Improvement of Attention-Deficit/Hyperactivity Disorder Symptoms in School-Aged Children, Adolescents, and Young Adults With Autism via a Digital Smartglasses-Based Socioemotional Coaching Aid: Short-Term, Uncontrolled Pilot Study

Digital Horizons: Enhancing Autism Support with Augmented Reality

PURPOSE

This paper aims to comprehensively review the application of Augmented Reality interventions in supporting individuals diagnosed with Autism Spectrum Disorder. The main research question guiding this review is: What effects do AR interventions have on various aspects of functioning in individuals with ASD?

METHODS

A systematic review methodology was employed to analyze 49 articles published between 2013 and 2023. These articles were selected based on their relevance to AR interventions for individuals with ASD. The review examines the diverse technological landscape of AR interventions, the various platforms utilized, and the effectiveness of different AR techniques.

RESULTS

Findings reveal the prevalence of smartphones, tablets, smart glasses, and head-mounted displays as primary platforms for AR interventions, with positive outcomes reported across various domains including social interaction skills, communication abilities, and academic performance. Marker-based, superimposition-based, and projection-based AR techniques demonstrate potential in creating personalized and engaging experiences tailored to the unique needs of individuals with ASD.

CONCLUSION

Despite progress in communication and social skills interventions, gaps remain in understanding and addressing attention-related issues and emotion recognition. The review underscores the need for more rigorous study designs and objective evaluation methods to ascertain the efficacy of AR interventions for individuals with ASD. Looking ahead, collaborative efforts between researchers, developers, practitioners, and individuals with ASD are crucial for advancing innovation, addressing limitations, and ensuring the meaningful integration of AR technology into interventions aimed at enhancing the quality of life for individuals on the autism spectrum. Further exploration and utilization of the latest advancements in artificial intelligence and affective computing are warranted to develop solutions that effectively address real-world challenges faced by individuals with autism.

Neurodiversity: post-cognitivist foundations of the 3E approach for educational inclusion of autistic students with technology

The concept of neurodiversity has gained strength in the last years to highlight the value of individual differences based on relevant variations in brain functioning. Inclusive education has embraced neurodiversity to promote a culture centered on valuing diversity, in response to clinical models based on deficits or disorders. This theoretical-critical article argues for the need to complement the current foundations of neurodiversity with post-cognitivist perspectives that reaffirm the brain-body-environment continuum, in order to enrich inclusive educational practices for autistic individuals. We begin by reviewing and discussing the concept of neurodiversity and neurocentric arguments in light of post-cognitivism. We then explore the potential of the 3E Cognition approach (embodied, enacted, and environmentally scaffolded) for addressing autism, aiming to provide a holistic understanding that contributes to the practical application of cognitive neuroscience findings in inclusive education. Finally, we present some guidelines and practical cases for creating inclusive educational environments based on digital technologies that enhance agency and sensory multimodality for autistic students.

Mixed Reality in Clinical Settings for Pediatric Patients and Their Families: A Literature Review

In the post-pandemic context, there has been an increasing demand for technology-based interventions in education and healthcare systems, such as augmented and mixed reality technologies. Despite the promising outcomes of applying mixed reality (MR), there is limited aggregated evidence focusing on child-patient interventions in hospital-based or clinical settings. This literature review aimed to identify and synthesize existing knowledge on MR technologies applied to pediatric patients in healthcare settings. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search of the Scopus and Web of Science databases was conducted to identify articles published in the last 10 years that address the application of augmented and/or MR technologies in pediatric hospital settings or clinical environments to improve patient and family outcomes. A total of 45 articles were identified, and following a rigorous screening and eligibility process, 4 review articles were selected for qualitative synthesis. From these reviews, 10 studies with relevant interventions and measured effects were extracted. The extracted studies were analyzed based on eight key attributes: country of origin, study design, characteristics of the study population, primary clinical setting, type of MR device used, nature of the intervention, variables measured, and significant effects observed in the outcome variables. The analysis revealed diverse approaches across different clinical settings, with a common focus on improving both emotional well-being and learning outcomes in pediatric patients and their families. These findings suggest that MR-based pediatric interventions generally provide children and their parents with positive emotional experiences, enhancing both learning and treatment outcomes. However, the studies reviewed were heterogeneous and varied significantly in terms of clinical settings and MR applications. Future research should focus on developing more controlled study designs that specifically target the pediatric population to strengthen the evidence base for MR interventions in healthcare.

Effects of a Nonwearable Digital Therapeutic Intervention on Preschoolers With Autism Spectrum Disorder in China: Open-Label Randomized Controlled Trial

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder that can cause difficulty with communication and social interactions as well as complicated family dynamics. Digital health interventions can reduce treatment costs and promote healthy lifestyle changes. These therapies can be adjunctive or replace traditional treatments. However, issues with cooperation and compliance prevent preschool patients with ASD from applying these tools. In this open-label, randomized controlled trial, we developed a nonwearable digital therapy called virtual reality-incorporated cognitive behavioral therapy (VR-CBT).

