Gray Atherton
Liam Cross- Department of Psychology, Edge Hill University, Ormskirk, United Kingdom
Many interventions that target improvements in social communication and other cognitive, learning, and physical issues have been developed to help autistic people. The gamification of interventions offers an alternative approach to fostering and assessing desired behaviors and cognitions in a more naturalistic and emergent setting. In this scoping review aimed at educators, practitioners, and parents of those with autism, we detail studies that have tested game-based approaches to improving the lives of autistic children, adolescents, and adults, focusing on how research into gamification and autism can both progress and can be progressed and implemented. We offer parents, professionals and academics resources to incorporate game-based psycho-educational programs into their current practice.
Autism Spectrum Condition (ASC) is a neurodevelopmental condition that affects approximately 2% of the population. The DSM V (American Psychiatric Association, 2013) which is commonly used for diagnosis describes people with autism as individuals with restricted interests, repetitive behaviors, and social and communicative differences. Autism can be diagnosed using various methods, with the ADI, ADOS, DISCO being the gold standard amongst other diagnostic tools.
Autism was first identified in the mid twentieth century Kanner (1943) and Asperger (1944) through a series of case studies, which described children who showed little interest in social interactions, but high interest in restricted topics. Notably, the children showed atypical interactions during periods of play. For example, rather than building structures with the blocks, a child would use a repetitive motion to move the blocks in recurring ways (i.e., banging them together). When a parent would try and join in the block play, the child would brush their hand away as if their hand was an object rather than belonging to a social agent (Kanner, 1943). Autistic children display atypical play behaviors, tending to prefer independent play, often repetitive, showing less imitation, lacked joint action, and social interaction.
This is notable in that early play behaviors are considered pivotal childhood milestones for several reasons. As discussed at length by Piaget (1997), play behaviors allow a child to engage with emerging cognitive skills. For instance, pretend play enables children to learn concepts such as false belief, and more structured turn-taking board games teach reciprocity and strategy. Crucially, when one is playing with another in a competitive or cooperative game, the experience affords both practice and development of a range of skills, including communication, perspective-taking, emotional regulation, emotional recognition, and sportsmanship. Games also offer children the opportunity to engage in shared attention and joint action with other social agents, as players will imitate other partners' play behaviors to facilitate joint engagement (Eckerman and Stein, 1990). The process of developing joint attention through game-based interactions are even observed across other species (Tanner and Byrne, 2010).
In this way, while a game is ostensibly an enjoyable, entertaining leisure activity, any game, no matter how serious, is simultaneously teaching players how to behave in a group context. Due to in-built rewards systems that track advancement, games may be especially motivating over and above other types of educational interventions (Filsecker and Hickey, 2014). For this reason, it is unsurprising that researchers hoping to improve the lives of autistic people have turned to games when designing interventions.
For example, many autistic people respond differently to social stimulation compared to those who are neurotypical (Chevallier et al., 2012). While typically developed children may automatically imitate a teacher or peer's behaviors, autistic children do not as readily imitate other social actors (Gowen, 2012). They may also be less interested in joining in with a shared activity or remaining focused on a joint goal (Wong and Kasari, 2012). For this reason, the built-in reward system involved in most games (i.e., points, levels, progress bars, feedback) may provide additional incentives. This positive reinforcement may motivate autistic people to continue participating in the game, allowing them to complete the intervention and remain socially engaged with the other players.
Furthermore, games are in and of themselves teaching cognitive and social skills. For instance, a multiplayer game teaches joint attention, turn-taking, strategy, and appropriate social behaviors in response to other players (Rogerson et al., 2018). Some autistic people struggle with these skills and are often late to develop them in line with neurotypicals. Thus, using games, which encourage developing social skills and behaviors, could offer a highly effective interventional format that enables autistic people to improve upon these abilities.
In a broader context, learning and playing games are central to a child's social development in that playing games allows them to form independent relationships with peers (Piaget, 1997). As autistic children often have difficulty forming peer relationships and are more likely to be excluded from social settings (Chamberlain et al., 2007), developing game-play skills may be an essential tool for autistic children to build social capital with peers. Creating opportunities for autistic and neurotypical children to connect in naturally motivating activities like shared enjoyment of a game could serve two essential purposes. First, by playing games in mixed groups, neurotypical and autistic children can learn from one another and build “double empathy” skills, which refers to the ability to understand both neurotypical and autistic perspectives (Milton, 2012). Second, autistic and neurotypical children can form reciprocal relationships based on shared interests (i.e., board gaming clubs).
