article critique
Using game technology to teach six elementary school children with autism to take a shower independently Ya-Shu Kanga and Yao-Jen Changb
aDepartment of Special Education, Chung Yuan Christian University, Chung-Li, Taiwan; bDepartment of Electronic Engineering, Chung Yuan Christian University, Chung-Li, Taiwan
ABSTRACT Objective: This paper contributes to research investigating the effectiveness of video game intervention in shower training of children with autism spectrum disorders. Previous studies have supported the use of video games in special education. Methods: We employed the Kinect sensor to gamify shower training. Specifically, a non-concurrent multiple baseline design was adopted to demonstrate the relation between game-based intervention and taking a shower independently. Six children in a special education class at a regular elementary school participated in the experiment. Results: Data showed that the percentage of correct task steps significantly increased among all six participants; motivation to engage in training was enhanced as well, thus improving task performance during the intervention and maintenance phases. Conclusions: Although the game is a promising and highly accepted training tool for school-use, it currently remains error-prone, and the requested demand exceeds the support that can be provided by special education teachers. A more technically robust system, combined with additional attractive games, will likely result in higher participant motivation and superior task performance.
ARTICLE HISTORY Received 19 August 2017 Revised 14 July 2018 Accepted 14 July 2018
KEYWORDS Autism; Kinect; shower training; video game
Introduction
Social communication and social interaction include the child’s engagement in spontaneously reading and correctly interpret- ing verbal and nonverbal social and emotional cues; engage- ment in recognizing social and emotional information; different social behaviors and their consequences in diverse social tasks (e.g., how to initiate a conversation, how to negoti- ate needs, how to make group entry).1 People with autism spectrum disorder (ASD) demonstrate qualitative impairments in social communication and social interaction across multiple contexts. One of the most salient concerns of parents of chil- dren with autism, as well as parents of children with other disabilities, is whether or not their child will live a safe, pro- ductive, and independent life. Individuals acquiring indepen- dence early in life have more potential to thrive in domestic and vocational settings.2,3 Individuals with ASD may have difficul- ties in performing daily living tasks.4 Among other daily living tasks, independent showering/bathing is an essential life skill for people with ASD. Poor showering and bathing skills can cause physical discomfort and negatively impact personal hygiene, self-confidence, social competence, and acceptance, thereby resulting in dependence on caregivers for assistance.
The difficulties in verbal reasoning and short-term mem- ory present both pragmatic and pedagogic challenges in teaching children with ASD to take a shower (among other living skills) properly through traditional methods such as verbal instruction and memorization tasks.5 Instructional
strategies that incorporate visual supports (e.g., pictures, in vivo modeling, video modeling [VM]) are considered evi- denced-based practices that capitalize on the strengths of children with ASD.6–16 These technological interventions can help students with ASD become more independent and better prepared for adulthood by learning a variety of life skills. In particular, Piccin, Crippa, Nobile, Hardan, and Brambilla17 developed VM tools for helping individuals with ASD in increasing their ability to perform personal hygiene activities. Hayes and Hosaflook18 developed a mobile system to support youth with ASD learn about and track healthy hygiene behaviors to help teens and young adults develop skills for independent living and employment. Additionally, a randomized control trial examined the effectiveness of a 3- week video-modeling brushing intervention delivered to patients over the Internet.19 Among the various visual sup- ports available, VM has increased in popularity in the last three decades20 due to the advancement and availability of technology, the decreasing cost of producing videos, and its strategic efficiency in teaching daily living, as well as func- tional, vocational, academic, and social skills.11 These differ- ent strategies have generally been used in isolation; for example, children may use picture prompts, video prompts, or VM but usually do not adopt these strategies collectively. Recently, Cihak et al.21 used augmented reality technology, a new approach that fuses picture prompting and VM to train elementary students with autism in a chain task.
CONTACT Yao-Jen Chang yjchang@cycu.edu.tw Department of Special Education, Chung Yuan Christian University, Chung-Li, Taiwana Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ipdr.
