GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 1, Number 4, 2012 ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2012.0717
Roundtable Discussion
Game Interventions for Autism Spectrum Disorder Moderator: Bill Ferguson, PhD1 Participants: Cay Anderson-Hanley, PhD,2 Micah O. Mazurek, PhD,3 Sarah Parsons, PhD,4 and Zachary Warren, PhD 5
I
t is nearly impossible to spend a day without hearing news or personal stories regarding autism. To Google ‘‘autism + health games’’ yields thousands of postings. The disorder is so broad in its symptoms and manifestations that it is referred to as autism spectrum disorder or ASD. It is of such a high priority that research on reward circuitry, autism, and games teaching social perceptual skills was one of The Robert Wood Johnson Foundation Pioneer Fund’s first projects. Earlier this year I read an interesting article by Dr. Micah Mazurek of the University of Missouri stating children with ASD tend to be fascinated by screen-based technology (SBT) and spend the majority of their free time using nonsocial media, including television and videogames. I asked Dr. Mazurek if she could assemble a panel of experts to discuss ASD and how those with the disorder can benefit from their fascination of videogames. To that end, the following roundtable discussion shares the expertise of Dr. Mazurek and her fellow ASD research leaders, Dr. Cay Anderson-Hanley, Dr. Zachary Warren, and Dr. Sarah Parsons. Bill Ferguson: Thank you all for your time and expertise. ASD is a topic of growing interest and importance to parents, educators, and researchers from physiologists and neurologists through psychiatrists. In order to understand your work in assessing, understanding, and treating the disorder we must first define it. Dr. Mazurek, please begin our discussion with the accepted definition of ASD.
Micah Mazurek: Autism spectrum disorders—or ASD—are complex neurodevelopmental disorders that are characterized by impairments in communication and social interaction, and by engagement in restricted and repetitive behavior.1 Individuals with ASD are also at risk for a number of co-occurring challenges, including cognitive difficulties and co-occurring medical and psychiatric disorders.2,3 These core and associated difficulties can substantially affect outcomes for both individuals and their families. Individuals with ASD often experience reduced quality of life, decreased community engagement and participation, and substan-
tial difficulties with adaptive functioning.4,5 Unfortunately, long-term outcomes for adults with ASD are often poor, in terms of occupational success, independent living, and social function.6,7 Families of children with ASD also experience a number of challenges, including increased financial burden, high levels of stress, and decreased social support and community engagement.8–10 In addition, ASD is affecting a growing number of individuals and families each year, with marked increases in prevalence. Recent reports have estimated that the prevalence of ASD in the United States is approximately 1 in 88 children.11 As a result, there has been an increased focus on developing interventions that can effectively address core symptoms and improve overall functioning. Bill Ferguson: Thank you. What is known about effective treatment strategies for ASD, and what areas require further research? Zachary Warren: As Micah noted, the Centers for Disease Control and Prevention11 estimates one in 88 children has ASD. Effective identification and treatment of the disorder are often characterized as a public health emergency. The costs of ASD are thought to be enormous across the lifespan, with recent individual incremental lifetime cost projections exceeding $3.2 million. To address the powerful impairments and costs associated with ASD, a wide variety of potential interventions have been offered, but so far few have been subjected to the rigors of controlled clinical trials. The cumulative literature suggests earlier and more intensive interventions are efficacious for some children; however, outcomes vary greatly. This variation is poorly understood, and most individuals continue to display potent impairments in many areas despite improvements. Given the present limits of intervention science and the powerful nature of early impairments across the lifespan, there is urgent need for the development and application of novel treatment paradigms capable of substantially more efficacious individualized impact on the core deficits of ASD. More simply, there is much
1
Editor, Games for Health Journal: Research, Development, and Clinical Applications, Mary Ann Liebert, Inc., New Rochelle, New York. Union College, Schenectady, New York. 3 University of Missouri, Columbia, Missouri. 4 University of Southampton, Southampton, United Kingdom. 5 Vanderbilt University, Nashville, Tennessee. 2
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ROUNDTABLE DISCUSSION work to be done in achieving effective individualized intervention paradigms that dramatically improve core deficits and associated vulnerabilities related to ASD. Sarah Parsons: I agree. There is a lot of debate within the field of autism research regarding what constitutes the best or most effective educational approach for children and young people on the autism spectrum. There are strong proponents of intensive behavioral approaches to educational intervention who claim that these are the only kinds of methods that are scientifically valid and empirically supported.12,13 However, other reviews of educational interventions based on a broader analysis of the available evidence have come to a different conclusion, which is that there is not one single approach or method that is likely to work best for all children with autism, and a range of intervention approaches should be made available to schools and families.14–17 The evidence base for educational interventions for autism is characterized by small and poorly defined participant groups, as well as weak intervention designs, which make it difficult to understand how, and for whom, a particular approach may or may not lead to successful outcomes.14 In a systematic review of 100 empirical articles published between 2002 and 2008 only 12 were judged to offer a high "weight of evidence" through having larger samples and by implementing rigorous research designs.14 Research into early interventions for young children (about 3–6 years old) dominates the literature, and those that focus on early communicative behaviors seem to offer particular promise18–20 through being well-designed and targeting pivotal skills or behaviors at the core of autism. However, the focus on early intervention in autism, while well justified, has resulted in substantial gaps in knowledge in relation to effective educational approaches for older children on the autism spectrum; there is very little research that explores the experiences of secondary (high school) aged children in particular.14 More specifically, in relation to the use of technologies, the evidence base tends to be quite fragmented and focused chiefly on the usability and functionality of the technologies rather than their application for, and success in promoting, learning.21 In a recent review of virtual reality (VR) technologies for autism specifically, Parsons and Cobb22 noted that despite over 15 years of research, the evidence base remains limited with small-scale studies and equivocal results. Nevertheless, they conclude there are good reasons to continue research in this area. Bill Ferguson: As we discussed earlier, Dr. Mazurek, you found that children who have ASD often exhibit fascination with videogames and the like. How might SBTs be particularly well suited to the needs of individuals with ASD? Micah Mazurek: Many children and adolescents with ASD seem to be particularly interested in and motivated by SBTs, including computers, television, and videogames. Although research has yet to fully explore and understand this issue, our recent research indicates that screen-based activities (including videogames and television) are preferred activities for children and adolescents with ASD.23 Other research has shown that many individuals with ASD have strengths in visual perceptual skills and respond particularly well to visual stimuli.24–26
