Enhancing Joint Attention Skills in Children on the Autism Spectrum through an Augmented Reality Technology-Mediated Intervention
Abstract
:1. Introduction
1.1. Differences in JA between Non-Autistic and Autistic Children
1.2. Intervention Studies for Enhancing JA Skills in Autistic Children
1.3. Technology-Mediated Intervention Studies for Enhancing JA Skills in Autistic Children
1.4. Augmented Reality
1.5. Purpose of This Study
2. Materials and Methods
2.1. Participants
2.2. Setting and Technology Equipment
2.3. The Pictogram Room
2.4. Materials
- Which poster is s/he looking at? The researcher and the child sat opposite to each other and the teacher next to or behind the child. The researcher took two posters and positioned them next to her eyes, one on the left and one on the right. Then, she moved her eyes to look at one of them and Teacher A asked: “Which poster is she looking at?”. To obtain a correct response, the child had to point to or take hold of/take away the poster the researcher was looking at. The cartoon characters of the posters were familiar to the children but their favourite ones were not used to avoid impulsive choices based on their preferences. The assessment consisted of 10 trials in which the posters position and the gaze direction were randomly altered.
- Which turtle is s/he looking at? The researcher and the child sat opposite each other and the teacher next to or behind the child. The researcher held two turtles next to her eyes, one on the left and one on the right. Then, she moved her eyes to look at one of them and Teacher A asked: “Which turtle is she looking at?”. To obtain a correct response, the child had to point to or take hold of/take away the turtle the researcher was looking at. The assessment consisted of 10 trials. On the first five trials, the turtles had the same colour (two blue or two green), and on the subsequent five trials they had different colours (one blue and one green). Two same-coloured turtles were used for ensuring that the children did not choose their favourite colour turtle but they selected the target they thought was the correct one.
- Which poster is the dummy looking at? and 4. Which turtle is the dummy looking at? The same procedure as in (1) Which poster is s/he looking at? and (2) Which turtle is s/he looking at? assessments was followed but the researcher wore the dummy costume, the objects were placed next to the dummy’s eyes and she randomly alternated the dummy’s gaze direction. The teacher was the one to ask the child “Which poster is the dummy looking at?” or “Which turtle is the dummy looking at?”.
2.5. Research Design
2.6. Procedures
- Pre-baseline Phase (week 1)
- Baseline Phase (weeks 2–4)
- Learning Phase (weeks 3–5)
- Intervention Phase (weeks 4–7)
- Post-intervention Phase
2.7. Data Preparation and Analysis
2.7.1. Operationalisation of the Measured Variables
2.7.2. Data Analysis
3. Results
3.1. Participant Improvement within the Pictogram Room Scoring System
3.2. The Effectiveness of the Intervention in the Participants’ RJA Skills
3.3. Generalisation of the Participants’ RJA Skills
3.4. Research Report Rigour and Strength
4. Discussion
4.1. Findings Summary
4.2. Findings Supporting Previous Studies
4.3. Advantages of the Applied AR-TMI
- Length
- Availability and accessibility
- Ecological validity
- Designing spectrum-comprehensive intervention studies
- Engagement
4.4. Limitations
4.5. Implications for Research and Practice
4.5.1. Previous Experiences and Adaptations Using an AR System
4.5.2. The Meaning of Selecting Appropriate Materials
4.5.3. Using Other Pictogram Room Features and Taking Advantage of New Technology Developments
4.5.4. The Importance of the Setting and the Interventionists
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Participant’s Code | Sex | Chronological Age (Years, Months) | DSM-5 (Diagnosis) | GARS-2 | SCQ | Leiter-R (IQ) |
---|---|---|---|---|---|---|
P1 | Male | 7, 10 | Autism (Level 3) with intellectual and language impairment | 111 | 15 | 63 |
P2 | Female | 8, 6 | Autism (Level 3) with intellectual and language impairment | - | 28 | 52 |
P3 | Male | 6, 7 | Autism (Level 2) with intellectual and language impairment | 81 | 13 | 80 |
P4 | Male | 5, 1 | Autism (Level 3) with intellectual and language impairment | 96 | 18 | 70 |
P5 | Male | 5, 5 | Autism (Level 3) with intellectual and language impairment, with ADHD | 98 | 31 | 54 |
P6 | Male | 3, 6 | Autism (Level 3) with intellectual and language impairment | 87 | 12 | 77 |
Assessment Tool | Purpose | Forms/Items Used | Scores |
---|---|---|---|
The Social Communication Questionnaire (SCQ; [90]) | To confirm the participants’ autism diagnoses and severity levels 1 | The current form of this scale, which focuses on behaviours observed during the most recent three months of a child’s life. | ≥15, highly suggestive of autism |
The Leiter International Performance Scale, Revised [91] | To get the participants’ intelligence quotient (IQ) scores | The brief version of this non-verbal test, which consists of two main broad areas: Visualisation and Reasoning. | IQ < 85, suggests a below-average cognitive ability; IQ < 70, is highly suggestive of intellectual disability (ID) |