DEVELOPMENTAL NEUROREHABILITATION 2019, VOL. 22, NO. 5, 329–337 https://doi.org/10.1080/17518423.2018.1501778
© 2018 Taylor & Francis
An alternative approach to developing skills in children with ASD is game-based training, a strategy made possible by the recent advancements in sensor and human–computer interaction technology. The gamification of training involves the child playing a video game that engages him or her in a target behavior, with the goal of subsequently imitating it in real life. Gameplay demands focus and attention, motivates the user to practice, and provides the user with a sense of achievement, even if the user cannot perform that task in the real world.22,23 Therefore, gamification has become a new candidate for an intervention strategy that can successfully teach a variety of skills to individuals with ASD. Gotsis et al.24
designed a video game intervention for children with ASD, and their preliminary results showed that games focusing on social skills training have the potential to improve adaptive behaviors and quality of life for children with ASD. Dickinson and Place25 showed that game-based interventions using the Nintendo game system (Kyoto, Japan) and the “Mario & Sonic at the Olympics” software package appear to be poten- tial mechanisms that can improve the social functioning of children with ASD. Similarly, Cai et al.26 designed a game called “Virtual Dolphinarium” that showed promising results in promoting learning and positive behavior among children with ASD.
In short, previous studies have supported the use of video games in special education. However, despite the extent of difficulties related to showering that are faced by individuals with ASD and the importance of independent showering, no study has yet addressed how interactive game technology can be used to teach multistep showering skills to children with ASD. In addition, teachers in special education schools cannot train children with ASD to take a shower independently, unless the school is equipped with showering facilities and the training program is provided. Nevertheless, even with the necessary equipment provided, such training programs are time consuming and labor intensive. Therefore, we developed an interactive game that turns shower training into a fun learning experience, in addition to allowing teachers to max- imize their classroom availability for other educational pur- poses. For example, instructors in large classrooms may not have sufficient time for repeated one-on-one instruction or live modeling. However, children can play the showering game at school without showering facilities under their tea- chers’ supervision until their ability to take a shower has become sufficiently independent.
The motion capture capability of Kinect makes it a candi- date for implementing assistive technology targeting students with ASD. For example, the MEBook system used Kinect sensor to inject self-images into a social narrative game to teach students with ASD proper greeting behaviors.27 The Kinect sensor was also used to automatically detect stereoty- pical motor movements such as hand flapping.28 In this study, we gamified independent shower training using the Kinect sensor to motivate children with ASD who had not developed showering skills. Specifically, we developed a game based on Kinect’s gesture recognition technology, which has recently increased in popularity in the video game interaction design domain. The incorporation of gesture recognition technology prevents the children from having to wear intrusive body
sensors; additionally, Kinect provides real-time three-dimen- sional (3D) anatomical landmark position data, and it is inexpensive, portable, and simple to set up. Studies have also shown that the Microsoft Kinect and 3D motion analysis systems have comparable intertrial reliability and excellent concurrent validity.29–31
Chang, Chen, and Huang32 and Chang, Han, and Tsai33
have leveraged the human gesture recognition capabilities of Kinect to determine whether a user performed exercises cor- rectly in physical rehabilitation. Hung, Chang, and Han34 also used Kinect to recognize actions when they developed a video game that demonstrated the potential to increase range of motion for adolescents with cerebral palsy. However, our study is the first to use Kinect in the development of inter- active games for children with ASD to encourage engagement in shower training. The game was designed according to a showering task analysis, which outlined the task steps involved in taking a shower and simulated them in the com- puter game.
The purpose of this study was to examine whether game technology is an effective way to teach elementary students with ASD to take a shower independently and to determine the long-term maintenance effects of using game technology to facilitate independent showering.
Method
Participants
Four male and two female elementary school children with ASD (Allen, Bart, Chris, Diane, Emilie, and Fred) participated in this study. All of the children were enrolled in special education programs under the autism category, and their cog- nitive and adaptive functioning fell within the moderate intel- lectual disability range. Specifically, the children were recruited based on the following criteria: (a) diagnosis of autism or an intellectual disability, (b) an Individual Education Plan goal to improve adaptive behavior related to personal care, (c) no physical disability that would impede the performance of the skill, (d) ability to understand the objects in the video game such as shampoo and showerhead, (e) ability to recognize the model in the game was controlled by the children’s body, and (f) agreeing to participate in the study. Table 1 presents a list of the characteristics of each participant.
