Brain-Computer Interfaces for Children With Complex Communication Needs and Limited Mobility: A Systematic Review

The lived experiences of play and the perspectives of disabled children and their parents surrounding brain-computer interfaces

Brain-computer interfaces (BCI) offer promise to the play of children with significant physical impairments, as BCI technology can enable disabled children to control computer devices, toys, and robots using only their brain signals. However, there is little research on the unique needs of disabled children when it comes to BCI-enabled play. Thus, this paper explored the lived experiences of play for children with significant physical impairments and examined how BCI could potentially be implemented into disabled children's play experiences by applying a social model of childhood disability. Descriptive qualitative methodology was employed by conducting four semi-structured interviews with two children with significant physical impairments and their parents. We found that disabled children's play can be interpreted as passive or active depending on one's definition and perceptions surrounding play. Moreover, disabled children continue to face physical, economic, and technological barriers in their play, as well as play restrictions from physical impairments. We urge that future research should strive to directly hear from disabled children themselves, as their perspectives may differ from their parents' views. Also, future BCI development should strive to incorporate video games, recreational and entertainment applications/platforms, toys and switch-adapted toys, and power wheelchairs to better support the play of children with significant physical impairments.Implications for RehabilitationAssistive technology research should strive to examine the social, infrastructural, and environmental barriers that continue to disable and restrict participation for disabled children and their families through applying a social model of childhood disability and other holistic frameworks that look beyond individual factorsFuture research that examines the needs and lives of disabled children should strive to directly seek the opinions and perspectives of disabled children themselvesBrain-computer interface development should strive to incorporate video games, recreational and entertainment applications/platforms, toys and switch-adapted toys, and power wheelchairs to better support the play of children with significant physical impairments.

Case report: Novel use of clinical brain-computer interfaces in recreation programming for an autistic adolescent with co-occurring attention deficit hyperactivity disorder

Background

In recent years, several autistic children and youth have shown interest in Holland Bloorview Kids Rehabilitation Hospital's clinical brain computer interface (BCI) program. Existing literature about BCI use among autistic individuals has focused solely on cognitive skill development and remediation of challenging behaviors. To date, the benefits of recreational BCI programming with autistic children and youth have not been documented.

Purpose

This case report summarizes the experiences of an autistic male adolescent with co-occurring attention deficit hyperactivity disorder using a BCI for recreation and considers possible benefits with this novel user population.

Methods

A single retrospective chart review was completed with parental guardian's consent.

Findings

The participant demonstrated enjoyment in BCI sessions and requested continued opportunities to engage in BCI programming. This enjoyment correlated with improved Canadian Occupational Performance Measure (COPM) scores in BCI programming, outperforming scores from other recreational programs. Additionally, clinicians observed changes in social communication efforts and self-advocacy in this first autistic participant.

Conclusion

The use of brain computer interfaces in recreational programming provides a novel opportunity for engagement for autistic children and youth that may also support skill development.

Fatigue in children using motor imagery and P300 brain-computer interfaces

BACKGROUND

Brain-computer interface (BCI) technology offers children with quadriplegic cerebral palsy unique opportunities for communication, environmental exploration, learning, and game play. Research in adults demonstrates a negative impact of fatigue on BCI enjoyment, while effects on BCI performance are variable. To date, there have been no pediatric studies of BCI fatigue. The purpose of this study was to assess the effects of two different BCI paradigms, motor imagery and visual P300, on the development of self-reported fatigue and an electroencephalography (EEG) biomarker of fatigue in typically developing children.

METHODS

Thirty-seven typically-developing school-aged children were recruited to a prospective, crossover study. Participants attended three sessions: (A) motor imagery-BCI, (B) visual P300-BCI, and (C) video viewing (control). The motor imagery task involved an imagined left- or right-hand squeeze. The P300 task involved attending to one square on a 3 × 3 grid during a random single flash sequence. Each paradigm had respective calibration periods and a similar visual counting game. Primary outcomes were self-reported fatigue and the power of the EEG alpha band both collected during resting-state periods pre- and post-task. Self-reported fatigue was measured using a 10-point visual analog scale. EEG alpha band power was calculated as the integrated power spectral density from 8 to 12 Hz of the EEG spectrum.

