identifying priorities for interventions based on augmented reality

PURPOSE

Literature supports the use of technological tools such as augmented reality, 3 D avatars and mobile devices to improve individuals with autism spectrum disorder skills. Possibilities of including these technological tools in intervention and the critical issues related to intervention design are essential research questions. The aim of the current work is to present an interdisciplinary research study on the design of an autism intervention considering these technologies.

MATERIALS AND METHODS

This study used qualitative evidence and thematic analysis to identify the main design guidelines. A semi-structured interview was administered to a total of twenty participants representing four stakeholder categories: ASD, clinicians, therapists and caregivers. Interviews focussed on three dimensions related to user, technology and environment since they represent a complex system within which the individual using technology is situated.

RESULTS

Thematic analysis of the interviews identified a total of 10 themes considered central to the design of the technological intervention.

CONCLUSIONS

Since the application of technology in autism intervention is a relatively new area, the guidelines related to the potential incentives and barriers of the proposed technology are helpful to inform future treatment studies.Implications for RehabilitationThis study highlights the strengths and barriers associated with the use of smartphones and augmented reality in autism spectrum disorder interventions considering the dimensions within which the user using assistive technology is located.Strengths and major concerns that emerged are key points to consider during the development of the technological intervention.Considering these points can foster the use of technology within the intervention and promote its effectiveness.

Bringing the autistic lifeworld to supportive technology design: an enactive approach

Supportive technologies for autistic individuals are promising in principle, yet their uptake remains limited. Critics argue that in current designs of supportive technologies, autism is mostly framed as a 'disorder' whose limitations can be pragmatically compensated for. To increase uptake, designers should get a better handle on how to incorporate the full richness of the autistic experience into the design process. This paper presents an integrative framework of the autistic lifeworld, called Autistic Lifeworld Design (hereafter: ALD). ALD evolved in a transdisciplinary research setting, substantiated by 11 design case studies with autistic young adults as well as theoretical inquiries into enactivism, design and autism. It consists of four dimensions of experience - sensory, habitual, social, and affective -, each providing specific pointers on how to better understand how autistic people experience the world and how supportive technologies may complement that experience. By adopting an enactive approach, ALD enables a reframing of supportive technology as helping to sustain different levels of homoeostasis. It offers a novel lens that allows designers to put the lived experiences of autistic individuals at the centre of the design process, with special attention to the role of bodily structures and processing in shaping these experiences.

Identifying the most important research, policy and practice questions for substance use, problematic alcohol use and behavioural addictions in autism (SABA-A): A priority setting partnership

BACKGROUND

Autistic people are more likely to report problematic alcohol and other substance use when compared to the general population. Evidence suggests that up to one in three autistic adults may have an alcohol or other substance use disorder (AUD/SUD), although the evidence base for behavioural addictions is less clear. Autistic people may use substances or engage in potentially addictive behaviours as a means of coping with social anxiety, challenging life problems, or camouflaging in social contexts. Despite the prevalence and detrimental effects of AUD, SUD and behavioural addictions in community samples, literature focusing on the intersection between autism and these conditions is scarce, hindering health policy, research, and clinical practice.

METHODS

We aimed to identify the top 10 priorities to build the evidence for research, policy, and clinical practice at this intersection. A priority-setting partnership was used to address this aim, comprising an international steering committee and stakeholders from various backgrounds, including people with declared lived experience of autism and/or addiction. First, an online survey was used to identify what people considered key questions about Substance use, alcohol use, or behavioural addictions in autistic people (SABA-A). These initial questions were reviewed and amended by stakeholders, and then classified and refined to form the final list of top priorities via an online consensus process.

OUTCOMES

The top ten priorities were identified: three research, three policy, and four practice questions. Future research suggestions are discussed.