OBJECTIVE

The aim of this study was to assess the adjunctive function of VR-CBT by comparing the effects of VR-CBT plus learning style profile (LSP) intervention with those of LSP-only intervention in preschool children with ASD.

METHODS

This trial was performed in China on 78 preschool children (age 3-6 years, IQ>70) diagnosed with ASD who were randomized to receive a 20-week VR-CBT plus LSP intervention (intervention group, 39/78, 50%) or LSP intervention only (control group, 39/78, 50%). The primary outcome was the change of scores from baseline to week 20, assessed by using the parent-rated Autism Behavior Checklist (ABC). Secondary outcomes included the Childhood Autism Rating Scale (CARS), Attention-Deficit/Hyperactivity Disorder Rating Scale-IV (ADHD-RS-IV), and behavioral performance data (accuracy and reaction time) in go/no-go tasks. All primary and secondary outcomes were analyzed in the intention-to-treat population.

RESULTS

After the intervention, there was an intervention effect on total ABC (β=-5.528; P<.001) and CARS scores (β=-1.365; P=.02). A similar trend was observed in the ABC subscales: sensory (β=-1.133; P=.047), relating (β=-1.512; P=.03), body and object use (β=-1.211; P=.03), and social and self-help (β=-1.593; P=.03). The intervention also showed statistically significant effects in improving behavioral performance (go/no-go task, accuracy, β=2.923; P=.04). Moreover, a significant improvement of ADHD hyperactivity-impulsivity symptoms was observed in 53 children with comorbid ADHD based on ADHD-RS-IV (β=-1.269; P=.02). No statistically significant intervention effect was detected in the language subscale of ABC (β=-.080; P=.83). Intervention group girls had larger improvements in ABC subscales, that is, sensory and body and object use and in the CARS score and accuracy of go/no-go task (all P<.05) than the control group girls. Statistically significant intervention effects could be observed in hyperactivity-impulsivity symptoms in the intervention group boys with comorbid ADHD compared with those in the control group boys (β=-1.333; P=.03).

CONCLUSIONS

We found potentially positive effects of nonwearable digital therapy plus LSP on core symptoms associated with ASD, leading to a modest improvement in the function of sensory, motor, and response inhibition, while reducing impulsivity and hyperactivity in preschoolers with both ASD and ADHD. VR-CBT was found to be an effective and feasible adjunctive digital tool.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2100053165; http://www.chictr.org.cn/showproj.aspx?proj=137016.

Effectiveness of a Personalized, Chess-Based Training Serious Video Game in the Treatment of Adolescents and Young Adults With Attention-Deficit/Hyperactivity Disorder: Randomized Controlled Trial

BACKGROUND

Compared with traditional approaches, gaming strategies are promising interventions for the treatment of attention-deficit/hyperactivity disorder (ADHD). We developed a serious game, The Secret Trail of Moon (TSTM), for ADHD treatment.

OBJECTIVE

The main objective of this clinical trial was to demonstrate the effectiveness of an add-on, either TSTM or Therapeutic Chess (TC), in previously optimally drug-titrated, clinically stable patients with ADHD.

METHODS

This study is a prospective, unicentric, randomized clinical trial in clinically stable patients with ADHD, aged 12 to 22 years. The TSTM (n=35) and TC groups (n=34) performed 12 weekly sessions of their respective treatments. The control group (CG) patients (n=35) were called by phone every week, but they received no cognitive intervention. The primary end point was the change from baseline to end point in the parent "Behavior Rating Inventory of Executive Function-2" (BRIEF-2; patients' parents) in the per-protocol population (31 serious videogame: 24 TC and 34 CG).

RESULTS

Our study failed to probe clear-cut improvements in the global score of the BRIEF-2. However, the TC group showed improvements in measures of emotional control, emotional regulation, and inattention. The TSTM group showed improvements in measures of emotional regulation, inattention, and school context.

CONCLUSIONS

TSTM and TC did not improve executive function symptoms, but they improved ADHD symptomatology related to emotional regulation. Further studies with bigger samples are required to confirm these preliminary findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04355065; https://clinicaltrials.gov/ct2/show/NCT04355065.

Use of augmented reality in mental health-related conditions: A systematic review

Objective

Augmented reality (AR) is a relatively new technology that merges virtual and physical environments, augmenting one's perception of reality. AR creates a computer-generated environment that evokes a unique perception of reality, where real and virtual objects are registered with one another, which operates interactively and in real time. Recently, the medical application of AR technology has dramatically increased with other assisted technologies, from training to clinical practice. The ability to manipulate the real environment extensively has given AR interventions an advantage over traditional approaches. In this study, we aim to conduct a systematic review of the use of AR to have a better understanding of how the use of AR may affect patients with mental health-related conditions when combined with gamification.