RESULTS

Thirty-two children completed the protocol (age range 7-16, 63% female). Self-reported fatigue and EEG alpha band power increased across all sessions (F(1,155) = 33.9, p < 0.001; F = 5.0(1,149), p = 0.027 respectively). No differences in fatigue development were observed between session types. There was no correlation between self-reported fatigue and EEG alpha band power change. BCI performance varied between participants and paradigms as expected but was not associated with self-reported fatigue or EEG alpha band power.

CONCLUSION

Short periods (30-mintues) of BCI use can increase self-reported fatigue and EEG alpha band power to a similar degree in children performing motor imagery and P300 BCI paradigms. Performance was not associated with our measures of fatigue; the impact of fatigue on useability and enjoyment is unclear. Our results reflect the variability of fatigue and the BCI experience more broadly in children and warrant further investigation.

Design of aided augmentative and alternative communication systems for children with vision impairment: psychoacoustic perspectives

Children with complex communication needs often have multiple disabilities including visual impairments that impact their ability to interact with aided augmentative and alternative communication (AAC) systems. Just as the field benefited from a consideration of visual cognitive neuroscience in construction of visual displays, an exploration of psychoacoustics can potentially assist in maximizing the possibilities within AAC systems when the visual channel is either (a) not the primary sensory mode, or (b) is one that can be augmented to ultimately benefit AAC outcomes. The purpose of this paper is to highlight background information about psychoacoustics and present possible future directions for the design of aided AAC system technologies for children with visual impairments who rely on auditory information to learn and utilize AAC.

Promoting Simple and Engaging Brain-Computer Interface Designs for Children by Evaluating Contrasting Motion Techniques

PURPOSE

There is an increasing focus on using motion in augmentative and alternative communication (AAC) systems. In considering brain-computer interface access to AAC (BCI-AAC), motion may provide a simpler or more intuitive avenue for BCI-AAC control. Different motion techniques may be utilized in supporting competency with AAC devices including simple (e.g., zoom) and complex (behaviorally relevant animation) methods. However, how different pictorial symbol animation techniques impact BCI-AAC is unclear.

METHOD

Sixteen healthy children completed two experimental conditions. These conditions included highlighting of pictorial symbols via both functional (complex) and zoom (simple) animation to evaluate the effects of motion techniques on P300-based BCI-AAC signals and offline (predicted) BCI-AAC performance.

RESULTS

Functional (complex) animation significantly increased attentional-related P200/P300 event-related potential (ERP) amplitudes in the parieto-occipital area. Zoom (simple) animation significantly decreased N400 latency. N400 ERP amplitude was significantly greater, and occurred significantly earlier, on the right versus left side for the functional animation condition within the parieto-occipital bin. N200 ERP latency was significantly reduced over the left hemisphere for the zoom condition in the central bin. As hypothesized, elicitation of all targeted ERP components supported offline (predicted) BCI-AAC performance being similar between conditions.

CONCLUSION

Study findings provide continued support for the use of animation in BCI-AAC systems for children and highlight differences in neural and attentional processing between complex and simple animation techniques.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24085623.