The first participant, Allen, was 9 years old and in the third grade. Although Allen had few verbal communication skills and understood a limited set of instructions, he was able to use the Picture Exchange Communication System (PECS) to
Table 1. Children’s characteristics.
Participant Age CTONI-2 VABS-II adaptive behavior
standard scores (%) VABS-II age equivalents
Allen 9:3 76 74 4 6:2 Bart 9:9 < 65 58 0.3 3:10 Chris 11:6 < 65 61 0.5 5:2 Diane 9:4 75 58 0.3 3:8 Emilie 9:8 < 65 49 < 0.1 2:0 Fred 11:9 < 65 55 0.1 3:8
Note. CTONI-2: Comprehensive Test of Nonverbal Intelligence—Second Edition; VABS-II: Vineland Adaptive Behavior Scales-II, Second Edition; %: percentile.
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communicate. The second participant, Bart, was also 9 years old and in the third grade. He had complex communication needs and primarily used a letter board or iPad to commu- nicate. Chris, the third participant, was 10 years old and in the fourth grade. Similar to Allen, Chris had limited verbal skills and used the PECS to communicate. Diane was 9 years old and in the third grade. She had no verbal communication, could not understand oral instructions, and had difficulties with social adaptation. Emilie was 9 years old and in the third grade. She had few verbal skills and understood a limited set of instructions; she also had difficulty with hand–eye coordi- nation. Fred was 11 years old and in the fifth grade. Similar to Diane, he did not verbally communicate, could not under- stand oral instructions, and had difficulty with academic learning. None of the participants had previous experience with Kinect. The information about the participants was gathered from the teachers. All six participants were given pseudonyms to protect their privacy, and informed consent was provided by the service organization, individual staff members involved in the study, and the main caregivers on behalf of the children with ASD. The study was approved by the Regional Institutional Review Board under approval num- ber LSHIRB No. 15-007-A2.
Setting
All of the students attended a special education class for part of their school day to address functional or life skill difficul- ties. Nine other students with multiple disabilities were also present in their classroom. During the baseline, game-based intervention, and maintenance phases, the children took a shower independently in their own bathroom at home, as the skill of showering naturally occurred in that location. The game-based intervention phase occurred only in the special education classroom. The Kinect sensor requires an area of 15 ft by 9 ft for motion capture of the player. Within this area, furniture should be removed. The bathrooms where the interventions took place were participants’ own bath- rooms installed with a camera. The shower taking was video recorded and later examined by the special education teachers for evaluating correctness according to task analysis.
Materials
The game is called Take a Shower! and was designed accord- ing to the 25 steps that were identified for taking a shower (Table 2). The task-fidelity checklist as shown in Table 2 was developed by the special education teachers that we worked with. These steps were determined based on the School Ability Index which was released by the Ministry of Education for all of the elementary and secondary schools. The children were guided through each step in the task- fidelity checklist. The game started by children selecting a favorite cartoon model by holding the hand over the selected model on the screen for 3 s. The movements of the model including undressing, picking up the hand shower, and turn- ing on/off the water were controlled by the child using the body. To make the game more fun, a water fairy was used as a visual cue and moved around each part of a body to guide
children to wet the body accordingly. For example, to prompt the children to wet the chest, the fairy would stop at the chest of the cartoon model. Points were scored when children aimed their handheld showerhead at the water fairy accu- rately. Similarly, an animated germ demon would mark the parts of the body of a model that needs cleaning, and a score would be generated based on how much of the model the students shampooed using a shampoo wand activated by real showering motions in front of the Kinect camera. Figure 1 shows a few screenshots including selecting a role, wetting the body, and applying the shampoo. The reinforcement includes a cute animal that pops up on the screen to give praise such as “You are so great!” when a job is well done. In addition, to make it more fun, the face of the germ demon changes into a sad expression before disappearance when the part of the body the germ demon stops at is cleaned.