249 Many technologies, including game-based systems, also offer structured and organized frameworks and frequent and immediate reinforcement. These features may be especially relevant for children with ASD, given that they often have significant problems with executive functioning.27,28 Executive functioning skills are higher-order cognitive abilities that include skills such as planning, organization, mental flexibility, and self-monitoring. Problems in these areas often contribute to difficulties with adaptive functioning and may limit an individual’s ability to fully benefit from traditional teaching strategies. The inherent structure of many SBTs and systems may allow opportunities for success and learning, while providing supports that directly address executive functioning problems. SBTs also have the potential to systematically adjust the demands for social interaction, an area that is inherently difficult for individuals with ASD. Zachary Warren: I certainly agree with Dr. Mazurek that there are numerous reasons why incorporating technology, specifically computer and screen-based systems, into intervention practices may be particularly relevant for children and adolescents with ASD. The strength of these types of technologies for ASD intervention includes malleability, controllability, modifiable sensory stimulation, individualizable approach, safety, and potential reduction of problematic aspects of human interaction during treatment. It has been shown that computer and VR-based intervention may provide a simplified but exploratory interaction environment for children with ASD. For example, while social interaction in a VR environment does not necessarily include direct human-to-human interaction, having the controllable complexity of a virtual world with minimized distractions or distresses may allow for simplified but embodied social interaction that is less intimidating or confusing for children with ASD than some complex real-world social interactions. Computer and VR intervention methodologies potentially have the ability to address the substantial difficulties with generalization of learned skills to the real-world by introducing not only more control over teaching basic elements of complex skills, but also the ability to systematically employ and reinforce these skills within many different, controllable, realistic interaction environments. Traditional methods of social and adaptive skill intervention often are not able to control environments or repeat exposure to naturalistic environments with an intensity that may lead to more substantial change; however, the virtual world can be designed to break down, repeat, add, and subtract aspects of the environment in any manner necessary to achieve a task goal. Further, individuals with ASD may also demonstrate improved learning with VR environments as this technology can enhance salient aspects of visual or physical learning that may be more powerful than traditional learning paradigms. Computer systems and VR environments can easily change the attributes of or add/remove objects in ways that may not be possible in a real-world setting but could be valuable to teach both concrete and abstract concepts. Therefore, these highly versatile technologies can offer the benefit of illustrating scenarios that can be changed to accommodate various situations that may not be feasible in a given therapeutic
250 setting because of space limitations, resource deficits, safety concerns, etc. Furthermore, sensory challenges, both impairing interests and sensitivities, are often part of ASD profiles. The audiovisual output of the computer and VR is likewise easily controlled to make more salient/engaging tasks, reduce, and systematically address sensory difficulties/interests. VR has also shown the capacity to ease the burden, both time and effort, of trained therapists in an intervention process as well as the potential to allow untrained personnel (e.g., parents or peers) to aid a participant in the intervention. Therefore, computer and VR technology represents a medium well suited for creating interactive intervention paradigms for skill training in the core areas of impairment for children with ASD. Cay Anderson-Hanley: Yes, there is no doubt that SBTs provide a compact and programmable environment that can readily be adapted to the needs of a person with ASD. There is great potential for reliable and immediate reinforcement of desired behaviors based on interactivity between the person and his or her virtual environment (VE). Sarah Parsons: That is right. There are a number of arguments about this, but early on Swettenham29 suggested that a computer offers a stable, familiar, and predictable environment that can be adapted to suit individual needs. Given that we know children on the autism spectrum tend to prefer predictability in responding these features have specific advantages. Also, Wilson et al.30 argued that the amount, level, and type of inputs (e.g. visual, auditory) can be controlled directly, which means that specific tasks can be completed in the absence of distracting cues; again, given that we know there can be sensory sensitivities experienced by children with autism, being able to control these aspects could be beneficial.31 Bill Ferguson: How might SBTs be useful in the treatment of ASD? Sarah Parsons: In relation to VR technologies specifically there are particular affordances that could be especially useful in terms of supporting learning for children on the autism spectrum. Applications for autism and recognition of the potential of VR for children on the autism spectrum began to appear in the mid to late 1990s with Dorothy Strickland pioneering the testing of early hardware with two young children with autism.32–34 Cheryl Trepagnier35 also recognized the potential of VR for people with autism, arguing that the ability to reduce distraction and support executive functions and communication within VEs made them particularly noteworthy for cognitive rehabilitation, including social skills training for children with autism. Peter Mitchell and I31 developed this argument further and suggested that VEs could be particularly helpful educational tools for people on the autism spectrum because they offered the potential to combine the strengths of effective intervention components from both the cognitive and behavioral research traditions, for example, repetition and practice of the skill across a range of contexts, role-play within realistic settings from different perspectives, explanation/interpretation of the social skill(s) being taught, and