Finally, games are particularly well-suited for customization and need not be overly reliant on outside support. Once children learn the rules of a game, many will be able to interact independently through the game without adult oversight (Lancy and Grove, 2011). The ability to develop independent, peer focused social spheres may be beneficial for autistic children who are often overly reliant on adult assistance, which may interfere with their ability to form friendships (Milley and Machalicek, 2012). Additionally, games are built upon fundamental mechanics (i.e., turn-taking, point collection, random dice throws, card matching, bluffing) that can then be modified to fit a specific theme (i.e., fantasy, space, trains, action-adventure). As most autistic people have restricted interests in a particular domain, they may be particularly interested in games that fit a particular theme. The customization of both analog (traditional board games) and digital (computer and video games) games also makes it possible to design interventions that mainly target specific skills while still providing entertainment.
In sum, playing games are not just childhood fun; they play an essential role in early development and improve cognitive and social functioning throughout the lifespan (Noda et al., 2019). Thus, developing game-based skills, and using games to engage individuals with ASC may be beneficial. Many researchers have recognized this and have developed game-based therapeutic programs that educators, professionals, and families could adopt.
This review will discuss a selection of game-based interventions, which span both analog and digital formats. This scoping review is not intended to offer a meta-analysis or comprehensive systematic review of every use of gamification in autism, but rather provide a pragmatic resource for educators, practitioners, and parents of those with autism who are interested in the use of gamification. The field has not yet as developed to a place where one can definitely state what makes any single or collection of games better than others. As we shall discuss, there is a multitude of issues present in the literature (sample sizes, lack of controls, measurement issues, etc). However, a selection of games are nonetheless identified in order to highlight to practitioners, educators, and parents some of the games that have been utilized in this field, which could be easily implemented in relevant settings and would benefit from further investigation. This scoping review therefore aims to offer an accessible review of some of the existing literature on the use of games in autism interventions to practitioners, parents, and educators and highlight some of the available options. We conclude with our assessment of where game-based research into autism is headed, and how games can continue to improve the lives of people with ASC, including recommendations for game-developers and developmental researchers.
Methods
To locate relevant research for the literature review, Google Scholar, PubMed, ScienceDirect search engines were utilized. Initial search terms included: Board games, Tabletop games, Mobile games, Video games, Computer games, Games, Game play, Autism, Autistic. These combinations returned a large number of hits, from Google Scholar alone three combinations produced over 1,650,000 returns. The search criteria were therefore restricted to articles published in the last 20 years (from the year 2000 onwards) and the following key, catch-all search terms were used: Autism, Autistic, Games. Searches were performed in the summer of 2020. In addition to these searches, both Ancestry (earlier articles cited by a given article) and Descendary (subsequent articles citing a given article and other papers by authors/labs of a given article) approaches were utilized in combination with key papers.
Articles that were consistent with the overarching aim of this review were isolated. These consisted of articles that offered pragmatic and applicable solutions to the concerns of autistic individuals and their families. Such articles typically focused on interventions utilizing gamification for socio-communicative, or non-social (cognitive, learning, movement) issues faced by autistic individuals and therefore this distinction was made for the purpose of organizing, synthesizing, and reporting findings. All research exploring the therapeutic use of gamification in ASC was sought out, alongside work that explored the use of gamification in assessing aspects of ASC and research exploring autistic interaction with and preferences for games. All relevant studies which used games to improve social or non-social skills amongst autistic individuals were included. Additionally, work which targeted other populations (such as ADHD, Dyslexia) but focused on topics with considerable crossover with and relevance for ASC were also included. Details of all the studies reviewed including their methodology, sample size, and summaries of said studies are reported in Tables 1, 2 split by digital (Table 1) and then analog (Table 2) games. This body of work is first synthesized below, with a focus on how this work can be used in practice categorized by those studies concerning socio-communicative outcomes, and non-social outcomes as well as work looking at autistic players game preferences, in order to provide an accessible resource for practitioners, educators and parents.
Table 1. Summary details of studies using digital gamification approaches for autism interventions.
Table 2. Summary details of studies using analog gamification approaches for autism interventions.