This study tested the proposed system in an urban special education class, which receives students with special needs from kindergarten through elementary school. The Kinect device was connected to a Lenovo Thinkpad T61 notebook computer, and the game software developed in-house was installed with Microsoft Windows 7. The computer had an audio module, which we used to deliver audio feedback, and an external 22-in LCD screen that was used for visual inter- action. The software was coded using the Kinect2Scratch soft- ware and the Scratch software language environment tools to form an integrated development platform. The interactive interface with audio and video feedback was programmed to reinforce children’s motivation to engage in the training. For optimal performance of the Kinect sensor, the participants were required to stand approximately 3 ft in front of the Kinect module.
Variables and data collection
The independent variable in this study was the use of game-based intervention, and the dependent variable was the number of organized task steps for taking a shower which were completed
Table 2. Task-fidelity checklist for taking a shower.
1. Undress 2. Pick up and hold the hand shower 3. Turn on water 4. Wet the body 5. Turn off water 6. Put down the hand shower 7. Squeeze shampoo 8. Apply the shampoo on the left neck 9. Apply the shampoo on the right neck 10. Apply the shampoo on the left arm 11. Apply the shampoo on the right arm 12. Apply the shampoo on the chest 13. Apply the shampoo on the tummy 14. Pick up and hold the hand shower 15. Turn on water 16. Rinse the left neck 17. Rinse the right neck 18. Rinse the left arm 19. Rinse the right arm 20. Rinse the chest 21. Rinse the tummy 22. Turn off water 23. Put down the hand shower 24. Wipe the body with towel 25. Get dressed
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independently. Data were collected through the use of a data sheet designed to record the task chain. All of the parents agreed to use a mobile phone to record their children during showering. Video clips were carefully handled and processed by two special educa- tion teachers who served as raters in the study. Event recording procedures were used to record each step as independently per- formed or incorrectly performed. An independent response was defined as initiating the first step in the task analysis within 5 s and completing each step within 20 s without parental assistance. The number of independent steps completed was divided by the total number of steps of the task analysis (i.e., 25) and then multiplied by 100 to calculate the percentage of steps completed indepen- dently. The final statistics were graphed for visual analysis.
Experimental conditions
A non-concurrent multiple baseline design35 was adopted to demonstrate the relation between game-based intervention and the ability to take a shower independently. The experiment com- prised three phases: (a) a baseline phase, in which at least a few sessions were performed to collect baseline data on the partici- pants; (b) an intervention phase, in which the gaming system was used for shower training; and (c) a maintenance phase, which was conducted 2 weeks after the intervention was finished and assessed the continued performance of the participants.
The six children were assigned into two groups due to their individual school schedules. Allen, Bart, and Chris constituted Group 1, and Diane, Emilie, and Fred constituted Group 2. Groups 1 and 2 participated in the experiments during the first half and the second half of the semester, respectively.
Baseline phase During the baseline phase, the children took a shower indepen- dently at home. Three sessions in a week were recorded, although the children took the shower on a daily basis. Their parents recorded the shower process but did not provide oral instructions or other intervention. In other words, the parents did not interfere with or try to prevent any inaccuracies from occurring in the participants’ performance. The baseline phase comprised a mini- mum of three sessions or until stability was achieved.
Intervention phase For the first session of this phase, students were instructed on how to operate the Kinect-based training game. They were first directed to physically turn on the device and start the game by raising their hands. When students had problems going through various task steps in the game, the teacher used
gestural or visual prompts. Pictures were used to prompt the children to stand within the range of the Kinect sensor, stand upright, or wave hands to start the game. Teachers were trained on how to prompt correct responding. Each child was required to finish every step in the game prior to initiat- ing the intervention phase, and a full game play took 15 min for each participant. The teacher supervised the children for the entire duration of the training session. Two sessions were scheduled for each child every week during the intervention phase. The participants used cues on the screen to complete the game play; in addition, picture-based feedback was used to enrich the training process and increase motivation to pay attention to the shower process. The teacher did not interfere with or try to prevent any inaccuracies from occurring in the participants’ performance. Depending on the score of the game, the teacher either praised the student or encouraged her or him to continue. The intervention phase consisted of 21 sessions. The teachers gave praise contingent on how many steps were completed correctly during game play. The praise was given when the child made a notable improvement com- pared to the last time. As students gained mastery of the showering steps, the cutoff of giving praise was increased. Teachers did not provide additional instruction to link the video game and the live showering. During this phase, chil- dren also took a shower independently at home. Children played the game by day at school for each session in the intervention phase and took the shower later when they came home. During the intervention phase, for each child, 5–6 h elapsed between the showering game and the home shower. Parents recorded this shower process for performance assessment but did not provide oral instructions or other intervention. Parents were particularly instructed not to rein- force correct showering. A text message was sent to remind the parents in the morning of the home shower sessions so that they did not forget the recording. Parents were instructed to facilitate home showering through a briefing they received at the school before the experiment began. Their fidelity was also monitored by the recording.