ROUNDTABLE DISCUSSION support in understanding how one’s own behavior and communication influences or impacts on others. Moreover, the nature of VEs mean that these strengths could then be extended through the safe and supportive space of a VE, which allows the user to have active control over his or her participation, where interaction can take many forms (for example, users may communicate verbally or via text via their avatars) and does not require face-to-face communication (which many people with autism might find uncomfortable), the level and number of nonverbal and verbal features of communication can be directly controlled and manipulated and adapted for individual needs, and behaviors and responses can be practiced and developed in a context that shares some similarities with the real world, thereby offering greater potential for transfer of skills and understanding to real-world situations.31 Cay Anderson-Hanley: Neuropsychological functions may be amenable to treatment with exergames, especially executive function, especially given prior literature on exercise across the age spectrum36 as well as research in our lab.37,38 Similarly, repetitive behaviors were shown to be modifiable in a pilot study from our lab per above.37 Advantages of SBTs are that we can test more specific hypotheses about the factors that affect symptoms of ASD by facile manipulation of on-screen content and interactive reinforcement. SBTs are also intriguing to humans, both young and old, such that exergames like the Wii [Nintendo] and the cybercycle readily draw people in. In terms of increasing exercise behavior there is a great deal of potential that is yet being realized as various factors are tested and equipment/technologies are adjusted. The exergames we have studied are extremely safe and compact, even allowing placement in classrooms and other facilities where an ASD student might have the opportunity to use it and benefit academic outcomes directly. A disadvantage would be if users develop a dependence upon the use of exergames and avoid direct experience with reality such as limiting outdoor play or direct socialization, both of which have other important benefits. Zachary Warren: Yes, we have found a growing number of studies investigating the application of advanced interactive technologies to ASD intervention, including computer technology, VR environments, and more recently robotic systems. It has been argued that specific applications of technological systems can be effectively harnessed to provide new important directions for intervention, given potential capacities for making treatments highly individualized, intensive, flexible, and adaptive, embedding novel quantitative metrics, and developing noninvasive methodologies, as well as providing a vehicle for embodied "social" interaction. While initial results applying technology to ASD intervention have demonstrated potential, and perhaps unique utility, to elicit certain behaviors, no existing technological system specifically addresses how to detect and flexibly respond to individually derived socially relevant behavioral cues of children with ASD within an intelligent adaptive intervention paradigm that ultimately promotes meaningful change related to the complex and important social communication impairments of the disorder. Moreover, systems have yet to demonstrate or realize dynamic co-system intervention capacity wherein
ROUNDTABLE DISCUSSION skills within technological environments can be coordinated with and generalized to subsequent intervention interactions with human partners within or beyond the system interaction itself. Bill Ferguson: So, how have you addressed these issues in your own work? Zachary Warren: Our ongoing collaborative work at Vanderbilt focuses on developing and integrating technological systems with behavioral engagement profiling systems capable of adapting controlled environments and reinforcing skills in core domains gradually but automatically. This work strives to promote targeted and personalized intervention via technology. Although sophisticated, individualized VR systems are not at present widely available in many intervention settings, the barriers to optimal, intensive behavioral and educational intervention are so potent and the costs associated with suboptimal intervention so great that the development of such tools may be actually more practical, cost-effective, and beneficial than currently available intervention approaches/ modalities. Cay Anderson-Hanley: In our lab, we have been studying the benefits of exergaming (combined physical and mental exercise) for a variety of clinical populations ranging from Alzheimer’s to schizophrenia to ASD. The literature is already very strongly supportive of traditional physical exercise, which yields a significant impact on a variety of cognitive, psychological, and behavioral outcomes across the age spectrum39 and specifically in ASD.40 Research on the benefits of mental exercise (such as in computer game play) is less conclusive41; the literature is formative, though, and questions relating to transfer and generalizability of ‘‘cognitive training’’ effects are still being explored. Our recent randomized clinical trial of 3 months of exergaming for older adults found that exercise on a VR-enhanced stationary bike or ‘‘cybercycle’’ led to greater cognitive benefit than similar time and exercise effort on a traditional stationary bike.38 We hypothesize that there is a synergistic effect of combined mental and physical exercise that leads to additional benefit. For persons with ASD, it may be that the combination of physical exercise can both occupy repetitive behavior needs while increasing cerebral blood flow and thus enhance executive controls, allowing increased focus on computerized tasks available on an exergame. We found in a pilot study in our lab with children with ASD that a single bout on a cybercycle did lead to decreased repetitive behaviors and some increase in executive control.37 But much more research is needed to tease apart contributing factors and also examine longer-term outcomes. Sarah Parsons: My recent work has focused on collaborative VEs (CVEs) for supporting children on the autism spectrum in developing their collaboration and social conversation skills. They can work with peers (with and without autism), and the technology is designed to run on standard PCs and laptops and so should be more accessible for use in schools. Formal evaluations of the CVEs in use (yet to be written up and published!) suggest that there has been a positive impact of using the CVEs, especially in relation to social conversation. Crucially, I am now working with other colleagues in
251 the United Kingdom who have also been involved in the development of different technologies for autism, on a project that involves handing over the technologies to teachers in schools and observing their use and exploration of it. Only in this way can we really gain a better understanding of the pedagogic value of interactive technologies in the classroom, and therefore how we can improve design decisions in future projects. Bill Ferguson: Thank you. What do you see as emerging areas of research in this area? Sarah Parsons: I think augmented reality will be one of the "next big things" in terms of interfaces. I also think that there will be a drive towards more sophisticated response modes (i.e., ways of capturing data from participants). As noted in a forthcoming book chapter42: When it comes to the person with autism, applied VR research should ideally be aiming for a context where researchers or practitioners are able to assess children’s needs and develop personalized VEs accordingly, rather than producing a "one size fits all" approach. However, VR technologies may not yet offer sufficient flexibility and ease of use for this to be attainable at present, although it would be hoped that such possibilities could be within reach in the near future. Researchers should also be aware of the advances in cognitive neuroscience and autism. In future virtual reality projects, electroencephalogram (EEG) caps could be adapted for use in VR labs and be worn by participants to measure cortical responses to the stimuli being presented. If VR can provide authentic and meaningful experiences that ‘closely resemble’ real-world contexts43 then understanding more about the neural signals that occur in response to such stimuli could ultimately assist researchers in developing assessment and intervention tools for autism. In other words, neural signals may provide a useful measure of responding to (e.g.) socially oriented stimuli in a well-controlled and immersive VE that could be assessed pre- and post-intervention. This would expand the range of possible outcome measures available in such studies but also inform how VEs could most effectively be designed and personalized.