Affective Neural Responses Sonified through Labeled Correlation Alignment

Sound synthesis refers to the creation of original acoustic signals with broad applications in artistic innovation, such as music creation for games and videos. Nonetheless, machine learning architectures face numerous challenges when learning musical structures from arbitrary corpora. This issue involves adapting patterns borrowed from other contexts to a concrete composition objective. Using Labeled Correlation Alignment (LCA), we propose an approach to sonify neural responses to affective music-listening data, identifying the brain features that are most congruent with the simultaneously extracted auditory features. For dealing with inter/intra-subject variability, a combination of Phase Locking Value and Gaussian Functional Connectivity is employed. The proposed two-step LCA approach embraces a separate coupling stage of input features to a set of emotion label sets using Centered Kernel Alignment. This step is followed by canonical correlation analysis to select multimodal representations with higher relationships. LCA enables physiological explanation by adding a backward transformation to estimate the matching contribution of each extracted brain neural feature set. Correlation estimates and partition quality represent performance measures. The evaluation uses a Vector Quantized Variational AutoEncoder to create an acoustic envelope from the tested Affective Music-Listening database. Validation results demonstrate the ability of the developed LCA approach to generate low-level music based on neural activity elicited by emotions while maintaining the ability to distinguish between the acoustic outputs.

Use of Invasive Brain-Computer Interfaces in Pediatric Neurosurgery: Technical and Ethical Considerations

Invasive brain-computer interfaces hold promise to alleviate disabilities in individuals with neurologic injury, with fully implantable brain-computer interface systems expected to reach the clinic in the upcoming decade. Children with severe neurologic disabilities, like quadriplegic cerebral palsy or cervical spine trauma, could benefit from this technology. However, they have been excluded from clinical trials of intracortical brain-computer interface to date. In this manuscript, we discuss the ethical considerations related to the use of invasive brain-computer interface in children with severe neurologic disabilities. We first review the technical hardware and software considerations for the application of intracortical brain-computer interface in children. We then discuss ethical issues related to motor brain-computer interface use in pediatric neurosurgery. Finally, based on the input of a multidisciplinary panel of experts in fields related to brain-computer interface (functional and restorative neurosurgery, pediatric neurosurgery, mathematics and artificial intelligence research, neuroengineering, pediatric ethics, and pragmatic ethics), we then formulate initial recommendations regarding the clinical use of invasive brain-computer interfaces in children.

EEG hybrid brain-computer interfaces: A scoping review applying an existing hybrid-BCI taxonomy and considerations for pediatric applications

Most hybrid brain-computer interfaces (hBCI) aim at improving the performance of single-input BCI. Many combinations are possible to configure an hBCI, such as using multiple brain input signals, different stimuli or more than one input system. Multiple studies have been done since 2010 where such interfaces have been tested and analyzed. Results and conclusions are promising but little has been discussed as to what is the best approach for the pediatric population, should they use hBCI as an assistive technology. Children might face greater challenges when using BCI and might benefit from less complex interfaces. Hence, in this scoping review we included 42 papers that developed hBCI systems for the purpose of control of assistive devices or communication software, and we analyzed them through the lenses of potential use in clinical settings and for children. We extracted taxonomic categories proposed in previous studies to describe the types of interfaces that have been developed. We also proposed interface characteristics that could be observed in different hBCI, such as type of target, number of targets and number of steps before selection. Then, we discussed how each of the extracted characteristics could influence the overall complexity of the system and what might be the best options for applications for children. Effectiveness and efficiency were also collected and included in the analysis. We concluded that the least complex hBCI interfaces might involve having a brain inputs and an external input, with a sequential role of operation, and visual stimuli. Those interfaces might also use a minimal number of targets of the strobic type, with one or two steps before the final selection. We hope this review can be used as a guideline for future hBCI developments and as an incentive to the design of interfaces that can also serve children who have motor impairments.

On the feasibility of simple brain-computer interface systems for enabling children with severe physical disabilities to explore independent movement

Introduction

Children with severe physical disabilities are denied their fundamental right to move, restricting their development, independence, and participation in life. Brain-computer interfaces (BCIs) could enable children with complex physical needs to access power mobility (PM) devices, which could help them move safely and independently. BCIs have been studied for PM control for adults but remain unexamined in children. In this study, we explored the feasibility of BCI-enabled PM control for children with severe physical disabilities, assessing BCI performance, standard PM skills and tolerability of BCI.