Maintenance phase This phase began 4 weeks after the intervention phase to deter- mine whether the participants maintained the skills that they had acquired. During this phase, participants did not have the gaming system but instead participated in the activity directly using the same task steps as they had during the baseline phase. Parents recorded their children’s shower procedures for performance assessment.
Figure 1. Game screenshots including selecting a role, wetting the body, and applying the shampoo.
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Interobserver agreement
Reliability observers watched the recorded videos and col- lected data on the number of steps performed correctly during at least 40% of the sessions and across all phases of the study for each participant (range 45–77%). The observers were special education teachers who were trained to collect data; we provided them with the task analysis data sheet, verbally explained the procedures, and answered all questions regard- ing the process. This training took approximately 25–40 min. Agreement between the trainer and reliability observers on the correctly performed steps was calculated on a session-by- session basis, using the following formula: agreements/(agree- ments + disagreements) × 100%. The interobserver agreement range was between 92% and 100%. The resulting agreement percentages were 95% on average.
Results
This study assessed the effectiveness of the proposed system with regard to elementary-age children with ASD acquiring the skills required to successfully take a shower indepen- dently. The percentage of steps performed independently for each child is presented in Figure 2. Overall, the children’s independent performance in terms of task correctness imme- diately increased when the game intervention was intro- duced, and all of the participants acquired and maintained the skills necessary for the task of taking a shower indepen- dently. During the baseline phase, Allen completed a mean of 60% of the steps for taking a shower independently; during the intervention and maintenance phases, his perfor- mance immediately improved to 89% and then further increased to 98%, respectively. Bart’s mean percentage of steps performed independently during the baseline phase was 28%; however, following the introduction of the inter- vention, his mean performance immediately ascended to 67%. During the intervention phase, Bart also required ver- bal, gestural, and one partial physical prompt. Bart main- tained 82% performance during the maintenance phase. Chris’s mean percentage of steps performed independently during the baseline phase was 75%. During the intervention and maintenance phases, his mean performance increased to 98% and then 100%, respectively. During the baseline phase, Diane completed a mean of 58% of the steps for taking a shower independently. During the intervention phase, her performance immediately improved to 98%, and she demon- strated 100% independence during the maintenance phase. Emilie’s mean percentage of steps performed independently during the baseline phase was 34%. Following the introduc- tion of the intervention, her mean performance immediately ascended to 90%; she later further improved to 99% perfor- mance during the maintenance phase. Finally, Fred’s mean percentage of steps performed independently during the baseline phase was 49%. During the intervention phase, his mean performance immediately increased to 79%; similar to Bart, Fred also required verbal, gestural, and one partial physical prompt. Fred successfully maintained 92% of the steps during the maintenance phase.
Discussion
For the six participants, Allen, Bart, Chris, Diane, Emilie, and Fred, the rate of improvement in taking a shower indepen- dently was 62%, 193%, 33%, 72%, 191%, and 88%, respec- tively. Furthermore, the results indicate that the proposed system, in conjunction with operant conditioning strategies, can facilitate the progress of children with ASD taking a shower independently. Across all the six participants, the skill maintained well in the absence of the video game. It might imply that the video game was a great instructional tool for the children with ASD to learn visually and the 21 sessions of interventions across 11 weeks made a positive impact on learning to take the shower independently. However, more future studies are needed to investigate this issue. The data in the results suggest that these students were capable of generalizing from the contrived shower simulation to the real shower under significantly different stimulus con- ditions. The improvements showed that the game-based inter- vention under a stimulus condition of being clothed in a classroom has generalized to a different stimulus condition of being unclothed in a bathroom.