Cay Anderson-Hanley: In my opinion, there are a great many variables to be explored in trying to understand the benefits of exergaming to a variety of cognitive, psychological and behavioral outcomes. For example, we have started to examine the impact on exercise effort of a live versus a virtual competitor on the screen.44 The ability to control the social environment of an exergame could have many exciting implications in the treatment of ASD, from learning to enjoy riding solo, to observing other riders, to communicating with them, and perhaps even to collaborating with them on a group ride. Similarly, other researchers have examined the impact of control over the appearance of one’s avatar, which opens the possibility for persons with ASD to refine selfexpression and other important social skills. Furthermore, the potential synergy of physical and mental exercise in cognitive benefit is particularly intriguing. We are currently running studies to tease apart the impact of mental and physical exercise as experiences in sync or interactively. For ASD there are many potential benefits of an exergaming intervention such as cybercycling, which need further research, including a decrease in repetitive behaviors and enhanced cognitive
252 control, and hopefully this can translate into improved academic and social outcomes. Zachary Warren: Yes, I think that despite numerous potential advantages, current computer and VR technologies as applied to intervention for individuals with ASD are often designed in an open-loop fashion. Various computer software packages and VR environments have been developed and applied to address specific deficits associated with autism (e.g., understanding of false belief, attention, expression recognition, social problem-solving, and social conventions). These systems may be able to chain learning via basic aspects of performance; however, they are not capable of a higher degree of individualization. Specifically, they cannot automatically detect, appropriately respond, and adapt reinforcement based on the individual affective and attentive needs of the children with ASD and thus cannot flexibly identify, predict, test, and modify task in a manner targeted to the specific child. Given the importance of affective and attentive information in ASD individualized intervention practice, a closed-loop design incorporating this information may be critical. Bill Ferguson: Micah, thank you so much for putting together this admirable panel and for your fascinating research. And sincere thanks to you, Cay, Sarah, and Zachary for sharing your important perspectives with us. Best wishes to you all for success in this important field of research in ASD. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000. 2. Myers SM, Johnson CP. Management of children with autism spectrum disorders. Pediatrics 2007; 120:1162–1182. 3. Simonoff EM, Pickles AP, Charman TP, et al. Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a populationderived sample. J Am Acad Child Adolesc Psychiatry 2008; 47:921–929. 4. Hilton CL, Crouch MC, Israel H. Out-of-school participation patterns in children with high-functioning autism spectrum disorders. Am J Occup Ther 2008; 62:554–563. 5. Lee L-C, Harrington R, Louie B, Newschaffer C. Children with autism: Quality of life and parental concerns. J Autism Dev Disord 2008; 38:1147–1160. 6. Billstedt E, Gillberg C, Gillberg C. Autism after adolescence: Population-based 13- to 22-year follow-up study of 120 individuals with autism diagnosed in childhood. J Autism Dev Disord 2005; 35:351–360. 7. Howlin P, Goode S, Hutton J, Rutter M. Adult outcome for children with autism. J Child Psychol Psychiatry 2004; 45:212–229. 8. Cassidy A, McConkey R, Truesdale-Kennedy M, Slevin E. Preschoolers with autism spectrum disorders: The impact on families and the supports available to them. Early Child Dev Care 2008; 178:115–128. 9. Montes G, Halterman JS. Psychological functioning and coping among mothers of children with autism: A population-based study. Pediatrics 2007; 119:1040–1046. 10. Schieve LA, Blumberg SJ, Rice C, et al. The relationship between autism and parenting stress. Pediatrics 2007; 119(Suppl 1):S114–S121.
ROUNDTABLE DISCUSSION 11. Centers for Disease Control and Prevention. Prevalence of autism spectrum disorders—Autism and Developmental Disabilities Monitoring Network, United States, 2008. MMWR Surveill Summ 2012; 61(SS03):1–19. 12. Foxx RM. Applied behavior analysis treatment of autism: The state of the art. Child Adolesc Psychiatr Clin North Am 2008; 17:821–834. 13. Keenan M, Henderson M, Kerr K, Dillenburger K. Applied Behavior Analysis and Autism: Building a Future Together. London: Jessica Kingsley Publishers, 2006. 14. Parsons S, Guldberg K, MacLeod A, et al. International review of the literature of evidence of best practice provision in the education of persons with autistic spectrum disorders. National Council for Special Education, Ireland, 2009. http://www .ncse.ie/uploads/1/2_NCSE_Autism.pdf (accessed July 2, 2012). 15. Parsons S, Guldberg K, MacLeod A, et al. International review of the evidence on best practice in educational provision for children on the autism spectrum. Eur J Special Needs Educ 2011; 26:47–63. 16. Howlin P. Evaluating psychological treatments for children with autism-spectrum disorders. Adv Psychiatr Treat 2010; 16:133–140. 17. Spreckley M, Boyd R. Efficacy of applied behavioral Intervention in preschool children with Autism for improving cognitive, language, and adaptive behavior: A systematic review and meta-analysis. J Pediatr 2009; 154:319–321. 18. Kasari C, Freeman S, Paparella T. Joint attention and symbolic play in young children with autism: A randomized controlled intervention study. J Child Psychol Psychiatry 2006; 47:611–620. 19. Aldred C, Green J, Adams C. A new social communication intervention for children with autism: Pilot randomised controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry 2004; 45:1420–1430. 20. Mahoney G, Perales F. Using relationship-focused intervention to enhance the social-emotional functioning of young children with autism spectrum disorders. Top Early Child Special Educ 2003; 23:77–89. 21. Abbott C. e-Inclusion: Learning Difficulties and Digital Technologies. Bristol, UK: Futurelab, 2007. 22. Parsons S, Cobb S. State-of-the art of virtual reality technologies for children on the autism spectrum. Eur J Special Needs Educ 2011; 26:355–366. 23. Mazurek MO, Shattuck PT, Wagner M, Cooper B. Prevalence and correlates of screen-based media use among youths with autism spectrum disorders. J Autism Dev Disord 2011 Dec 8 [Epub ahead of print]. DOI: 10.1007/s10803-011-1413-8. 24. Jolliffe T, Baron-Cohen S. Are people with autism and Asperger syndrome faster than normal on the embedded figures test? J Child Psychol Psychiatry 1997; 38:527–534. 25. Mineo B, Ziegler W, Gill S, Salkin D. Engagement with electronic screen media among students with autism spectrum disorders. J Autism Dev Disord 2009; 39:172–187. 26. Mottron L, Dawson M, Soulie`res I, et al. Enhanced perceptual functioning in autism: An update, and eight principles of autistic perception. J Autism Dev Disord 2006; 36:27–43. 27. Hill EL. Executive dysfunction in autism. Trends Cogn Sci 2004; 8:26–32. 28. Kenworthy L, Yerys B, Anthony L, Wallace G. Understanding executive control in autism spectrum disorders in the lab and in the real world. Neuropsychol Rev 2008; 18:320–338. 29. Swettenham JG. Can children with autism be taught to understand false belief using computers? J Child Psychol Psychiatry 1996; 37:157–165.