Method

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching Pubmed and Web of Science databases.

Results and Conclusion

We identified 48 relevant studies that fulfill the criteria. The studies were grouped into four categories: Neurodevelopmental disorders, anxiety and phobia, psychoeducation & well-being, and procedural & pain management. Our results revealed the effectiveness of AR in mental health-related conditions. However, the heterogeneity and small sample sizes demonstrate the need for further research with larger sample sizes and high-quality study designs.

Extended reality for mental health: Current trends and future challenges

Virtual and augmented reality have been used to diagnose and treat several mental health disorders for decades. Technological advances in these fields have facilitated the availability of commercial solutions for end customers and practitioners. However, there are still some barriers and limitations that prevent these technologies from being widely used by professionals on a daily basis. In addition, the COVID-19 pandemic has exposed a variety of new scenarios in which these technologies could play an essential role, like providing remote treatment. Disorders that traditionally had received less attention are also getting in the spotlight, such as depression or obsessive-compulsive disorder. Improvements in equipment and hardware, like Mixed Reality Head Mounted Displays, could help open new opportunities in the mental health field. Extended reality (XR) is an umbrella term meant to comprise Virtual reality (VR), mixed reality (MR), and augmented reality (AR). While XR applications are eminently visual, other senses are being explored in literature around multisensory interactions, such as auditory, olfactory, or haptic feedback. Applying such stimuli within XR experiences around mental disorders is still under-explored and could greatly enrich the therapeutic experience. This manuscript reviews recent research regarding the use of XR for mental health scenarios, highlighting trends, and potential applications as well as areas for improvement. It also discusses future challenges and research areas in upcoming topics such as the use of wearables, multisensory, and multimodal interaction. The main goal of this paper is to unpack how these technologies could be applied to XR scenarios for mental health to exploit their full potential and follow the path of other health technologies by promoting personalized medicine.

Extended Reality (XR) and telehealth interventions for children or adolescents with autism spectrum disorder: Systematic review of qualitative and quantitative studies

World Health Organization reported that almost one in 100 children is diagnosed with autism spectrum disorder (ASD) worldwide. Extended Reality (XR) and Telehealth interventions are evident to be effective for ASD treatments. While there is no comprehensive systematic review to summarize and evaluate the evidence for promoting the accessibility of different technology-based treatment regiments. This paper aims to verify the efficacy and validity of XR and Telehealth interventions for children and adolescents with ASD. We reviewed 112 studies from databases of PubMed, Web of Science and Cochrane Library, published in English between January 2010 to April 1st, 2022. We found that after interventions, positive improvements for ASD participants were observed in social interaction, acceptance, and engagement, communication and speech, emotion recognition and control, daily living skill, problem behavior reduction, attention, cost reduction, anxiety symptom reduction, pretend play, contextual processing, match to sample skill, and insomnia control. Our findings provide a solid and positive evidence of XR and Telehealth interventions in improving the treatment outcomes for children and adolescents with ASD. In the future, more research with RCTs and standardized outcome measurements are required to establish the therapeutic efficiency of the two interventions independently or combined.

A Pilot Study of Improving Self-Regulation and Social Interaction with Peers: An “Exciting School”

Social interaction skills are related to successful academic performance and mental health. One of the key elements of socio-emotional competence is self-regulation. The main aim of this study was to analyze the effect of a self-regulation program at a primary school on the social interactions of neurotypical children and children with special educational needs, from the teachers’ and parents’ perspectives. A pre-post study was conducted. The children (n = 107) followed 10 sessions, each one of 50 min, for ten weeks, between January and April 2021. To assess the changes in children’s social interaction, the Peer Social Maturity Scale was administered to the teachers. After the intervention, parents completed a questionnaire designed ad hoc to understand the effectiveness of children’s emotional self-regulation. The results showed a statistically significant improvement in peer interaction skills. The families were satisfied with the program, due to the improvement in their children’s knowledge about their own emotions and those of the other people, and the learning strategies to regulate their emotions. Likewise, parents indicated that it would be necessary to complement the program with teaching and emotional regulation strategies for them. The “Exciting School” program could help improve the social skills of school-aged children.