The Review
Socio-Communicative Outcomes
The social aspects of autism are among the most widely researched and focus most prominently within targeted interventions. Many gaming interventions for those with ASC also concentrate on developing social skills, though the mechanisms used to improve these skills vary.
Several gaming interventions, particularly with younger children with ASC, use behavioral approaches embedded within game-play to increase social responsiveness and scaffold social development. For instance, Daubert et al. (2015) used Power Cards, small double-sided index cards, to improve game-based behaviors in young children with ASC. The Power Cards featured on one side the autistic child's favorite character, while the other side described how that character would optimally behave when playing board games (such as having good sportsmanship and encouraging other players). For instance, one participant interested in the Ninja Turtles had Power Cards written from the perspective of one of the turtles who demonstrated appropriate play behavior (i.e., the Ninja Turtle Donatello telling his friends “You did it!” and “You won!”). Participants viewed these cards at the beginning of the game-play session, and when needed, were prompted to review the cards when they needed reminders. Results showed that the participants significantly improved their ability to initiate and relinquish a turn following the intervention.
Several studies also developed games that used modeling combined with behavioral reinforcement. Ferguson et al. (2013) used Nintendo Wii Baseball to teach six children with ASC sportsmanship skills over ten sessions in an outpatient clinic. Instructors first modeled appropriate game-play behaviors such as taking turns and giving a compliment post-game and then awarded points to players who engaged in the behaviors. Jung and Sainato (2015) also used modeling in their intervention with slightly younger children with ASC. Borrowing from the Power Card method, children's special interest characters (i.e., a princess) featured in video recordings of adults modeling appropriate game-play behaviors. Children first watched the videos before playing board games like Candy Land, and then used them as references when they needed prompting. When the children engaged in appropriate behaviors during the game, they were rewarded with tokens. Both studies found behavioral reinforcement and modeling led to increases in appropriate behavior. Jung and Sainato (2015) also found increased engagement with peers and generalization of learned skills to a novel game.
Central to both the Jung and Sainato (2015) and Daubert et al. (2015) studies was the incorporation of restricted interests to enhance game-based motivation. Another study that utilized this approach was Baker (2000). In this intervention children with ASC were encouraged to develop game-play behaviors by playing pre-existing games tailored to reflect their unique special interests. For instance, one boy had a preoccupation with crashing toy cars together. To incorporate this into a game, the researchers devised a version of Bingo that involved choosing toy cars to launch off a ramp and crash, thus triggering a Bingo tile to be called. Using a single-case design, the researchers demonstrated that, following from baseline, the three children tested showed significantly improved play-based behaviors, which transferred to games that were not based on special interests.
Thus far, the projects discussed relied upon existing, “off the shelf” games and modified them to include behavioral conditioning, modeling, and special interests. Other studies instead created new games to teach social constructs explicitly. For instance, several games used narrative storytelling to teach children with ASC socio-communicative skills. Tobias in the Zoo (Carvalho et al., 2015), TouchStory (Davis et al., 2007), and iPad play story (Murdock et al., 2013) all used mobile gaming technology to encourage children with ASC to interact with virtual “storybooks.” In Tobias in the Zoo children interacted with an avatar, Tobias, who experienced different scenarios (i.e., a zoo visit, a birthday party) which caused him to experience various emotions. To win the game, the child needed to correctly identify Tobias' feelings at various points in the story. TouchStory consisted of autistic children dragging story panels, which were pictures showing sequential story scenes, into the correct position relative to one another. In the iPad play story, pairs of autistic children read a story together on an iPad about various characters experiencing certain events (i.e., firefighters in a fire truck going to rescue a girl from a treehouse). After reading the story, the children then interacted with toy versions of the story characters and were encouraged to re-enact the story through symbolic play. While Tobias in the Zoo requires formal testing, children's narrative comprehension following TouchStory showed some improvement. Following the iPad play story, children demonstrated the ability to use the narrative they read on the iPad as the basis for their reciprocal pretend play (Murdock et al., 2013).
Several games explicitly focused on emotion recognition, an area of delayed development for autistic individuals, to target improvement. In Life is Game (Abirached et al., 2011), autistic children picked a custom avatar and then identified the avatar's emotional expressions. There were also options for making the game more challenging by hiding the eyes or mouth. Let's Face It (Tanaka et al., 2010) consisted of seven computer games that encouraged different facial recognition skills, including recognizing facial identities, emotions, and holistic processing of eyes. After 20 weeks, autistic children showed improved face recognition (such as holistic processing of the eyes) but did not improve all targeted skills (such as facial identity recognition).