ROUNDTABLE DISCUSSION 30. Wilson PN, Foreman N, Stanton D. A rejoinder. Disabil Rehabil 1998; 20:113–115. 31. Parsons S, Mitchell P. The potential of virtual reality in social skills training for people with autistic spectrum disorders. J Intellect Disabil Res 2002; 46:430–443. 32. Strickland D. A virtual reality application with autistic children. Presence Teleoperators Virtual Environ 1996; 5:319–329. 33. Strickland D. Virtual reality for the treatment of autism. In: Riva G, ed. Virtual Reality in Neuro-Psycho-Physiology. Amsterdam: Ios Press, 1998, pp 81–86. 34. Strickland D, Marcus LM, Mesibov GB, Hogan K. Brief report: Two case studies using virtual reality as a learning tool for autistic children. J Autism Dev Disord 1996; 26: 651–659. 35. Trepagnier CG. Virtual environments for the investigation and rehabilitation of cognitive and perceptual impairments. Neurorehabilitation 1999; 12:63–72. 36. Hillman CH, Erickson KI, Kramer AF. Be smart, exercise your heart: Exercise effects on brain and cognition. Nat Rev Neurosci 2008; 9:58–65. 37. Anderson-Hanley C, Tureck K, Schneiderman RL. Autism and exergaming: Effects on repetitive behaviors and cognition. Psychol Res Behav Manag 2011; 4:129 –137. 38. Anderson-Hanley C, Arciero PJ, Brickman AM, Nimon JP, Okuma N, Westen SC, Merz ME, Pence BD, Woods JA,
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Roundtable Discussion
Game Interventions for Autism Spectrum Disorder Moderator: Bill Ferguson, PhD1 Participants: Cay Anderson-Hanley, PhD,2 Micah O. Mazurek, PhD,3 Sarah Parsons, PhD,4 and Zachary Warren, PhD 5
I
t is nearly impossible to spend a day without hearing news or personal stories regarding autism. To Google ‘‘autism + health games’’ yields thousands of postings. The disorder is so broad in its symptoms and manifestations that it is referred to as autism spectrum disorder or ASD. It is of such a high priority that research on reward circuitry, autism, and games teaching social perceptual skills was one of The Robert Wood Johnson Foundation Pioneer Fund’s first projects. Earlier this year I read an interesting article by Dr. Micah Mazurek of the University of Missouri stating children with ASD tend to be fascinated by screen-based technology (SBT) and spend the majority of their free time using nonsocial media, including television and videogames. I asked Dr. Mazurek if she could assemble a panel of experts to discuss ASD and how those with the disorder can benefit from their fascination of videogames. To that end, the following roundtable discussion shares the expertise of Dr. Mazurek and her fellow ASD research leaders, Dr. Cay Anderson-Hanley, Dr. Zachary Warren, and Dr. Sarah Parsons. Bill Ferguson: Thank you all for your time and expertise. ASD is a topic of growing interest and importance to parents, educators, and researchers from physiologists and neurologists through psychiatrists. In order to understand your work in assessing, understanding, and treating the disorder we must first define it. Dr. Mazurek, please begin our discussion with the accepted definition of ASD.
Micah Mazurek: Autism spectrum disorders—or ASD—are complex neurodevelopmental disorders that are characterized by impairments in communication and social interaction, and by engagement in restricted and repetitive behavior.1 Individuals with ASD are also at risk for a number of co-occurring challenges, including cognitive difficulties and co-occurring medical and psychiatric disorders.2,3 These core and associated difficulties can substantially affect outcomes for both individuals and their families. Individuals with ASD often experience reduced quality of life, decreased community engagement and participation, and substan-
tial difficulties with adaptive functioning.4,5 Unfortunately, long-term outcomes for adults with ASD are often poor, in terms of occupational success, independent living, and social function.6,7 Families of children with ASD also experience a number of challenges, including increased financial burden, high levels of stress, and decreased social support and community engagement.8–10 In addition, ASD is affecting a growing number of individuals and families each year, with marked increases in prevalence. Recent reports have estimated that the prevalence of ASD in the United States is approximately 1 in 88 children.11 As a result, there has been an increased focus on developing interventions that can effectively address core symptoms and improve overall functioning. Bill Ferguson: Thank you. What is known about effective treatment strategies for ASD, and what areas require further research? Zachary Warren: As Micah noted, the Centers for Disease Control and Prevention11 estimates one in 88 children has ASD. Effective identification and treatment of the disorder are often characterized as a public health emergency. The costs of ASD are thought to be enormous across the lifespan, with recent individual incremental lifetime cost projections exceeding $3.2 million. To address the powerful impairments and costs associated with ASD, a wide variety of potential interventions have been offered, but so far few have been subjected to the rigors of controlled clinical trials. The cumulative literature suggests earlier and more intensive interventions are efficacious for some children; however, outcomes vary greatly. This variation is poorly understood, and most individuals continue to display potent impairments in many areas despite improvements. Given the present limits of intervention science and the powerful nature of early impairments across the lifespan, there is urgent need for the development and application of novel treatment paradigms capable of substantially more efficacious individualized impact on the core deficits of ASD. More simply, there is much
1
Editor, Games for Health Journal: Research, Development, and Clinical Applications, Mary Ann Liebert, Inc., New Rochelle, New York. Union College, Schenectady, New York. 3 University of Missouri, Columbia, Missouri. 4 University of Southampton, Southampton, United Kingdom. 5 Vanderbilt University, Nashville, Tennessee. 2
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ROUNDTABLE DISCUSSION work to be done in achieving effective individualized intervention paradigms that dramatically improve core deficits and associated vulnerabilities related to ASD. Sarah Parsons: I agree. There is a lot of debate within the field of autism research regarding what constitutes the best or most effective educational approach for children and young people on the autism spectrum. There are strong proponents of intensive behavioral approaches to educational intervention who claim that these are the only kinds of methods that are scientifically valid and empirically supported.12,13 However, other reviews of educational interventions based on a broader analysis of the available evidence have come to a different conclusion, which is that there is not one single approach or method that is likely to work best for all children with autism, and a range of intervention approaches should be made available to schools and families.14–17 The evidence base for educational interventions for autism is characterized by small and poorly defined participant groups, as well as weak intervention designs, which make it difficult to understand how, and for whom, a particular