The Autism Diagnostic Observation Schedule, Second Edition (ADOS-2; [92]) | To measure the participants’ RJA skills | The RJA item of module 1 and the corresponding toy (i.e., remote-controlled toy animal). | Following the ADOS-2 scoring system for this item, scores ranged from 0 (the child used the orientation of the evaluator’s eyes as a cue to look towards the target, without the need for pointing) to 3 (the child did not orient to the object even when the object was activated) |
The Early Social Communication Scales (ESCS; [93]) | To measure the participants’ RJA skills | The RJA module includes an assessment in which the child sits in a chair in front of the evaluator. Four posters are placed on four different points related to the child’s position: left or right (L/R RJA), and back left or back right (Behind RJA). The evaluator looks at one of the posters and the child should respond by turning his/her head and looking in the same direction as the evaluator. In this study, six trials for L/R RJA and six trials for Behind RJA were performed with each child during each assessment session. | The coefficient between the number of trials in which the child presented RJA and the total number of trials |
Phases of the Study | Groups (1–3) | Weeks (1–12) | Sessions (1–9) | Assessments | Pictogram Room Games |
---|---|---|---|---|---|
Pre-baseline Phase | |||||
One-off assessments | 1–3 | 1 | 1 | SCQ, Leiter-R | |
Pre-assessments | 1–3 | 1 | 1 | ADOS-2, ESCS, Which poster is s/he looking at? Which turtle is s/he looking at? | |
Baseline Phase | 1 | 2 | 3 | Which poster is the dummy looking at? Which turtle is the dummy looking at? | |
2 | 2–3 | 6 | |||
3 | 2–4 | 9 | |||
Learning Phase | 1 | 3 | 3 | Which poster is the dummy looking at? Which turtle is the dummy looking at? | Touch |
2 | 4 | 3 | |||
3 | 5 | 3 | |||
Intervention Phase | 1 | 4–5 | 6 | Which poster is the dummy looking at? Which turtle is the dummy looking at? | Gaze following |
2 | 5–6 | 6 | |||
3 | 6–7 | 6 | |||
Post-intervention Phase | |||||
Post-assessments | 1–3 | 8 | 1 | ADOS-2, ESCS, Which poster is s/he looking at? Which turtle is s/he looking at? | |
Follow-up assessments | 1–3 | 12 | 2 | Which poster is the dummy looking at? Which turtle is the dummy looking at? Which poster is s/he looking at? Which turtle is s/he looking at? |
Variable | Assessment Tool | Assessment Unit | Scoring System | Scoring System Description |
---|---|---|---|---|
v1 | Pictogram Room games | General performance | 0–3 | 0 = player did not complete the level game 3 = player completed the level game on his/her own |
v2 | Which poster is the dummy looking at? | Percentage of correct responses | 0–100% | 0% = 0 correct responses in 10 trials 100% = 10 correct responses in 10 trials |
v3 | Which turtle is the dummy looking at? | Percentage of correct responses | 0–100% | 0% = 0 correct responses in 10 trials 100% = 10 correct responses in 10 trials |
v4 | Which poster is s/he looking at? | The proportion of correct responses | 0–1 | 0 = 0 correct responses in 10 trials 1 = 10 correct responses in 10 trials |
v5 | Which turtle is s/he looking at? | The proportion of correct responses | 0–1 | 0 = 0 correct responses in 10 trials 1 = 10 correct responses in 10 trials |
v6 | ESCS | L/R RJA Behind RJA | 0–1 | 0 = 0 correct responses in 6 trials 1 = 6 correct responses in 6 trials |
v7 | ADOS-2 | RJA | 0–3 | 0 = the lowest RJA level 3 = the highest RJA level |
Participant | V4 | V5 | V6: ESCS | V7: ADOS-2 | |||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Poster | Turtle | L/R RJA | Behind RJA | ||||||||||
Pre | Post | F-Up | Pre | Post | F-Up | Pre | Post | Pre | Post | Pre | Post | ||
Group 1 | P1 | 0.30 | 00.90 | 0.90 | 0.30 | 1 | 1 | 0.17 | 0.83 | 0 | 0.67 | 2 | 2 |
P2 | 0.30 | 1 | 1 | 0.20 | 1 | 1 | 0.33 | 0.83 | 0.17 | 0.67 | 2 | 1 | |
Group 2 | P3 | 0.30 | 1 | 1 | 0.30 | 1 | 1 | 0.67 | 1 | 0.50 | 1 | 1 | 0 |
P4 | 0.20 | 1 | 0.90 | 0.30 | 0.90 | 0.90 | 0.50 | 0.83 | 0.17 | 0.83 | 2 | 2 | |
Group 3 | P5 | 0.40 | 0.80 | 0.90 | 0.20 | 0.80 | 0.70 | 0.17 | 0.67 | 0 | 0.33 | 3 | 3 |
P6 | 0.30 | 1 | 1 | 0.20 | 1 | 1 | 0.33 | 1 | 0.33 | 0.83 | 2 | 1 | |
IOA | 1 | 1 | 0.97 | 0.92 | |||||||||
Kappa | 1 | 1 | 0.94 | 0.88 |
Rigour Rating | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Primary Quality Indicators | Secondary Quality Indicators | ||||||||||
PART | IV | DV | BSLN | VIS AN | EXP CON | IOA | KAP | FID | BR | G/M | SV |
H | H | H | H | H | H | Y | Y | N | Y | Y | Y |
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Pérez-Fuster, P.; Herrera, G.; Kossyvaki, L.; Ferrer, A. Enhancing Joint Attention Skills in Children on the Autism Spectrum through an Augmented Reality Technology-Mediated Intervention. Children 2022, 9, 258. https://doi.org/10.3390/children9020258
Pérez-Fuster P, Herrera G, Kossyvaki L, Ferrer A. Enhancing Joint Attention Skills in Children on the Autism Spectrum through an Augmented Reality Technology-Mediated Intervention. Children. 2022; 9(2):258. https://doi.org/10.3390/children9020258
Chicago/Turabian StylePérez-Fuster, Patricia, Gerardo Herrera, Lila Kossyvaki, and Antonio Ferrer. 2022. "Enhancing Joint Attention Skills in Children on the Autism Spectrum through an Augmented Reality Technology-Mediated Intervention" Children 9, no. 2: 258. https://doi.org/10.3390/children9020258