The Potential of AR Solutions for Behavioral Learning: A Scoping Review

In recent years, educational researchers and practitioners have become increasingly interested in new technologies for teaching and learning, including augmented reality (AR). The literature has already highlighted the benefit of AR in enhancing learners’ outcomes in natural sciences, with a limited number of studies exploring the support of AR in social sciences. Specifically, there have been a number of systematic and scoping reviews in the AR field, but no peer-reviewed review studies on the contribution of AR within interventions aimed at teaching or training behavioral skills have been published to date. In addition, most AR research focuses on technological or development issues. However, limited studies have explored how technology affects social experiences and, in particular, the impact of using AR on social behavior. To address these research gaps, a scoping review was conducted to identify and analyze studies on the use of AR within interventions to teach behavioral skills. These studies were conducted across several intervention settings. In addition to this research question, the review reports an investigation of the literature regarding the impact of AR technology on social behavior. The state of the art of AR solutions designed for interventions in behavioral teaching and learning is presented, with an emphasis on educational and clinical settings. Moreover, some relevant dimensions of the impact of AR on social behavior are discussed in more detail. Limitations of the reviewed AR solutions and implications for future research and development efforts are finally discussed.

A Review of Virtual Coaching Systems in Healthcare: Closing the Loop With Real-Time Feedback

This review focuses on virtual coaching systems that were designed to enhance healthcare interventions, combining the available sensing and system-user interaction technologies. In total, more than 1,200 research papers have been retrieved and evaluated for the purposes of this review, which were obtained from three online databases (i.e.,PubMed, Scopus and IEEE Xplore) using an extensive set of search keywords. After applying exclusion criteria, the remaining 41 research papers were used to evaluate the status of virtual coaching systems over the past 10 years and assess current and future trends in this field. The results suggest that in home coaching systems were mainly focused in promoting physical activity and a healthier lifestyle, while a wider range of medical domains was considered in systems that were evaluated in lab environment. In home patient monitoring with IoT devices and sensors was mostly limited to activity trackers, pedometers and heart rate monitoring. Real-time evaluations and personalized patient feedback was also found to be rather lacking in home coaching systems and this is the most alarming find of this analysis. Feasibility studies in controlled environment and an ongoing active research on Horizon 2020 funded projects, show that the future trends in this field are aiming to close the loop with automated patient monitoring, real-time evaluations and more precise interventions.

Effectiveness of Virtual/Augmented Reality-Based Therapeutic Interventions on Individuals With Autism Spectrum Disorder: A Comprehensive Meta-Analysis

In recent years, the application of virtual reality (VR) for therapeutic purposes has escalated dramatically. Favorable properties of VR for engaging patients with autism, in particular, have motivated an enormous body of investigations targeting autism-related disabilities with this technology. This study aims to provide a comprehensive meta-analysis for evaluating the effectiveness of VR on the rehabilitation and training of individuals diagnosed with an autism spectrum disorder. Accordingly, we conducted a systematic search of related databases and, after screening for inclusion criteria, reviewed 33 studies for more detailed analysis. Results revealed that individuals undergoing VR training have remarkable improvements with a relatively large effect size with Hedges g of 0.74. Furthermore, the results of the analysis of different skills indicated diverse effectiveness. The strongest effect was observed for daily living skills (g = 1.15). This effect was moderate for other skills: g = 0.45 for cognitive skills, g = 0.46 for emotion regulation and recognition skills, and g = 0.69 for social and communication skills. Moreover, five studies that had used augmented reality also showed promising efficacy (g = 0.92) that calls for more research on this tool. In conclusion, the application of VR-based settings in clinical practice is highly encouraged, although their standardization and customization need more research.

Mobile Augmented Reality Technologies for Autism Spectrum Disorder Interventions: A Systematic Literature Review

Over the past decade, enhanced computing capabilities and mobile technologies have begotten the upsurge of innovative mobile health (mHealth) solutions, and many research efforts have occurred recently in the area of technology-based interventions (TBI) for autism spectrum disorders (ASD). Mobile augmented reality (MAR) refers to AR systems that use the handheld mobile device medium (mobile phones, tablets or smart glasses). This article reports the results of a systematic review undertaken on the use of MAR for ASD-related skills learning from the year 2010. It aims to provide an insight into the current state of research on MAR interventions and to provide guidance to relevant designers and researchers. We searched seven databases and retrieved 625 articles initially. After exclusion and screening, 36 articles were reviewed reporting on using MAR to improve various skills of children and adolescents with ASD, and 10 research questions related to PICO (P: Population, I: Intervention, C: Comparison, O: Outcomes) were addressed. This study identifies challenges that still exist in the research efforts towards the development of applications exploiting the MAR for ASD interventions: technology issues, research design consideration, subjective assessment etc. The studies examined suggest researchers should focus on users and improve the quality of the MAR app. In addition, more effective research methods and evaluation methods could be involved in future studies to facilitate the development of MAR intervention applications.