Rather than explicitly teach socio-communicative skills, some games embedded them within the game's mechanics. Dell'Angela et al. (2020) modified three existing board games already popular with children to target specific emotional competence skills. For instance, the researchers changed the game Code Names (a game where players must give clues to their teammates to link target words) so that rather than pick any word as a clue, players instead had to pick an emotional word as their clue. In a large sample of typically developed children, the researchers found that children with higher emotional competence skills were the most successful at the game and found the game most accessible. In another study, Bernardini et al. (2014) created the computer game ECHOES in which autistic children interacted with an avatar in a magical garden in a way that supported the use of certain behaviors. For instance, embedded within game-play were cues that encouraged joint attention and symbol use. While these behaviors frequency was not directly assessed, the children became more socially responsive to practitioners throughout multiple gaming sessions.
While many games focused on improving socio-communicative abilities in autistic individuals, several took a different approach. Rather than behaviourally reinforcing behaviors or explicitly teaching individual social skills, some interventions used games to more indirectly encourage social communication between players. For instance, Wainer et al. (2014) developed an imitation game to be played with two players with ASC and KASPAR the robot. KASPAR was a humanoid animated doll that could verbally and physically interact with humans. Using a digitized version of Simon Says, researchers found that the children spent more time interacting with one another when playing the game with KASPAR than when playing with only one other.
In Pico's Adventure (Malinverni et al., 2017), children interacted with an avatar, parents, and peers in a virtual environment where they must complete challenges to assist Pico the alien, an animated character. Exploratory results showed that through engagement with the task, autistic children were more expressive and directive with one another within game-play. Finally, autistic children were tested on their ability to interact with one another when playing the Collaborative Puzzle Game (Battocchi et al., 2009), which was presented on a digital tabletop and required players to move digital puzzle pieces simultaneously with a partner. Results showed that players who were required to collaborate in this way were more coordinated and engaged in more complex interactions.
While most of the games previously discussed cater to children, several games have been beneficial to autistic adolescents and adults for socio-communication skill development. In an ethnographic study, Fein (2015) spent time at a summer camp for adolescents with ASC where they spend time engaging in Live Action Role Playing and tabletop role-playing games like Dungeons and Dragons. Fein (2015) found that the games were incredibly engaging for campers. It allowed for structured social interactions between players specific to the game and promoted a narrative of inclusion and acceptance within the games' stories. Katō (2019) tested the effect of tabletop role-playing games on improvements in social speech and changes in quality of life in adolescents with autism following either four or fourteen sessions of tabletop role-playing games. For the four participants who played fourteen sessions, socio-communicative skills improved following the intervention. For the children who played four sessions, total scores on a quality of life measure significantly increased.
Qualitative research on online games for autistic adults also suggests that they can improve socio-communicative skills and quality of life. Mazurek et al. (2015) found that autistic adults spent more time on average playing video games than neurotypicals. They experienced distinct social rewards from video game-play, including forming friendships with the video gaming community and relief from social stress. Gallup et al. (2016) also found that in addition to forming friendships with others in massive multiplayer online communities, autistic adolescents reported socio-communicative improvements in online settings where they could practice skills in safe spaces. They also reported an improvement in their ability to use online communication strategies. Full details of the studies discussed here can be found in Table 1 (digital games) and Table 2 (analog games).
Non-social Outcomes and Game Preferences
Individuals often experience challenges in other life areas outside of socio-communicative domains, including academic and physical difficulties. Several studies targeted improvements in these specific domains through the use of games. We now turn our attention to work exploring non-social outcomes of gamified research in ASC and autistic game preferences.
TeachTown (Whalen et al., 2010) is a computer-assisted intervention designed to teach young autistic children social and academic skills through an online curriculum. TeachTown is delivered to children daily and utilizes pivotal response training to reinforce correct responses through verbal praise and graphics. In a randomized control trial, children who received TeachTown instruction showed improvement compared to those in the control group on a standardized vocabulary measure. They also significantly improved their scores from baseline, and those who spent more time in the program showed the most improvement. Satsangi and Bofferding (2017) designed a simple board game to improve the numerical knowledge of autistic children by teaching them to roll dice and move tokens along a colored number line. Results showed that across the 10 participants, the ability to make numerical estimates significantly improved amongst those who practiced matching numbers rather than colors. Finally, many autistic individuals have difficulty with prosody or speech production. Hoque et al. (2009) developed a computerized speech therapy game that focused on improving a player's speech intelligibility. Across a suite of games, results suggested that in eight children, five of whom had an ASC diagnosis, language learning improved.