On the Evaluation of Engagement in Immersive Applications When Users Are on the Autism Spectrum

New generation wearable devices allow for the development of interactive environments tailored for Virtual Reality (VR)- and Augmented Reality (AR)-based treatment of Autism Spectrum Disorders (ASD). Experts agree on their potential; however, there is lack of consensus on how to perform trials and the need arises for evaluation frameworks, methods, and techniques appropriate for the ASD population. In this paper, we report on a study conducted with high-functioning ASD people in the 21-23 age range, with the objectives of (1) evaluating the engagement of two headsets offering distinct immersive experiences, (2) reasoning on the interpretation of engagement factors in the case of ASD people, and (3) translating results into general guidelines for the development of VR/AR-based ASD treatment. To this aim, we (1) designed two engagement evaluation frameworks based on behavioral observation measures, (2) set up two packages of reference immersive scenarios, (3) defined the association between metrics and scenarios, and (4) administered the scenarios in distinct sessions for the investigated headsets. Results show that the immersive experiences are engaging and that the apparent lack of success of some evaluation factors can become potential advantages within the framework of VR/AR-based ASD treatment design.

Design your life: user-initiated design of technology to empower autistic young adults

Purpose

This article describes the development and initial experiences of Design Your Life, a new design approach implementing user-initiated design of technological environments that support autistic young adults to live independently.

Design/methodology/approach

This article makes use of a phenomenological Research-through-Design approach. Investigation of possible ways in which a set of four guiding principles could be applied into a design toolkit for autistic young adults and their caregivers by means of three design case studies was conducted. Promising methods from the design practice and literature were applied and contrasted with the lived experiences and practical contexts of autistic young adults and their caregivers.

Findings

This exploratory research yielded several important insights for the design direction of Design Your Life. Reflecting on how the guiding principles played out in practice it was noted that: the case studies showed that stakeholders appreciate the approach. The design principles applied cannot be used without the help of a sparring partner. This suggests that caregivers may be trained in design-thinking to fulfil this role. The Design Your Life method will be iteratively developed, refined and validated in practice.

Originality/value

The presented approach puts design tools in the hands of the people who will use the technology. Furthermore, the approach sees technologies as empowering interventions by which a person can strengthen their own living environment. According to this article, this approach is new for this application. It provides valuable perspectives and considerations for autistic people, caregivers, researchers and policy makers.

Adapting Drug and Alcohol Therapies for Autistic Adults

Background

Autistic people may be at a higher risk of drug and alcohol misuse than the general population. Autistic people, however, are under-represented within drug and alcohol support services. This is the first survey of drug and alcohol therapists' perceptions of current service provision for autistic clients and recommendations for reasonable adjustments that therapists can make to enhance successful outcomes.

Methods

We conducted an online survey of 122 drug and alcohol therapists, exploring therapists' demographics, training and experience with autistic clients, approaches and adaptations used with autistic clients, and therapists' confidence with autistic clients. Within two focus groups, 11 members of the autistic and broader autism (e.g., family members, professionals) communities reflected on the reasonable adjustments reported by therapists.

Results

Most therapists had autistic clients and most therapists had received no autism-specific training. Alcohol misuse was the most common presenting issue, and most therapists reported that treatment outcomes were less favorable for autistic clients than for other groups. Therapists perceived that barriers to successful outcomes were (1) a lack of autism-specific training, (2) a need to adapt therapy for autistic clients, and (3) a lack of shared perspective between the therapist and the autistic client. Previous research has identified a range of reasonable adaptations and, when asked, therapists were moderately confident in their ability to deliver these. Members of the autistic and broader autism communities coproduced guidance detailing how therapists can best adapt their practice for autistic clients including how to structure sessions and the language to use within sessions.

Conclusion

This study highlights a need for practical and theoretical training for drug and alcohol therapists to support successful adaptation to current service provision for autistic clients and to develop a shared perspective on the desired aims and outcomes of the therapeutic process.

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).