Comprehensive circRNA Expression Profile and Construction of circRNAs-Related ceRNA Network in a Mouse Model of Autism

Autism is a common disease that seriously affects the quality of life. The role of circular RNAs (circRNAs) in autism remains largely unexplored. We aimed to detect the circRNA expression profile and construct a circRNA-based competing endogenous RNA (ceRNA) network in autism. Valproate acid was used to establish an in vivo model of autism in mice. A total of 1,059 differentially expressed circRNAs (477 upregulated and 582 downregulated) in autism group was identified by RNA sequencing. The expression of novel_circ_015779 and novel_circ_035247 were detected by real-time PCR. A ceRNA network based on altered circRNAs was established, with 9,715 nodes and 150,408 edges. Module analysis was conducted followed by GO and KEGG pathway enrichment analysis. The top three modules were all correlated with autism-related pathways involving “TGF-beta signaling pathway,” “Notch signaling pathway,” “MAPK signaling pathway,” “long term depression,” “thyroid hormone signaling pathway,” etc. The present study reveals a novel circRNA involved mechanisms in the pathogenesis of autism.

Updates in technology-based interventions for attention deficit hyperactivity disorder

PURPOSE OF REVIEW

Technological advancement has led to the development of novel treatment approaches for attention deficit hyperactivity disorder (ADHD). This review aims to review recent studies which employ the use of technology to treat ADHD, with particular focus on studies published during a 1-year period from February 2019 to February 2020.

RECENT FINDINGS

Most recent studies involved children aged 12 years and below. Interventions included cognitive training through games, neurofeedback and a combination of several approaches. More novel approaches included trigeminal nerve stimulation and brain-computer interface, and studies had utilized technology such as X-box Kinect and eye tracker. There was a shift towards delivering intervention at home and in school, enabled by technology. The study outcomes were variable and mainly included executive functioning measures and clinical ratings. These interventions were generally safe with few reported adverse events.

SUMMARY

Technology has enabled interventions to be delivered outside of the clinic setting and presented an opportunity for increased access to care and early intervention. Better quality studies are needed to inform on the efficacy of these interventions.

Computer vision in autism spectrum disorder research: a systematic review of published studies from 2009 to 2019

The current state of computer vision methods applied to autism spectrum disorder (ASD) research has not been well established. Increasing evidence suggests that computer vision techniques have a strong impact on autism research. The primary objective of this systematic review is to examine how computer vision analysis has been useful in ASD diagnosis, therapy and autism research in general. A systematic review of publications indexed on PubMed, IEEE Xplore and ACM Digital Library was conducted from 2009 to 2019. Search terms included ['autis*' AND ('computer vision' OR 'behavio* imaging' OR 'behavio* analysis' OR 'affective computing')]. Results are reported according to PRISMA statement. A total of 94 studies are included in the analysis. Eligible papers are categorised based on the potential biological/behavioural markers quantified in each study. Then, different computer vision approaches that were employed in the included papers are described. Different publicly available datasets are also reviewed in order to rapidly familiarise researchers with datasets applicable to their field and to accelerate both new behavioural and technological work on autism research. Finally, future research directions are outlined. The findings in this review suggest that computer vision analysis is useful for the quantification of behavioural/biological markers which can further lead to a more objective analysis in autism research.

The use of wearable technology to measure and support abilities, disabilities and functional skills in autistic youth: a scoping review

BACKGROUND

Wearable technology (WT) to measure and support social and non-social functioning in Autism Spectrum Disorder (ASD) has been a growing interest of researchers over the past decade. There is however limited understanding of the WTs currently available for autistic individuals, and how they measure functioning in this population.

OBJECTIVE

This scoping review explored the use of WTs for measuring and supporting abilities, disabilities and functional skills in autistic youth.

METHOD

Four electronic databases were searched to identify literature investigating the use of WT in autistic youth, resulting in a total of 33 studies being reviewed. Descriptive and content analysis was conducted, with studies subsequently mapped to the ASD International Classification of Functioning, Disability and Health Core-sets and the ICF Child and Youth Version (ICF-CY).

RESULTS

Studies were predominately pilot studies for novel devices. WTs measured a range of physiological and behavioural functions to objectively measure stereotypical motor movements, social function, communication, and emotion regulation in autistic youth in the context of a range of environments and activities.

CONCLUSIONS

While this review raises promising prospects for the use of WTs for autistic youth, the current evidence is limited and requires further investigation.

Toward Continuous Social Phenotyping: Analyzing Gaze Patterns in an Emotion Recognition Task for Children With Autism Through Wearable Smart Glasses

BACKGROUND

Several studies have shown that facial attention differs in children with autism. Measuring eye gaze and emotion recognition in children with autism is challenging, as standard clinical assessments must be delivered in clinical settings by a trained clinician. Wearable technologies may be able to bring eye gaze and emotion recognition into natural social interactions and settings.

OBJECTIVE

This study aimed to test: (1) the feasibility of tracking gaze using wearable smart glasses during a facial expression recognition task and (2) the ability of these gaze-tracking data, together with facial expression recognition responses, to distinguish children with autism from neurotypical controls (NCs).