Many autistic individuals experience motor difficulties, including reduced coordination and reduced physical activity levels than those with typical development. To improve the physical capabilities of autistic people, several active games have been modified or created to meet the community's needs. For instance, Edwards et al. (2017) had children with and without ASC engage in a Nintendo Wii program using several sports-related competitive games for 6 h over 6 weeks. They found that neither ASC nor NT children improved on objective measures of object control (i.e., throwing, kicking, and catching a ball). However, the ASC group significantly improved their perception of their object control competencies, indicating Nintendo Wii games can improve sports-related confidence. PuzzleWalk was an intervention created to improve the physical activity levels of autistic adults (Kim et al., 2020). To complete a puzzle, adults walked in a particular pattern displayed on their mobile phones. Preliminary results showed that it was seen as user-friendly and engaging and could be a useful way to encourage physical activity in the adult ASC community.
Individuals with ASC also experience difficulties maintaining rhythm, which some hypothesize may account for some of the social differences observed in the population (Trevarthen and Daniel, 2005). Though not initially developed for children with ASC, but instead children with ADHD, Giannaraki et al. (2019) developed the game ADDventourous Rhythmic Planet, a game that is played in virtual reality in which players use a drum to create rhythm. In this story-based adventure, the hero is an alien that continues onto the game's next stages if the player reproduces a rhythm correctly. The game also progresses from single to multiplayer, encouraging coordinated movement with peers. In another game, Magic Mat, Politopoulos et al. (2019) created a mat that can track movement and guide on-screen actions. In their study, users could play a whole-body form of Tetris in which moving on the mat guided blocks to fall in corresponding gaps at the bottom of a large video screen facing the player. Though both ADDventurous Rhythmic Planet and Magic Mat have not been formally tested, nor were they explicitly designed for children with ASC, both tap areas of need (for examples of movement and rhythm problems in autistic individuals see, Marsh et al., 2013) in novel ways through the use of unique technologies.
From Research to Practice
A primary aim of this work is to highlight and provide access to these interventions so that they can be more widely adopted. To achieve this, we have provided several resources intended to synthesize and categorize relevant research in the way most useful to practitioners, based on the skills they target and the equipment and materials needed to implement them. A summary of relevant work is therefore divided into analog and digital games and summarized in two tables. Table 1 presents research on the effects of digital games, and Table 2 the effects of analog games, on the social and non-social development of children with ASC. With the exception (in both cases) of several studies using games with typical and other special populations, all of which tap skills that are relevant to ASC. In these tables, we detail the project, the participants, the methods, and the usability of the project. These resources are intended to give an overview of relevant game-based autism interventions that have been developed and tested, rather than an exhaustative list.
Digital Games
Example Digital Games
TeachTown (Whalen et al., 2010) is an excellent example of how digital games can be formally tested and incorporated into ASC therapeutic curricula. In this computer game, children with ASC completed daily online challenges, teaching them academic and social skills lessons. Children who participated in TeachTown were compared to waitlisted children, providing a much-needed control condition. Two types of data were collected, scores on cognitive assessments pre and post-intervention, and scores within the TeachTown game which tracked daily progress. Finally, teachers who participated in TeachTown incorporated TeachTown materials into their lesson plans, ensuring that TeachTown concepts were not learned in isolation but retained through different forms of engagement (i.e., a blended learning model). Such measures and supplementary materials provided much-needed rigor and structure to the intervention, which would be helpful if adopted by similar digital gaming interventions.
The Collaborative Puzzle Game in Battocchi et al. (2009) and the imitation game with KASPAR the robot (Wainer et al., 2014) are also examples of how digital technology can enhance gaming interventions for ASC. Though the technology used in these interventions is not yet commonplace (KASPAR is still a prototype), they are examples of digital gaming interventions that may become commonplace in future autism interventions. Importantly, both studies demonstrate how relatively simple games (puzzles, Simon Says) can be modified to be more technologically complex while still retaining the integral elements of game play.