approach may or may not lead to successful outcomes.14 In a systematic review of 100 empirical articles published between 2002 and 2008 only 12 were judged to offer a high "weight of evidence" through having larger samples and by implementing rigorous research designs.14 Research into early interventions for young children (about 3–6 years old) dominates the literature, and those that focus on early communicative behaviors seem to offer particular promise18–20 through being well-designed and targeting pivotal skills or behaviors at the core of autism. However, the focus on early intervention in autism, while well justified, has resulted in substantial gaps in knowledge in relation to effective educational approaches for older children on the autism spectrum; there is very little research that explores the experiences of secondary (high school) aged children in particular.14 More specifically, in relation to the use of technologies, the evidence base tends to be quite fragmented and focused chiefly on the usability and functionality of the technologies rather than their application for, and success in promoting, learning.21 In a recent review of virtual reality (VR) technologies for autism specifically, Parsons and Cobb22 noted that despite over 15 years of research, the evidence base remains limited with small-scale studies and equivocal results. Nevertheless, they conclude there are good reasons to continue research in this area. Bill Ferguson: As we discussed earlier, Dr. Mazurek, you found that children who have ASD often exhibit fascination with videogames and the like. How might SBTs be particularly well suited to the needs of individuals with ASD? Micah Mazurek: Many children and adolescents with ASD seem to be particularly interested in and motivated by SBTs, including computers, television, and videogames. Although research has yet to fully explore and understand this issue, our recent research indicates that screen-based activities (including videogames and television) are preferred activities for children and adolescents with ASD.23 Other research has shown that many individuals with ASD have strengths in visual perceptual skills and respond particularly well to visual stimuli.24–26
249 Many technologies, including game-based systems, also offer structured and organized frameworks and frequent and immediate reinforcement. These features may be especially relevant for children with ASD, given that they often have significant problems with executive functioning.27,28 Executive functioning skills are higher-order cognitive abilities that include skills such as planning, organization, mental flexibility, and self-monitoring. Problems in these areas often contribute to difficulties with adaptive functioning and may limit an individual’s ability to fully benefit from traditional teaching strategies. The inherent structure of many SBTs and systems may allow opportunities for success and learning, while providing supports that directly address executive functioning problems. SBTs also have the potential to systematically adjust the demands for social interaction, an area that is inherently difficult for individuals with ASD. Zachary Warren: I certainly agree with Dr. Mazurek that there are numerous reasons why incorporating technology, specifically computer and screen-based systems, into intervention practices may be particularly relevant for children and adolescents with ASD. The strength of these types of technologies for ASD intervention includes malleability, controllability, modifiable sensory stimulation, individualizable approach, safety, and potential reduction of problematic aspects of human interaction during treatment. It has been shown that computer and VR-based intervention may provide a simplified but exploratory interaction environment for children with ASD. For example, while social interaction in a VR environment does not necessarily include direct human-to-human interaction, having the controllable complexity of a virtual world with minimized distractions or distresses may allow for simplified but embodied social interaction that is less intimidating or confusing for children with ASD than some complex real-world social interactions. Computer and VR intervention methodologies potentially have the ability to address the substantial difficulties with generalization of learned skills to the real-world by introducing not only more control over teaching basic elements of complex skills, but also the ability to systematically employ and reinforce these skills within many different, controllable, realistic interaction environments. Traditional methods of social and adaptive skill intervention often are not able to control environments or repeat exposure to naturalistic environments with an intensity that may lead to more substantial change; however, the virtual world can be designed to break down, repeat, add, and subtract aspects of the environment in any manner necessary to achieve a task goal. Further, individuals with ASD may also demonstrate improved learning with VR environments as this technology can enhance salient aspects of visual or physical learning that may be more powerful than traditional learning paradigms. Computer systems and VR environments can easily change the attributes of or add/remove objects in ways that may not be possible in a real-world setting but could be valuable to teach both concrete and abstract concepts. Therefore, these highly versatile technologies can offer the benefit of illustrating scenarios that can be changed to accommodate various situations that may not be feasible in a given therapeutic
250 setting because of space limitations, resource deficits, safety concerns, etc. Furthermore, sensory challenges, both impairing interests and sensitivities, are often part of ASD profiles. The audiovisual output of the computer and VR is likewise easily controlled to make more salient/engaging tasks, reduce, and systematically address sensory difficulties/interests. VR has also shown the capacity to ease the burden, both time and effort, of trained therapists in an intervention process as well as the potential to allow untrained personnel (e.g., parents or peers) to aid a participant in the intervention. Therefore, computer and VR technology represents a medium well suited for creating interactive intervention paradigms for skill training in the core areas of impairment for children with ASD. Cay Anderson-Hanley: Yes, there is no doubt that SBTs provide a compact and programmable environment that can readily be adapted to the needs of a person with ASD. There is great potential for reliable and immediate reinforcement of desired behaviors based on interactivity between the person and his or her virtual environment (VE). Sarah Parsons: That is right. There are a number of arguments about this, but early on Swettenham29 suggested that a computer offers a stable, familiar, and predictable environment that can be adapted to suit individual needs. Given that we know children on the autism spectrum tend to prefer predictability in responding these features have specific advantages. Also, Wilson et al.30 argued that the amount, level, and type of inputs (e.g. visual, auditory) can be controlled directly, which means that specific tasks can be completed in the absence of distracting cues; again, given that