For interventions that involve visual modeling, participants watch the training video first and perform the target behavior later by recalling the content in the training video. However, the memory retention may not be sufficient to support the execution of the specific tasks for the population we address. In contrast, the Kinect-based game intervention enabled par- ticipants to practice showering while they played the game. The change of this intervention might hypothetically involve less mental workload in the improvement of the home shower sessions.
In the baseline phase, the parents reported that Allen often forgot to clean the neck and arms; he was also easily distracted by the bubbles. However, with the introduction of the training game, the teachers found that he gradually understood that he had to clean the neck and arms to continue the game (which he was motivated to do because he loved playing the game). After repeated practice, Allen also remembered to pay atten- tion to cleaning his own neck and arms when showering at home, according to the parents. By contrast, the parents reported that Bart had great difficulty in taking a shower independently during the baseline phase. The teachers also found that he did not adapt to the game well in the early stage of intervention. With the assistance of the teacher, he was able to grasp the game after 2 weeks of practice; however, the teacher found that he could not completely generalize the skills he learned in the game to his daily life. Nevertheless, the results showed that Bart showed great progress overall, when his task performance score in the maintenance phase was compared with that in the baseline phase. Bart’s parents reported that he was motivated to improve showering skills because he always wanted to look clean but often could not; after the training, he was very happy to finally be successful. According to the parents, Chris was able to take a shower independently during the baseline phase. However, the task step analysis showed that the “washing the neck” step was often neglected. The teachers found that Chris enjoyed the game very much, and he was happy when he played the game
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Figure 2. Task performance of Allen, Bart, Chris, Diane, Emilie, and Fred.
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and even happier when he scored; he even frequently asked the teacher to give him more time to play the game. The teacher agreed in the hope that he could improve his task performance for neck cleaning in the shower. The results confirmed that he generalized the skill very well.
After a review of her recording by the teachers, it was revealed that Diane always neglected the neck part during the baseline phase. The teachers also found that she was less engaged at the beginning of the intervention phase because she had difficulty understanding oral instructions; therefore, the teacher used gestures to help Diane gradually adapt to the game. With repeated practice, she finally understood that the neck cleaning was an integral part of showering. The results showed that she eventually generalized the skill very well and made tremendous progress during the maintenance phase. According to the teachers, Emilie liked the shower training game because she liked water; however, she had difficulty adapting to the game at the beginning of the intervention phase. With repeated practice, she eventually handled the game very well. A review of the video recording revealed that she often neglected the chest and tummy areas during the showers, and more training time was thus spent on those parts. The results showed that she finally acquired the task skill and maintained her performance in the phase. The final participant, Fred, often skipped task steps during the baseline phase, according to the parents. The teachers found that he had become interested the moment he saw the game for the first time; thus, he actively participated in the game at every intervention session. After repeated practice, the results showed that Fred gradually familiarized himself with the task steps required to take a shower, and his task performance score increased significantly in the maintenance phase.
Social validity was evaluated through a survey, which assessed the participants’ experience and success during the study. The survey was administered during a brief interview to each child’s parents, with questions analyzing personal opinions regarding practical use of the video game. Open- ended and closed questions examined the parents’ general thoughts regarding the video game and asked whether the game had helped their children learn the showering skills. Other questions assessed whether the game changed the method by which each participant took the shower indepen- dently. Parents were also asked whether they would like to have their children participate in the future and what tasks would be helpful for their children to learn. Finally, the inter- view addressed whether they had discussed the video game with anyone outside of school. One researcher asked each participant’s parents the questions, and another audio recorded the verbal responses. Another survey was distributed to each teacher as a hard copy on which to write responses. These questions evaluated the participants’ satisfaction and their perception of whether the video game was acceptable and useful with students.