For instance, in the Puzzle Game, which used a Diamond Touch table, players completed jigsaw puzzles with a partner. In the experimental condition, players could not move a puzzle piece unless it was also being touched simultaneously by another player, meaning they had to work in synchrony to move the pieces around the table. By analyzing the game log, the researchers found that the additional need for synchrony with a partner increased the level of interaction between players, and led to more problem-solving (it is worth noting that synchronous movements have been shown to foster a wide range of prosocial outcomes amongst those who take part including, rapport, cooperation, and a reduction in prejudice), for a review see Cross et al. (2019). This is an excellent example of how a digital tabletop's unique capabilities can be maximized to improve an existing game design (i.e., a collaborative puzzle). Battocchi et al. (2009) also demonstrated the improvement that a digital game affords with regards to progress tracking. By having the puzzle activity presented digitally, the researchers could effortlessly record every move made by the players, which allowed for a fine-grained analysis of dyadic coordination. Additionally, the game had a fully programmed feedback mechanism, which allowed for audible reinforcement throughout the game (i.e., animations produced after players completed the puzzle), without requiring outside input.
KASPAR the robot is an even more pronounced example of the ways that technology can supplement the role of the practitioner. In this study KASPAR took a human practitioner's place to motivate and guide two players to interact with one another, reducing the need for professionals and allowing for peer-directed play. Furthermore, though not directly compared to a human professional, KASPAR is unique in that he is a fully animated robot. The novelty of playing a game with KASPAR compared to a therapist likely enhanced the intervention's effects, particularly as research suggests children with ASC are more receptive to non-human social stimuli (Atherton and Cross, 2018). Indeed, the study showed that the players were more socially responsive in KASPAR's presence than when playing alone with their partner. This is a pertinent example of how novel technology stimulates players' imaginations and creates memorable social experiences that may offer advantages over more commonplace gaming platforms.
Benefits and Areas of Improvement: Digital Games
Engineers who design complex games for use in ASC interventions, often in collaboration with autistic individuals and special educators, benefit from their ability to provide in-depth descriptions of the game development process. Such detail is undoubtedly of use to future developers hoping to build upon these advancements. Indeed, many of these games appear to be primarily developed to showcase what can be technologically possible in an ASC intervention. These technological innovations almost certainly offer improvements regarding an intervention's novelty and the player's immersive experience within the game. As autistic people report high levels of enjoyment when engaging with digital media (Gillespie-Lynch et al., 2014), it is not surprising that many game-based interventions rely on computerized technology. Digital games offer several advantages over analog games, including in-built performance tracking, more effortless customization, and improved visual engagement that may be particularly important for people with ASC.
However, what is gained with regard to novelty and innovation is often lost in the validity and viability of many of these digitalised games. Very few of the more technologically advanced games developed for people with ASC have formally tested their game effects. Instead, many of these studies have relied on anecdotal reports from parents, educators, or researchers or simply report what they expect repeated game-play would produce. While these programs are clearly at the forefront of technical innovation, testing the behavioral effects of digital gaming needs to be prioritized. This is particularly paramount with the aim to encourage more wide-spread adoption. As many of these games rely on expensive equipment (i.e., VR, digital touch tables, motion tracking devices, robots), investment in testing its suitability and efficacy is needed to justify everyday users investment.
To address these issues, engineers may want to include psychologists and educators in developing their programs to advise how targeted skills can be measured within the game and how these games can be situated into relevant curriculum. For instance, many of these games could involve built-in progress tracking, which shows how players changed their game-play strategies and behaviors over time. As these digital games can automatically store player data, developers should look at ways to analyse program logs to show functional improvements over time (i.e., increased frequency and complexity of interactions between co-players).
Analog Games
Example Analog Games
While technology is becoming more widely accessible, many innovative gaming technologies are still quite expensive and require more widespread access. However, there is no doubt that these innovative technologies will be more prominently featured in autism interventions in the coming years. A few are particularly promising and draw on the unique strengths of digital intervention and its benefits over analog games, to which we now turn.