we know there can be sensory sensitivities experienced by children with autism, being able to control these aspects could be beneficial.31 Bill Ferguson: How might SBTs be useful in the treatment of ASD? Sarah Parsons: In relation to VR technologies specifically there are particular affordances that could be especially useful in terms of supporting learning for children on the autism spectrum. Applications for autism and recognition of the potential of VR for children on the autism spectrum began to appear in the mid to late 1990s with Dorothy Strickland pioneering the testing of early hardware with two young children with autism.32–34 Cheryl Trepagnier35 also recognized the potential of VR for people with autism, arguing that the ability to reduce distraction and support executive functions and communication within VEs made them particularly noteworthy for cognitive rehabilitation, including social skills training for children with autism. Peter Mitchell and I31 developed this argument further and suggested that VEs could be particularly helpful educational tools for people on the autism spectrum because they offered the potential to combine the strengths of effective intervention components from both the cognitive and behavioral research traditions, for example, repetition and practice of the skill across a range of contexts, role-play within realistic settings from different perspectives, explanation/interpretation of the social skill(s) being taught, and
ROUNDTABLE DISCUSSION support in understanding how one’s own behavior and communication influences or impacts on others. Moreover, the nature of VEs mean that these strengths could then be extended through the safe and supportive space of a VE, which allows the user to have active control over his or her participation, where interaction can take many forms (for example, users may communicate verbally or via text via their avatars) and does not require face-to-face communication (which many people with autism might find uncomfortable), the level and number of nonverbal and verbal features of communication can be directly controlled and manipulated and adapted for individual needs, and behaviors and responses can be practiced and developed in a context that shares some similarities with the real world, thereby offering greater potential for transfer of skills and understanding to real-world situations.31 Cay Anderson-Hanley: Neuropsychological functions may be amenable to treatment with exergames, especially executive function, especially given prior literature on exercise across the age spectrum36 as well as research in our lab.37,38 Similarly, repetitive behaviors were shown to be modifiable in a pilot study from our lab per above.37 Advantages of SBTs are that we can test more specific hypotheses about the factors that affect symptoms of ASD by facile manipulation of on-screen content and interactive reinforcement. SBTs are also intriguing to humans, both young and old, such that exergames like the Wii [Nintendo] and the cybercycle readily draw people in. In terms of increasing exercise behavior there is a great deal of potential that is yet being realized as various factors are tested and equipment/technologies are adjusted. The exergames we have studied are extremely safe and compact, even allowing placement in classrooms and other facilities where an ASD student might have the opportunity to use it and benefit academic outcomes directly. A disadvantage would be if users develop a dependence upon the use of exergames and avoid direct experience with reality such as limiting outdoor play or direct socialization, both of which have other important benefits. Zachary Warren: Yes, we have found a growing number of studies investigating the application of advanced interactive technologies to ASD intervention, including computer technology, VR environments, and more recently robotic systems. It has been argued that specific applications of technological systems can be effectively harnessed to provide new important directions for intervention, given potential capacities for making treatments highly individualized, intensive, flexible, and adaptive, embedding novel quantitative metrics, and developing noninvasive methodologies, as well as providing a vehicle for embodied "social" interaction. While initial results applying technology to ASD intervention have demonstrated potential, and perhaps unique utility, to elicit certain behaviors, no existing technological system specifically addresses how to detect and flexibly respond to individually derived socially relevant behavioral cues of children with ASD within an intelligent adaptive intervention paradigm that ultimately promotes meaningful change related to the complex and important social communication impairments of the disorder. Moreover, systems have yet to demonstrate or realize dynamic co-system intervention capacity wherein
ROUNDTABLE DISCUSSION skills within technological environments can be coordinated with and generalized to subsequent intervention interactions with human partners within or beyond the system interaction itself. Bill Ferguson: So, how have you addressed these issues in your own work? Zachary Warren: Our ongoing collaborative work at Vanderbilt focuses on developing and integrating technological systems with behavioral engagement profiling systems capable of adapting controlled environments and reinforcing skills in core domains gradually but automatically. This work strives to promote targeted and personalized intervention via technology. Although sophisticated, individualized VR systems are not at present widely available in many intervention settings, the barriers to optimal, intensive behavioral and educational intervention are so potent and the costs associated with suboptimal intervention so great that the development of such tools may be actually more practical, cost-effective, and beneficial than currently available intervention approaches/ modalities. Cay Anderson-Hanley: In our lab, we have been studying the benefits of exergaming (combined physical and mental exercise) for a variety of clinical populations ranging from Alzheimer’s to schizophrenia to ASD. The literature is already very strongly supportive of traditional physical exercise, which yields a significant impact on a variety of cognitive, psychological, and behavioral outcomes across the age spectrum39 and specifically in ASD.40 Research on the benefits of mental exercise (such as in computer game play) is less conclusive41; the literature is formative, though, and questions relating to transfer and generalizability of ‘‘cognitive training’’ effects are still being explored. Our recent randomized clinical trial of 3 months of exergaming for older adults found that exercise on a VR-enhanced stationary bike or ‘‘cybercycle’’ led to greater cognitive benefit than similar time and exercise effort on a traditional stationary bike.38 We hypothesize that there is a synergistic effect of combined mental and physical exercise that leads to additional benefit. For persons with ASD, it may be that the combination of physical exercise can both occupy repetitive behavior needs while increasing cerebral blood flow and thus enhance executive controls, allowing increased focus on computerized tasks available on an exergame. We found in a pilot study in our lab with children with ASD that a single bout on a cybercycle did lead to decreased repetitive behaviors and some increase in executive control.37 But much more research is needed to tease apart contributing factors and also examine longer-term outcomes. Sarah Parsons: My recent work has focused on collaborative VEs (CVEs) for supporting children on the autism spectrum in developing their collaboration and social conversation skills. They can work with peers (with and without autism), and the technology is designed to run on standard PCs and laptops and so should be more accessible for use in schools. Formal evaluations of the CVEs in use (yet to be written up and published!) suggest that there has been a positive impact of using the CVEs, especially in relation to social conversation. Crucially, I am now working with other colleagues in
