Design of Performance-Sensitive Adaptive Response Technology for Children with Autism: Usability Study

Research Article

Austin J Autism & Relat Disabil. 2016; 2(2): 1016.

Design of Performance-Sensitive Adaptive Response Technology for Children with Autism: Usability Study

Kuriakose S*, Pradeep Raj KB and Lahiri U

Electrical Engineering, IIT Gandhinagar, Gujarat, India

*Corresponding author:Kuriakose S, Electrical Engineering, IIT Gandhinagar, Gujarat, India

Received: Febraury 18, 2016; Accepted: March 22, 2016; Published: March 28, 2016


Autism is characterized by deficits in social communication and imagination. Conventional intervention techniques, though powerful, have limitations, e.g., limited availability of trained resources, limitations in simulating variations in social situations at the therapist’s clinic, etc. Several researchers have been studying technology-assisted techniques, e.g., Virtual Reality (VR). In our study, we have explored the potential of VR-based system that can adapt itself in an individualized manner based on one’s task performance, to offer social contexts that requires one to adhere to social etiquettes during navigation (Interaction Task-I) in a social environment and interact with virtual peers exhibiting subtle emotional expressions (Interaction Task-II) to complete a social task. Additionally, our system has been augmented with real -time physiological data acquisition capability in a synchronized manner. Results of a preliminary usability study, designed as a proof-of-concept application, indicates the potential of our VR-based system to systematically administer some of the aspects of social communication among individuals thereby indicating varying implications on both performance and physiological indices that in turn can serve as a complementary measure in the hands of the interventionist by detecting potential physiology -related biomarkers of one’s anxiety while interacting with VR-based social situations.

Keywords: Autism, Virtual Reality, Physiology, Anxiety


ASD: Autism Spectrum Disorder; PART: Performance-Sensitive Adaptive Response Technology; SCQ: Social Communication Questionnaire; SRS: Social Responsiveness Scale; TD: Typically Developing; SCAS: Spence Children’s Anxiety Rating Scale; IDEA: Individuals with Disabilities Education Act; PPG: Pulseplethysmogram; EDA: Electrodermal Activity; SKT: Skin Temperature


Autism, a behaviorally defined syndrome, is characterized by core deficits in social interaction, communication and fixed or repetitive behavior [1]. These core deficits in social communication adversely affect one’s adaptive independence. Although the etiology of autism and the characteristics responsible for differential response to treatment is not yet well understood, there is an increasing consensus that intensive behavioral and educational programs can strengthen the social communication skills and significantly improve long term outcomes for individuals with Autism Spectrum Disorder (ASD) [2,3]. For effective and intensive intervention, one-to-one therapy requires long hours from qualified therapists/clinicians, who are often rarely available or are beyond the financial resources of families [4]. Therefore, high quality behavioral intervention is often inaccessible to ASD population. Motivated by the critical need of intensive intervention services, particularly in developing countries like India, emerging technology may provide an alternative assistive solution. Given the promise of observation -based conventional intervention techniques where the therapist carefully monitors one’s performance in a task to adjust her intervention strategy, the purpose of our present research is to design a technology -assisted platform (Performancesensitive Adaptive Response Technology (PART) henceforth) that is capable of adapting itself based on one’s task performance in an individualized manner. Additionally, in conventional settings, the therapist also monitors one’s affective states, e.g., anxiety, for effective floor-time therapy [5] that is often subjective in nature. In our present research, we hypothesize that the PART system has potential to have implications on one’s task performance, thereby helping to learn at least some of the aspects of social communication and also identify biomarkers of one’s anxiety level while serving as a complementary tool for the therapist by detecting anxiety-provoking elements of social interaction in an individualized manner. Here we have designed a Usability Study with PART system using a Virtual Reality (VR) programming platform, as proof-of-concept application and not as a full-fledged intervention system.

Role of Virtual Reality (VR) in autism intervention

A wide array of technology-assisted intervention tools for adolescents with autism are explored, namely, computer technology [6], VR [7], and robotic systems [8]. Among these solutions, we chose VR, because of its malleability, controllability, modifiable sensory stimulation, individualized approach, safety and potential reduction of problematic aspects of human interaction, particularly during initial skill training [4,9]. The flexible VR-based technology with the ability to mimic real environments in terms of imagery and contexts [4] can offer an efficient generalization of skills from the VR environment to the real world. Also, advanced computing technology has made VR-based systems readily available and affordable [9]. These attributes make VR a suitable candidate for designing skill training platforms for ASD.

Literature review shows pioneering work by researchers on the applicability of VR-based platform for addressing daily living skills for adolescents with autism [4,10]. Studies have shown the use of VR addressing different aspects of social communication, e.g., social context, subtle social cues, social interaction, facial emotional expression [8], navigation in a social scenario [4] etc. in an isolated way. Presently available VR-based systems for individuals with ASD are capable of modifying tasks based only on objective performance characteristics (i.e., correct or incorrect) of responses [11,12] with no structured feedback from facilitators that can serve as cues to the participants while interacting with the social scenario. Also, some of these pioneering research studies have not devised mechanisms to identify physiology-related biomarkers of one’s anxiety that might be informative to the interventionist /caregiver regarding elements of social interaction that are anxiety -provoking for individuals with ASD. This is important, since individuals with ASD are restricted in their explicit expression of their anxiety. In fact, this might help to identify areas of social interaction where an individual would benefit from intervention/skill training not possible with currently-available VR-based studies. In our present work, we have designed a usability study with a PART system to expose our participants to different aspects of social communication in an integrated and structured manner accompanied with virtual peers who act like facilitators. Here we expose our participants to both navigation-related social norms and etiquettes, and also to subtle emotional aspects of social communication with potential to identify physiology-related biomarkers of one’s anxiety.