Dell'Angela et al. (2020) offers a way to circumvent some of the challenges analog game studies present. In their study, the researchers devised a testing paradigm that tested how emotional competency measures correlated with in-game behaviors and perceived difficulty, and they compared game play across off the shelf and modified games. The video-coding and observational measures used in Baker (2000), Jung and Sainato (2015), and Daubert et al. (2015) revealed the nuanced changes in behavior that took place over many sessions. However, researchers with more limited resources and larger samples may want to utilize instead control groups or measures of within-subjects effects to assess behavioral change. As demonstrated by Dell'Angela et al. (2020), assessing how existing emotional and social competency measures relate to aspects of games that tap into these skills (i.e., perceived level of difficulty, points scored, number of games won) would allow for more sophisticated understanding of a game's cognitive effects. Taking such measures pre- and post-intervention could then be used to evaluate individual player's progress across an intervention (as was done in Teach Town).
Though it requires further formal testing, the studies focused on role-playing games in adolescent samples are quite promising with regards to their broader impact on social development. In Fein (2015) and Katō (2019) adolescents with ASC interacted with each other over an extended period of time, developing characters, and engaging in extended verbal interactions. Importantly, adolescents who participated had existing interests in these games, meaning that they had the opportunity to spend time with others who shared their enthusiasm and interests. Role-playing tabletop games may be particularly attractive to professionals who work with autistic adolescents as they encourage peers to form groups with other like-minded individuals, are readily available, and encourage independent social interaction between players. These games do not require professionals personalization as the games themselves require participants to create characters and self-directed narratives. Additionally, Fein (2015) suggested that autistic adolescents may feel more comfortable expressing themselves and experimenting socially by taking on a certain character in the game, and noted the positive culture that developed around role-playing games and autism acceptance. More formal research on the types of social interactions during role-playing games is warranted.
To move from research to practice, these two groups of researchers, i.e., those who specialize in game design and those who specialize in behavioral testing, should aim to blend their skill sets on joint ventures. In order for digital games to become widespread in professional settings, digital gaming prototypes should be more rigorously tested, particularly within the settings in which they are likely to be deployed (i.e., special schools and clinical practices). Care should also be taken that rich social interactions are not lost through increased attention to screens/graphics. Conversely, analog game interventions should be evaluated using less onerous testing procedures and should incorporate more sophisticated game designs that limit the need for outside support, and instead lead to peer-directed play. Understanding the unique benefits gained from digital vs. analog games should be comparatively assessed.
Benefits and Areas of Improvement: Analog Games
While arguably not as vivid and immersive, what analog games may offer over and above digital games are that they are played in person and require face to face contact, which may improve the social connection between players. Though some digital games preserved the opportunity for face-to-face contact within their game design (Collaborative Puzzle, KASPAR), many digital games could conceivably lead players to focus more on the game rather than their play partner. As analog board games require players to physically face one another around a board and directly engage with one another verbally, they may offer the opportunity for richer social interactions than many digital games. As people with ASC are well-documented in their difficulties with in-person emotional recognition and communication, playing in-person games may allow them to practice these skills while simultaneously improving explicit social knowledge.
Understanding the rich social interactions that take place during face-to-face gaming interventions was the primary focus of many of the studies using analog games. In contrast to the programs that focus primarily on technologically advanced game development, many analog games discussed instead placed their efforts into testing the effects of pre-existing analog games (i.e., Wii, Candy Land, Bingo). Studies such as Baker (2000), Jung and Sainato (2015), and Daubert et al. (2015) all used off the shelf board games in their interventions, relying on small samples and single-case designs. Unlike the studies detailing the creation of complex technical programs, these interventions were relatively simple in their development. Instead, they prioritized tailoring these games to suit a particular autistic child's needs. They also used complex testing procedures to understand subtle behavioral changes over time (i.e., assessing baselines, video coding play behaviors across numerous sessions, creating reinforcement schedules).
As ASC is a highly heterogeneous condition, meaning that there is great variation in symptoms and abilities within the population, using more tailored protocols and assessments is a sensible approach. Additionally, studies such as Baker (2000), Jung and Sainato (2015), and Daubert et al. (2015) were particularly interested in the subtle social behaviors players exhibited in relation to other players (i.e., eye contact, reciprocity, and shared attention). Both stimulating and measuring these types of behavioral improvements, particularly with young children with limited verbal ability, can be difficult to induce and record without spending time with the child and relying on observational measures gathered at multiple time points. However, the time required to individualize existing games for each participant and manually code behaviors places high demands on professionals. It also limits the ability to replicate these interventions in larger groups and maintain the program for longer time-periods. Additionally, as these pre-existing games are not as complex and novel, they may require more adult input to keep players engaged in the intervention (i.e., Power Cards, video modeling, prompting, rewarding).