The impact of using digitally-mediated social stories on the perceived competence and attitudes of parents and practitioners supporting children with autism

A Social Story (SS) is a highly acceptable and widely used intervention by the autism community. Yet, inconsistent implementation of the intervention is reported to be one of the causes of variability in terms of outcome research, particularly in a naturalistic context. This study aimed to (1) investigate whether digitally-mediated social stories (SSs) can improve competence in developing and delivering a SS and thus contribute towards improved implementation, and (2) investigate the impact of the digitally-mediated SS on attitudes towards the SS intervention. Ninety-three participants took an initial pre-engagement survey. Forty-eight of these participants also complete a post-engagement survey. A pre-post design was utilised with the participants who completed both surveys. These 48 participants were invited to develop a digitally-mediated SS with the aim of exploring how digitally-mediated SSs impacted perceived competence and attitudes. Post-engagement data was collected two weeks after the pre-engagement data. Outcomes of this study indicate that both perceived competence and attitudes improved after engaging with digitally-mediated SSs. It is concluded that digitally-mediated SS not only impacted the integrity of how the intervention was delivered but also the beliefs in the participants’ capabilities to develop and deliver a SS. Digitally-mediated SS, thus, has the potential to effectively support development and delivery whilst also addressing challenges related to intervention implementation in a naturalistic context.

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.

Virtual reality and naturalistic developmental behavioral interventions for children with autism spectrum disorder

BACKGROUND

Naturalistic Developmental Behavioral Interventions (NDBI) have been evaluated as the most promising interventions for children with autism spectrum disorder. In recent years, a growing body of literature suggests that technological advancements such as Virtual Reality (VR) are promising intervention tools. However, to the best of our knowledge no studies have combined evidence-based practice with such tools.

AIM

This article aims to review the current literature combining NDBI and VR, and provide suggestions on merging NDBI-approaches with VR.

METHODS

This article is divided into two parts, where we first conduct a review mapping the research applying NDBI-approaches in VR. In the second part we argue how to apply the common features of NDBI into VR-technology.

RESULTS

Our findings show that no VR-studies explicitly rely on NDBI-approaches, but some utilize elements in their interventions that are considered to be common features to NDBI.

CONCLUSIONS AND IMPLICATIONS

As the results show, to date, no VR-based studies have utilized NDBI in their intervention. We therefore, in the second part of this article, suggests ways to merge VR and NDBI and introduce the term Virtual Naturalistic Developmental Behavioral Interventions (VNDBI). VNDBI is an innovative way of implementing NDBI which will contribute in making interventions more accessible in central as well as remote locations, while reducing unwanted variation between service sites. VNDBI will advance the possibilities of individually tailoring and widen the area of interventions. In addition, VNDBI can provide the field with new knowledge on effective components enhancing the accuracy in the intervention packages and thus move forward the research field and clinical practice.

A Pilot Randomised Control Trial of Digitally-Mediated Social Stories for Children on the Autism Spectrum

Social stories is a widely used intervention for children on the autism spectrum, particularly within an educational context. To date, systematic reviews and meta analyses of the research evaluating social stories has produced mixed results, often due to a lack of methodological rigour and variability in the development and delivery of the social stories. To address the gap in methodological rigour, a pilot Randomised Control Trial (RCT) was conducted, incorporating a social stories intervention group (n = 9 children on the autism spectrum) and an attentional control group who received a poem (n = 6 children on the autism spectrum) using a digital platform to address variability. Digitally-mediated social stories were found to be effective in producing beneficial changes in behaviour outcomes, which were sustained at a six-week follow up.

Digitally-Mediated Social Stories Support Children on the Autism Spectrum Adapting to a Change in a 'Real-World' Context

Social Stories™ (SS) is a widely used intervention for children on the autism spectrum. A preliminary survey of 103 practitioners highlighted that SS are often used to support adapting to a change. This study investigated the use of digitally-mediated SS to support ten children on the autism spectrum attending a school summer camp. Teacher perceptions of anxiety, understanding and closeness to the goal of the SS were assessed before and after the intervention (prior to the event). The pre- post-intervention comparisons highlighted significant improvements in child understanding, anxiety, and closeness to goal with medium-large effect sizes. The child’s understanding and closeness to SS goal post-intervention related to their difficulties with the SS goal and their anxiety during the event.