Materials and methods

Patient-oriented pilot trial. Eight children with quadriplegic cerebral palsy attended two sessions where they used a simple, commercial-grade BCI system to activate a PM trainer device. Performance was assessed through controlled activation trials (holding the PM device still or activating it upon verbal and visual cueing), and basic PM skills (driving time, number of activations, stopping) were assessed through distance trials. Setup and calibration times, headset tolerability, workload, and patient/caregiver experience were also evaluated.

Results

All participants completed the study with favorable tolerability and no serious adverse events or technological challenges. Average control accuracy was 78.3 ± 12.1%, participants were more reliably able to activate (95.7 ± 11.3%) the device than hold still (62.1 ± 23.7%). Positive trends were observed between performance and prior BCI experience and age. Participants were able to drive the PM device continuously an average of 1.5 meters for 3.0 s. They were able to stop at a target 53.1 ± 23.3% of the time, with significant variability. Participants tolerated the headset well, experienced mild-to-moderate workload and setup/calibration times were found to be practical. Participants were proud of their performance and both participants and families were eager to participate in future power mobility sessions.

Discussion

BCI-enabled PM access appears feasible in disabled children based on evaluations of performance, tolerability, workload, and setup/calibration. Performance was comparable to existing pediatric BCI literature and surpasses established cut-off thresholds (70%) of “effective” BCI use. Participants exhibited PM skills that would categorize them as “emerging operational learners.” Continued exploration of BCI-enabled PM for children with severe physical disabilities is justified.

[Feedback strategies in assistive technology to promote social participation in children with cerebral palsy: Systematic review]

INTRODUCTION

Living with cerebral palsy has consequences such as social interaction. Assistive technologies used for improving independence only focuses on biological and physiological variables. The main objective in this review is to synthesize the evidence on interventions with assistive technologies, including feedback systems, with the aim of discovering outcomes of social participation in children with cerebral palsy.

METHODOLOGY

There were 5 databases from rehabilitation which showed 683 articles in which only 9 were included.

RESULTS

The studies assessed social participation with several instruments. The majority suggested positive effects in activities such as: walking, writing, playing, and social interaction. There were tools such as electronic pencils, switches, and exoskeletons present.

CONCLUSION

Due to the poor quality of the methodologies of these studies, the search does not establish solid conclusions. However, the evidence suggests that assistive technologies with feedback have a positive impact on aspects of social participation.

A pediatric near-infrared spectroscopy brain-computer interface based on the detection of emotional valence

Brain-computer interfaces (BCIs) are being investigated as an access pathway to communication for individuals with physical disabilities, as the technology obviates the need for voluntary motor control. However, to date, minimal research has investigated the use of BCIs for children. Traditional BCI communication paradigms may be suboptimal given that children with physical disabilities may face delays in cognitive development and acquisition of literacy skills. Instead, in this study we explored emotional state as an alternative access pathway to communication. We developed a pediatric BCI to identify positive and negative emotional states from changes in hemodynamic activity of the prefrontal cortex (PFC). To train and test the BCI, 10 neurotypical children aged 8–14 underwent a series of emotion-induction trials over four experimental sessions (one offline, three online) while their brain activity was measured with functional near-infrared spectroscopy (fNIRS). Visual neurofeedback was used to assist participants in regulating their emotional states and modulating their hemodynamic activity in response to the affective stimuli. Child-specific linear discriminant classifiers were trained on cumulatively available data from previous sessions and adaptively updated throughout each session. Average online valence classification exceeded chance across participants by the last two online sessions (with 7 and 8 of the 10 participants performing better than chance, respectively, in Sessions 3 and 4). There was a small significant positive correlation with online BCI performance and age, suggesting older participants were more successful at regulating their emotional state and/or brain activity. Variability was seen across participants in regards to BCI performance, hemodynamic response, and discriminatory features and channels. Retrospective offline analyses yielded accuracies comparable to those reported in adult affective BCI studies using fNIRS. Affective fNIRS-BCIs appear to be feasible for school-aged children, but to further gauge the practical potential of this type of BCI, replication with more training sessions, larger sample sizes, and end-users with disabilities is necessary.