Moving Forward
There are several areas of research that those interested in the effects of gaming on ASC may want to investigate in the future. First, it would be important to understand the effect that gamification in and of itself offers when employed in an autism intervention. Experimental studies that compare rates of behavioral change between groups who engage in game based vs. non-game based interventions are much needed. As games are meant to be intrinsically rewarding, measuring not only the effects of the game-based intervention has on particular skills, but also how it enhances the user experience, and how it socially engages a group of players, would be important areas of investigation.
Following on from this, it would be of interest to understand more about autistic user experience in relation to certain types of games. As highlighted by researchers who incorporated restricted interests into traditional board games, interacting with restricted interests can be particularly engaging and motivating for people with ASC. It would be of interest to test whether games that incorporate restricted interests boost participation and engagement. If so, it may be that some of the more common restricted interests could be incorporated into many different types of games, thus boosting player participation.
For older cohorts (adolescents and adults) researchers may want to investigate the social/hobbyist aspects of gaming and how this relates to ASC enthusiasts. Research suggests that autistic people are more likely to play video games, though less is understood about the relationship between autism and board gaming. Research into board and video game-play with adolescents and adults with ASC suggested that they experience increased quality of life and may have improved communication. This suggests that ASC friendly gaming communities may be a beneficial social outlet for those on the spectrum (Lancy and Grove, 2011).
While many studies offer promising results, it is clear from this review that more stringent testing procedures must be adopted to determine how effective many of these interventions are in naturalistic settings and how skills generalize over time.
As was also noted by Grossard et al. (2017), and what has also become apparent through this review, is that there appears to be a disconnect between two main research groups. Specifically, the aims of the engineers who design many of the cutting edge digital games, and the researchers who test pre-existing, more rudimentary games, are not always aligned.
These studies would particularly benefit from research into how educators, professionals, and families can readily implement them across settings (i.e., school, home, clinical practice). To aid professionals and families in deciding whether certain game-based interventions would meet their needs, a “ludography,” or game-based bibliography can be found in Table 3 where we focus specifically on the games used in these studies, detailing the player-experience, targeted outcome, and the necessary requirements for adopting such a program (i.e., materials, equipment). The primary purpose of this “ludography” or game-bibliography is to provide non-academic professionals who work with ASC individuals or parents of children with ASC a clear understanding of the choice of games available and the feasibility of implementing such a program. This table focuses specifically on the games used in ASC research and outlines necessary materials, equipment, and training to encourage more widespread adoption and validation of these approaches.
Table 3. “Ludography” detailing specific games tested on children with ASC and other conditions.
In conclusion, there are many games that have been developed as autism interventions, many of which are discussed in this scoping review. These gamified interventions target three key areas: socio-communication skills, academic skills, and physical skills. While many games have been developed, few have been tested with large samples and many have not shown how skills improved or whether they generalize to other settings. Digital games show promise in that they are designed to maximize engagement and reinforcement, but they need to be formally tested to see whether improvements in the game extend to improvements in real life. Off the shelf board games that have been adapted for autistic players should be tested on larger samples and would benefit from easier data collection processes and more sophisticated ways to customize them to individual players. The most effective and accessible interventions reviewed were those that encouraged interactions between players, and used simpler game designs. Researchers who specialize in behavioral testing, and those who specialize in gaming innovations will want to collaborate in future on gaming interventions that are both efficacious and innovative. More broadly, researchers should investigate the effects of gamification on autism interventions more generally, particularly as motivation as it relates to ASC is not yet fully understood.
Author Contributions
All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.
Funding
This work was supported by Game in Lab—Innovation Factory. It was conducted and written independently from any funding oversight.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher's Note
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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Keywords: autism, games, intervention, social cognition, emotional intelligence, gamification
Citation: Atherton G and Cross L (2021) The Use of Analog and Digital Games for Autism Interventions. Front. Psychol. 12:669734. doi: 10.3389/fpsyg.2021.669734
Received: 19 February 2021; Accepted: 28 June 2021;
Published: 09 August 2021.
Edited by:
Bradley Ferguson, University of Missouri, United StatesReviewed by:
Peter Kokol, University of Maribor, SloveniaSarah Macoun, University of Victoria, Canada
Copyright © 2021 Atherton and Cross. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Gray Atherton, gray.s.atherton@vanderbilt.edu