METHODS

We compared the eye gaze and emotion recognition patterns of 16 children with autism spectrum disorder (ASD) and 17 children without ASD via wearable smart glasses fitted with a custom eye tracker. Children identified static facial expressions of images presented on a computer screen along with nonsocial distractors while wearing Google Glass and the eye tracker. Faces were presented in three trials, during one of which children received feedback in the form of the correct classification. We employed hybrid human-labeling and computer vision-enabled methods for pupil tracking and world-gaze translation calibration. We analyzed the impact of gaze and emotion recognition features in a prediction task aiming to distinguish children with ASD from NC participants.

RESULTS

Gaze and emotion recognition patterns enabled the training of a classifier that distinguished ASD and NC groups. However, it was unable to significantly outperform other classifiers that used only age and gender features, suggesting that further work is necessary to disentangle these effects.

CONCLUSIONS

Although wearable smart glasses show promise in identifying subtle differences in gaze tracking and emotion recognition patterns in children with and without ASD, the present form factor and data do not allow for these differences to be reliably exploited by machine learning systems. Resolving these challenges will be an important step toward continuous tracking of the ASD phenotype.

Self-health monitoring and wearable neurotechnologies

Brain-computer interfaces and wearable neurotechnologies are now used to measure real-time neural and physiologic signals from the human body and hold immense potential for advancements in medical diagnostics, prevention, and intervention. Given the future role that wearable neurotechnologies will likely serve in the health sector, a critical state-of-the-art assessment is necessary to gain a better understanding of their current strengths and limitations. In this chapter we present wearable electroencephalography systems that reflect groundbreaking innovations and improvements in real-time data collection and health monitoring. We focus on specifications reflecting technical advantages and disadvantages, discuss their use in fundamental and clinical research, their current applications, limitations, and future directions. While many methodological and ethical challenges remain, these systems host the potential to facilitate large-scale data collection far beyond the reach of traditional research laboratory settings.

Review and Implementation of Self-Help and Automated Tools in Mental Health Care

Self-help and automated technologies can be useful for behavioral and mental health education and interventions. These technologies include interactive media, online courses, artificial intelligence-powered chatbots, voice assistants, and video games. Self-help media can include books, videos, audible media like podcasts, blog and print articles, and self-contained Internet sites. Social media, online courses, and mass-market mobile apps also can include such media. These technologies serve to decrease geospatial, temporal, and financial barriers. This article describes different self-help and automated technologies, how to implement such technologies in existing clinical services, and how to implement according to patient needs.

The Many Channels of Screen Media Technology in ADHD: a Paradigm for Quantifying Distinct Risks and Potential Benefits

PURPOSE OF REVIEW

Individuals with attention-deficit hyperactivity disorder (ADHD) may be unusually sensitive to screen media technology (SMT), from television to mobile devices. Although an association between ADHD and SMT use has been confirmed, its importance is uncertain partly due to variability in the way SMT has been conceptualized and measured. Here, we identify distinct, quantifiable dimensions of SMT use and review possible links to ADHD to facilitate more precise, reproducible investigation.

RECENT FINDINGS

Display characteristics, media multitasking, device notifications, SMT addiction, and media content all may uniquely impact the ADHD phenotype. Each can be investigated with a digital health approach and counteracted with device-based interventions. Novel digital therapeutics for ADHD demonstrate that specific forms of SMT can also have positive effects. Further study should quantify how distinct dimensions of SMT use relate to ADHD. SMT devices themselves can serve as a self-monitoring study platform and deliver digital interventions.

Gamification in Apps and Technologies for Improving Mental Health and Well-Being: Systematic Review

BACKGROUND

There is little research on the application of gamification to mental health and well-being. Furthermore, usage of gamification-related terminology is inconsistent. Current applications of gamification for health and well-being have also been critiqued for adopting a behaviorist approach that relies on positive reinforcement and extrinsic motivators.

OBJECTIVE

This study aimed to analyze current applications of gamification for mental health and well-being by answering 3 research questions (RQs). RQ1: which gamification elements are most commonly applied to apps and technologies for improving mental health and well-being? RQ2: which mental health and well-being domains are most commonly targeted by these gamified apps and technologies? RQ3: what reasons do researchers give for applying gamification to these apps and technologies? A systematic review of the literature was conducted to answer these questions.

METHODS

We searched ACM Digital Library, CINAHL, Cochrane Library, EMBASE, IEEE Explore, JMIR, MEDLINE, PsycINFO, PubMed, ScienceDirect, Scopus, and Web of Science for qualifying papers published between the years 2013 and 2018. To answer RQ1 and RQ2, papers were coded for gamification elements and mental health and well-being domains according to existing taxonomies in the game studies and medical literature. During the coding process, it was necessary to adapt our coding frame and revise these taxonomies. Thematic analysis was conducted to answer RQ3.