Challenges of brain-computer interface facilitated cognitive assessment for children with cerebral palsy

Brain-computer interfaces (BCIs) have been successfully used by adults, but little information is available on BCI use by children, especially children with severe multiple impairments who may need technology to facilitate communication. Here we discuss the challenges of using non-invasive BCI with children, especially children who do not have another established method of communication with unfamiliar partners. Strategies to manage these challenges require consideration of multiple factors related to accessibility, cognition, and participation. These factors include decisions regarding where (home, clinic, or lab) participation will take place, the number of sessions involved, and the degree of participation necessary for success. A strategic approach to addressing the unique challenges inherent in BCI use by children with disabilities will increase the potential for successful BCI calibration and adoption of BCI as a valuable access method for children with the most significant impairments in movement and communication.

A systematic review of research on augmentative and alternative communication brain-computer interface systems for individuals with disabilities

Augmentative and alternative communication brain-computer interface (AAC-BCI) systems are intended to offer communication access to people with severe speech and physical impairment (SSPI) without requiring volitional movement. As the field moves toward clinical implementation of AAC-BCI systems, research involving participants with SSPI is essential. Research has demonstrated variability in AAC-BCI system performance across users, and mixed results for comparisons of performance for users with and without disabilities. The aims of this systematic review were to (1) describe study, system, and participant characteristics reported in BCI research, (2) summarize the communication task performance of participants with disabilities using AAC-BCI systems, and (3) explore any differences in performance for participants with and without disabilities. Electronic databases were searched in May, 2018, and March, 2021, identifying 6065 records, of which 73 met inclusion criteria. Non-experimental study designs were common and sample sizes were typically small, with approximately half of studies involving five or fewer participants with disabilities. There was considerable variability in participant characteristics, and in how those characteristics were reported. Over 60% of studies reported an average selection accuracy ≤70% for participants with disabilities in at least one tested condition. However, some studies excluded participants who did not reach a specific system performance criterion, and others did not state whether any participants were excluded based on performance. Twenty-nine studies included participants both with and without disabilities, but few reported statistical analyses comparing performance between the two groups. Results suggest that AAC-BCI systems show promise for supporting communication for people with SSPI, but they remain ineffective for some individuals. The lack of standards in reporting outcome measures makes it difficult to synthesize data across studies. Further research is needed to demonstrate efficacy of AAC-BCI systems for people who experience SSPI of varying etiologies and severity levels, and these individuals should be included in system design and testing. Consensus in terminology and consistent participant, protocol, and performance description will facilitate the exploration of user and system characteristics that positively or negatively affect AAC-BCI use, and support innovations that will make this technology more useful to a broader group of people.

Clinical trial registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42018095345, PROSPERO: CRD42018095345.

Workshops of the Eighth International Brain-Computer Interface Meeting: BCIs: The Next Frontier

The Eighth International Brain-Computer Interface (BCI) Meeting was held June 7-9th, 2021 in a virtual format. The conference continued the BCI Meeting series' interactive nature with 21 workshops covering topics in BCI (also called brain-machine interface) research. As in the past, workshops covered the breadth of topics in BCI. Some workshops provided detailed examinations of specific methods, hardware, or processes. Others focused on specific BCI applications or user groups. Several workshops continued consensus building efforts designed to create BCI standards and increase the ease of comparisons between studies and the potential for meta-analysis and large multi-site clinical trials. Ethical and translational considerations were both the primary topic for some workshops or an important secondary consideration for others. The range of BCI applications continues to expand, with more workshops focusing on approaches that can extend beyond the needs of those with physical impairments. This paper summarizes each workshop, provides background information and references for further study, presents an overview of the discussion topics, and describes the conclusion, challenges, or initiatives that resulted from the interactions and discussion at the workshop.