The parents thought the video game was very useful and it had helped their children learn the showering skills effectively. The game also changed the method by which their children took the shower independently. Additionally, parents would like to have their children participate in the future and have shopping skills and pedestrian safety listed in the game-based
interventions also. Finally, parents discussed outside of school the video game with their friends who also had children with ASD. They highly recommended the game and encouraged their friends to contact the teachers for more information.
According to the teachers, participants enjoyed playing the video game and found the game to be an enjoyable motivator. “The game caught their attention, and they said they would prefer it to one-on-one teaching of the skills,” recorded one particular teacher. The teachers agreed that the video game improved independence and make teaching easier. The tea- chers expressed a wish for more time and resources to create additional video games for their students. They also found the video game to be up-to-date with current teaching methods. Teachers would like to use this method with their other students to reduce direct verbal prompting and other indivi- dual instruction. The teachers commented that education should include more technology where possible.
Showering and bathing skills children acquired during the intervention can bring physical comfort and positively impact personal hygiene, self-confidence, social competence, and acceptance, thereby resulting in a greater level of indepen- dence. Additionally, the game-based intervention can benefit children with ASD for the learning of other functional skills such as shopping, pedestrian safety, and food preparation.
As this and other studies have demonstrated, even simple tasks can present complex challenges for some individuals with ASD. Organizing tasks into a sequence of smaller steps or actions is an evidence-based practice for teaching new skills to students with severe developmental disabilities.36 Moreover, having an understanding of all the steps involved for a particu- lar task can assist in identifying those steps that require extra training and can help teach tasks in a logical progression.37 The results of the present study show that the proposed game helped children with ASD familiarize themselves with all the task steps involved in taking a shower and, in particular, assisted them with the task steps where they needed extra practice.
Gaming (e.g., the use of Kinect in this study) is a relatively new aspect of training. The game has a seeming advantage of serving an enjoyable motivator during the interventions. Nevertheless, it has been utilized for skills development for not only people with ASD but also for other populations such as those with intellectual disabilities, attention-deficit/hyper- activity disorder, or cognitive impairments.38–41 Gaming has a number of advantages compared with traditional learning. Specifically, this type of training can be directed toward the development of a particular skill by organizing exercises that are (or that gradually become) more challenging; is often perceived as enjoyable and motivating, which increases long- term adherence; and can in many cases be performed at home or at a central location, which increases the frequency of training.25
One key limitation of this study is that the results are based on only six cases. Therefore, a general conclusion cannot be extrapolated regarding the efficacy of the proposed system. The lack of data on errors made during video game playing is also a limitation of the study. We hope to enhance the game design by adding an error recognition feature. Future studies should include experiments that involve more participants with ASD and focus on further evaluating the game-based training system.
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Additionally, more interactive features should be added to enhance user experience. The effectiveness of this technology for people with other types of developmental disabilities should also be explored. We have started to design more game features that include the additional task steps needed to clean the lower limbs and the back. On the other hand, we are considering modifications that might be made to the task analysis to make the game more inclusive for children with profound ASD and make it easier to put on a task analysis. Notably, our research will continue to investigate if the results herein can be general- ized to the broader population of children with ASD or even to children with other disabilities. One of our ongoing research projects is to train parents and even grandparents to support learning through the video game.
Conclusions
To conclude, the proposed video game can be used for effec- tive shower training of children with ASD. The six partici- pants in this study showed overall improvements in their task performance following the intervention. Moreover, the train- ing game was well received by both the six participants and their special education teacher who used the intervention. Although the Take a Shower! system is a promising and highly accepted training tool for school-use, it currently remains error-prone, and the requested demand exceeds the support that can be provided by special education teachers. A more technically robust system, combined with additional attractive games, would likely result in higher participant motivation and enhanced task performance. This would subsequently both reduce the need for parents or caregivers to motivate their children extrinsically and allow for field researchers to investigate the effectiveness of the system.
Declaration of interest
The authors declared that they have no financial or nonfinancial conflicts of interests with respect to the publication of this research article.
Funding
This work was supported by the National Science Council [MOST 106-2221-E-033-011].
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