RESULTS

The search and screening process identified 70 qualifying papers that collectively reported on 50 apps and technologies. The most commonly observed gamification elements were levels or progress feedback, points or scoring, rewards or prizes, narrative or theme, personalization, and customization; the least commonly observed elements were artificial assistance, unlockable content, social cooperation, exploratory or open-world approach, artificial challenge, and randomness. The most commonly observed mental health and well-being domains were anxiety disorders and well-being, whereas the least commonly observed domains were conduct disorder and bipolar disorders. Researchers' justification for applying gamification to improving mental health and well-being was coded in 59% (41/70) of the papers and was broadly divided into 2 themes: (1) promoting engagement and (2) enhancing an intervention's intended effects.

CONCLUSIONS

Our findings suggest that the current application of gamification to apps and technologies for improving mental health and well-being does not align with the trend of positive reinforcement critiqued in the greater health and well-being literature. We also observed overlap between the most commonly used gamification techniques and existing behavior change frameworks. Results also suggest that the application of gamification is not driven by health behavior change theory, and that many researchers may treat gamification as a black box without consideration for its underlying mechanisms. We call for the inclusion of more comprehensive and explicit descriptions of how gamification is applied and the standardization of applied games terminology within and across fields.

Digital Attention-Related Augmented-Reality Game: Significant Correlation between Student Game Performance and Validated Clinical Measures of Attention-Deficit/Hyperactivity Disorder (ADHD)

As many as half of school children with autism spectrum disorder (ASD) exhibit symptoms of attention-deficit/hyperactivity disorder (ADHD), resulting in marked negative academic, social, and behavioral outcomes. The focus of the US Food and Drug Administration (FDA) on real-world data from novel digital sources, and the emergence of Current Procedural Terminology (CPT) codes to reimburse for digital monitoring and neurobehavioral testing suggest an increasing acceptance of the role of technology in augmenting clinical care and research. Empowered Brain is an augmented reality and artificial intelligence-based social-emotional communication aid for students with ASD. In this study, student performance on Empowered Brain is correlated to validated clinical measures of ADHD. Seven high school students with a diagnosis of ASD were recruited from a public high school. All students were assessed for severity of ADHD-related symptoms via three clinical gold-standard assessments, namely the Aberrant Behavioral Checklist (ABC), Social Responsiveness Scale 2 (SRS-2), and Teacher Report Form (TRF). Students used Empowered Brain over a one-week period. We measured the correlation of student in-game performance (as measured by point- and star-based rewards) relative to the hyperactivity subscale of the ABC (ABC-H), and the ADHD-subscale of the TRF. All seven students completed the study and managed to successfully use Empowered Brain. Students received a culminative total of 32 sessions, an average of 4.6 sessions per student (range 2–8). Student in-game performance demonstrated highly significant correlation relative to ABC-H (points: p = 0.0013; stars: p = 0.0013), and significant correlation to TRF ADHD scores (points: p = 0.012; stars: p = 0.012). No adverse effects were noted among students who used Empowered Brain. New technologies may herald novel ways of identifying and characterizing symptoms of ADHD in student populations. This study provides evidence that Empowered Brain in-game performance correlates with ADHD symptom severity in students with ASD. Larger samples are required to validate these findings, with more diverse participants that can also widen the generalizability of these findings to a broader range of brain conditions that manifest with inattention, impulsivity, and hyperactivity. Through further research, we may find that such technologies can help us to identify and longitudinally monitor such symptoms, and potentially aid in severity stratification and digital phenotyping.

Validity of Online Screening for Autism: Crowdsourcing Study Comparing Paid and Unpaid Diagnostic Tasks

BACKGROUND

Obtaining a diagnosis of neuropsychiatric disorders such as autism requires long waiting times that can exceed a year and can be prohibitively expensive. Crowdsourcing approaches may provide a scalable alternative that can accelerate general access to care and permit underserved populations to obtain an accurate diagnosis.

OBJECTIVE

We aimed to perform a series of studies to explore whether paid crowd workers on Amazon Mechanical Turk (AMT) and citizen crowd workers on a public website shared on social media can provide accurate online detection of autism, conducted via crowdsourced ratings of short home video clips.

METHODS

Three online studies were performed: (1) a paid crowdsourcing task on AMT (N=54) where crowd workers were asked to classify 10 short video clips of children as "Autism" or "Not autism," (2) a more complex paid crowdsourcing task (N=27) with only those raters who correctly rated ≥8 of the 10 videos during the first study, and (3) a public unpaid study (N=115) identical to the first study.