Choice of anxiety as target affective state

Here we wanted to understand the feasibility of using physiology -related biomarkers as potential indicators of one’s anxiety, a critical concern especially among clinical samples of autism. Increased anxiety diminishes the chances of effective learning [13]. Specifically, it might happen that a participant is performing well, but the urgency of demonstrating good performance might often lead to increased anxiety. This is particularly true for individuals with ASD who are often prone to elevated anxiety levels [14]. Also the manifestation of increased anxiety might be differentiated given the spectrum nature of Autism. This manifestation can be explicit, or implicit, or combination of these. Individuals with ASD are often restricted in explicit expression of their affective state [15], thereby placing limitations on traditional observation - based approaches where alternative technologies can be employed.

Role of physiology-based technology as viomarkers of anxiety

Many children with ASD are capable of yielding correct performance on objective task measures. However, it is their vulnerabilities surrounding elements of social communication, related to navigation or deciphering subtle emotional cues are so closely tied to their functional social impairments [16]. Added to this, individuals with ASD are often highly anxious [16]. Due to deficits in explicit expression of their anxiety level, estimation of anxiety becomes difficult. Here we tried to understand the potential of physiology-related biomarkers to act as indicators of one’s anxiety level while being exposed to both navigation-related and subtle emotional aspects of social communication.

The physiological signals being continuously available and not directly impacted by communication deficits can be alternatively used as markers of one’s anxiety level [17]. For example, recently, Kushki et al. in their non-VR based research involving both typical adults and individuals with ASD have shown that one’s skin temperature, electrodermal and cardiovascular activity [18] vary with the anxiety level. Specifically, activation of sympathetic nervous system with increased anxiety is manifested as increased heart rate (cardiovascular activity), increased activity of eccrine sweat glands (electrodermal activity) and decreased skin temperature [18]. This also holds good in VR-based interaction where researchers have shown that physiological signals can be evoked by different amounts in the presence of virtual environments [19,20] and the transition from one affective state to another is accompanied by dynamic shifts in indicators of Autonomic Nervous System activation [13]. Studies have reported the possibility of using VR -based system for treating patients with anxiety disorders where anxiety level is detected using heart rate, electrodermal activity, skin temperature, etc. [21]. However, none of these pioneering research studies have investigated the implications on one’s physiology as biomarkers of anxiety, when exposed to VR -based tasks that can address aspects of adhering to navigation-related social norms and additionally exploring the effect of subtle context -relevant emotional cues that are critical for effective social conversation.

Purpose of Study

In our present research, we have designed a usability study, as proof -of-concept application using the VR platform. In this, we exposed our participants to various aspects of social communication in a systematic and integrated manner, having components of navigation-related social etiquettes and context-relevant emotional expressions. The PART system was designed to be sensitive to one’s individualized performance. Additionally, we acquired the participant’s physiological signals in a time -synched manner along with VR-based task progression. Thus we intend to understand the manifestation of anxiety as well as variations in performance by dissociating a particular social context into subtask s of navigationrelated and emotion-related social context. Specifically, here we wanted to address following questions to help us to understand the potential of PART system:



We designed a usability study as proof-of-concept application in which six adolescents with ASD (ASD1-ASD6) and six TD (TD1- TD6) adolescents participated. The participant’s ID number (e.g., ASD1) was given in the order in which they came for the study. The ASD participants (n=6; Age: 16±4.5 (M±SD)) were selected from Pearl Special Needs Foundation and KGP children’s hospital, Gujarat, India. This school and hospital situated in and around Ahmedabad, Gujarat (western part of India) is well-known for their services. They provide education/intervention services to individuals with developmental disorders coming from families of different socio-economic backgrounds with children being Hindi/Gujarati speaking, but conversant in English. The TD participants (n=6; Age: 16±3 (M±SD)) were recruited from a neighborhood regular school. The inclusion criteria for participants with ASD required them to be high-functioning with some preliminary diagnosis of autism measures. We screened the participants for core autism-related symptoms using Social Responsiveness Scale (SRS) [22], and the Social Communication Questionnaire (SCQ) [23] administered in the presence of the therapist / clinician involved in our study. Table 1 shows the participants’ characteristics. All the TD participants were below the clinical thresholds in all the SRS and SCQ measures. All the ASD participants except ASD1 were above in either/both of the clinical cutoff scores for SRS and SCQ indicating that they were in the autism range. For ASD1, the SRS score showed that he was marginally in the autism range. Again, the SCQ score indicated that ASD1 was not in the clinical category. However, for ASD1, we found from his medical report from a reputed nearby hospital which used Individuals with Disabilities Education Act (IDEA) scale [24] that he was in the clinical range. Literature shows that the IDEA scale can also be used to report autism measures [24]. Additionally, ASD1 had the highest Spence Children’s Anxiety Rating Scale (SCAS) score [25]. The T-scores Table 1 indicates that TD participants on an average were less anxious than their ASD counterparts. We did not have access to participants’ IQ-related scores. However, all the participants were enrolled in a Special Needs (for ASD) and regular (for TD) School, where teachers selected the participants based on their impression about having an IQ above average.