251 the United Kingdom who have also been involved in the development of different technologies for autism, on a project that involves handing over the technologies to teachers in schools and observing their use and exploration of it. Only in this way can we really gain a better understanding of the pedagogic value of interactive technologies in the classroom, and therefore how we can improve design decisions in future projects. Bill Ferguson: Thank you. What do you see as emerging areas of research in this area? Sarah Parsons: I think augmented reality will be one of the "next big things" in terms of interfaces. I also think that there will be a drive towards more sophisticated response modes (i.e., ways of capturing data from participants). As noted in a forthcoming book chapter42: When it comes to the person with autism, applied VR research should ideally be aiming for a context where researchers or practitioners are able to assess children’s needs and develop personalized VEs accordingly, rather than producing a "one size fits all" approach. However, VR technologies may not yet offer sufficient flexibility and ease of use for this to be attainable at present, although it would be hoped that such possibilities could be within reach in the near future. Researchers should also be aware of the advances in cognitive neuroscience and autism. In future virtual reality projects, electroencephalogram (EEG) caps could be adapted for use in VR labs and be worn by participants to measure cortical responses to the stimuli being presented. If VR can provide authentic and meaningful experiences that ‘closely resemble’ real-world contexts43 then understanding more about the neural signals that occur in response to such stimuli could ultimately assist researchers in developing assessment and intervention tools for autism. In other words, neural signals may provide a useful measure of responding to (e.g.) socially oriented stimuli in a well-controlled and immersive VE that could be assessed pre- and post-intervention. This would expand the range of possible outcome measures available in such studies but also inform how VEs could most effectively be designed and personalized.
Cay Anderson-Hanley: In my opinion, there are a great many variables to be explored in trying to understand the benefits of exergaming to a variety of cognitive, psychological and behavioral outcomes. For example, we have started to examine the impact on exercise effort of a live versus a virtual competitor on the screen.44 The ability to control the social environment of an exergame could have many exciting implications in the treatment of ASD, from learning to enjoy riding solo, to observing other riders, to communicating with them, and perhaps even to collaborating with them on a group ride. Similarly, other researchers have examined the impact of control over the appearance of one’s avatar, which opens the possibility for persons with ASD to refine selfexpression and other important social skills. Furthermore, the potential synergy of physical and mental exercise in cognitive benefit is particularly intriguing. We are currently running studies to tease apart the impact of mental and physical exercise as experiences in sync or interactively. For ASD there are many potential benefits of an exergaming intervention such as cybercycling, which need further research, including a decrease in repetitive behaviors and enhanced cognitive
252 control, and hopefully this can translate into improved academic and social outcomes. Zachary Warren: Yes, I think that despite numerous potential advantages, current computer and VR technologies as applied to intervention for individuals with ASD are often designed in an open-loop fashion. Various computer software packages and VR environments have been developed and applied to address specific deficits associated with autism (e.g., understanding of false belief, attention, expression recognition, social problem-solving, and social conventions). These systems may be able to chain learning via basic aspects of performance; however, they are not capable of a higher degree of individualization. Specifically, they cannot automatically detect, appropriately respond, and adapt reinforcement based on the individual affective and attentive needs of the children with ASD and thus cannot flexibly identify, predict, test, and modify task in a manner targeted to the specific child. Given the importance of affective and attentive information in ASD individualized intervention practice, a closed-loop design incorporating this information may be critical. Bill Ferguson: Micah, thank you so much for putting together this admirable panel and for your fascinating research. And sincere thanks to you, Cay, Sarah, and Zachary for sharing your important perspectives with us. Best wishes to you all for success in this important field of research in ASD. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000. 2. Myers SM, Johnson CP. Management of children with autism spectrum disorders. Pediatrics 2007; 120:1162–1182. 3. Simonoff EM, Pickles AP, Charman TP, et al. Psychiatric disorders in children with autism spectrum disorders: Prevalence, comorbidity, and associated factors in a populationderived sample. J Am Acad Child Adolesc Psychiatry 2008; 47:921–929. 4. Hilton CL, Crouch MC, Israel H. Out-of-school participation patterns in children with high-functioning autism spectrum disorders. Am J Occup Ther 2008; 62:554–563. 5. Lee L-C, Harrington R, Louie B, Newschaffer C. Children with autism: Quality of life and parental concerns. J Autism Dev Disord 2008; 38:1147–1160. 6. Billstedt E, Gillberg C, Gillberg C. Autism after adolescence: Population-based 13- to 22-year follow-up study of 120 individuals with autism diagnosed in childhood. J Autism Dev Disord 2005; 35:351–360. 7. Howlin P, Goode S, Hutton J, Rutter M. Adult outcome for children with autism. J Child Psychol Psychiatry 2004; 45:212–229. 8. Cassidy A, McConkey R, Truesdale-Kennedy M, Slevin E. Preschoolers with autism spectrum disorders: The impact on families and the supports available to them. Early Child Dev Care 2008; 178:115–128. 9. Montes G, Halterman JS. Psychological functioning and coping among mothers of children with autism: A population-based study. Pediatrics 2007; 119:1040–1046. 10. Schieve LA, Blumberg SJ, Rice C, et al. The relationship between autism and parenting stress. Pediatrics 2007; 119(Suppl 1):S114–S121.
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