RESULTS

For Study 1, the mean score of the participants who completed all questions was 7.50/10 (SD 1.46). When only analyzing the workers who scored ≥8/10 (n=27/54), there was a weak negative correlation between the time spent rating the videos and the sensitivity (ρ=-0.44, P=.02). For Study 2, the mean score of the participants rating new videos was 6.76/10 (SD 0.59). The average deviation between the crowdsourced answers and gold standard ratings provided by two expert clinical research coordinators was 0.56, with an SD of 0.51 (maximum possible SD is 3). All paid crowd workers who scored 8/10 in Study 1 either expressed enjoyment in performing the task in Study 2 or provided no negative comments. For Study 3, the mean score of the participants who completed all questions was 6.67/10 (SD 1.61). There were weak correlations between age and score (r=0.22, P=.014), age and sensitivity (r=-0.19, P=.04), number of family members with autism and sensitivity (r=-0.195, P=.04), and number of family members with autism and precision (r=-0.203, P=.03). A two-tailed t test between the scores of the paid workers in Study 1 and the unpaid workers in Study 3 showed a significant difference (P<.001).

CONCLUSIONS

Many paid crowd workers on AMT enjoyed answering screening questions from videos, suggesting higher intrinsic motivation to make quality assessments. Paid crowdsourcing provides promising screening assessments of pediatric autism with an average deviation <20% from professional gold standard raters, which is potentially a clinically informative estimate for parents. Parents of children with autism likely overfit their intuition to their own affected child. This work provides preliminary demographic data on raters who may have higher ability to recognize and measure features of autism across its wide range of phenotypic manifestations.

Improved Socio-Emotional and Behavioral Functioning in Students with Autism Following School-Based Smartglasses Intervention: Multi-Stage Feasibility and Controlled Efficacy Study

Background: Students with Autism Spectrum Disorder (ASD) commonly demonstrate prominent social communication deficits, symptoms of attention-deficit/hyperactivity disorder, and chronic irritability. These challenges hinder academic progress and frequently persist despite educational, behavioral, and medical interventions. An assistive smartglasses technology may aid these individuals, especially if the technology is efficacious in ecologically-valid school settings. This study explored the feasibility and efficacy of Empowered Brain, a computerized smartglasses intervention designed as a socio-emotional behavioral aid for students with ASD. Methods: This two-part six-week study involved four school children with ASD from a public elementary school. The study incorporated an initial three-week feasibility stage followed by a three-week controlled longitudinal efficacy stage. Both stages involved the use of a twice-daily socio-emotional intervention with the smartglasses. Educators completed pre-intervention and post-intervention Aberrant Behavioral Checklist (ABC) ratings at the start of the feasibility stage, and weekly during the efficacy stage. Primary outcome measures were improvements in the ABC subscales of irritability, hyperactivity, and social withdrawal. Results: Students in both feasibility and efficacy stages demonstrated improvements (decreases) in irritability, hyperactivity, and social withdrawal compared to a baseline period and control periods, respectively. Participants in the controlled efficacy stage demonstrated decreased ABC subscale scores of 90% for irritability, 41.6% for hyperactivity, and 45.6% for social withdrawal. An intervention exposure-response improvement in irritability and hyperactivity was found during the efficacy stage. Educators rated the technology as superior or vastly superior compared to other assistive technologies. Conclusion: A substantial number of school children with ASD demonstrate chronic and impairing cognitive and behavioral challenges. This study provides evidence that Empowered Brain, a smartglasses-based socio-emotional aid for autism, is both feasible and efficacious in improving symptoms of social withdrawal, irritability, and hyperactivity in students with autism. The improvement is demonstrated as part of a longitudinal school-based intervention. Further studies involving larger samples and incorporation of randomized controlled trial methodology are underway to further elucidate the impact of this technology.

Safety and Lack of Negative Effects of Wearable Augmented-Reality Social Communication Aid for Children and Adults with Autism

There is a growing interest in the use of augmented reality (AR) to assist children and adults with autism spectrum disorders (ASD); however, little investigation has been conducted into the safety of AR devices, such as smartglasses. The objective of this report was to assess the safety and potential negative effects of the Empowered Brain system, a novel AR smartglasses-based social communication aid for people with ASD. The version of the Empowered Brain in this report utilized Google Glass (Google, Mountain View, CA, USA) as its hardware platform. A sequential series of 18 children and adults, aged 4.4 to 21.5 years (mean 12.2 years), with clinically diagnosed ASD of varying severity used the system. Users and caregivers were interviewed about the perceived negative effects and design concerns. Most users were able to wear and use the Empowered Brain (n = 16/18, 89%), with most of them reporting no negative effects (n = 14/16, 87.5%). Caregivers observed no negative effects in users (n = 16/16, 100%). Most users (77.8%) and caregivers (88.9%) had no design concerns. This report found no major negative effects in using an AR smartglasses-based social communication aid across a wide age and severity range of people with ASD. Further research is needed to explore longer-term effects of using AR smartglasses in this population.