Background
Methods
Participants
Experimental group (N = 14) | Control group (N = 10) | |
---|---|---|
GOLIAH + TAU | TAU | |
Demographics | ||
Age, mean (±SD) | 6.85 (±1.34) | 7.17 (±1.62) |
Male–Female | 14–0 | 10–0 |
Diagnosis | Autism: N = 3 | Autism: N = 3 |
ASD: N = 9 | ASD: N = 6 | |
Asperger: N = 2 | Asperger: N = 1 | |
ADI-R, current, mean (±SD) | ||
Social impairment score | 14.14 (±4.58) | 12.3 (±4.99) |
Communication score | 10 (±5.82) | 8.6 (±4.5) |
Repetitive interest score | 4 (±2.91) | 3.5 (±2.72) |
Development score | 3 (±1.36) | 2.5 (±1.35) |
Treatment as usual | As out patient: N = 12 | As out patient: N = 9 |
In day care hospital: N = 2 | In day care hospital: N = 1 | |
Mean total hours: 15.3 h | Mean total hours: 16 h | |
TAU details, mean [range] (hours/week) | ||
Speech therapy | 0.57 [0–2] | 0.57 [0–1.5] |
Psychotherapya
| 0.33 [0–1.5] | 0.75 [0–1.5] |
Occupational therapy | 0.3 [0–1] | 0.2 [0–0.75] |
Special education (out of school) | 3.66 [0–25] | 0.4 [0–4] |
Help at school | 10.2 [0–30] | 14.7 [0–30] |
Intervention
Brief description of the GOLIAH platform
Game type | Description | ESDM stimuli | N of sessions per child: mean [range] |
---|---|---|---|
Imitation games
| |||
Imitate free drawing | Imitation of the drawing done by the online therapist/parent | (lev.4) FM 4 | 38 [0–118] |
Imitate step by step drawing | Imitation of a drawing created step by step from the online therapist/parent (three difficulties) | (lev.4) FM 4 | 14.2 [0–43] |
Imitate speech | Imitation of words or phrases from the library (three difficulties) | (lev.2) IM 3, 9 | 22.5 [0–58] |
Imitate sounds | Imitation of sounds chosen from the library (four difficulties and two categories of stimuli) | (lev.2) IM 2 | 29.5 [0–100] |
Imitate actions | Imitation of the actions with balls made by the online therapist/parent (three difficulties and two types of task) | (lev.2) IM 6 | 16 [0–35] |
Imitate actions and build | Imitation of the actions with cubes made by the online therapist/parent (three difficulties and two types of task) | (lev.3) FM 3 | 10.7 [0–28] |
Guess the instrument | Identification of the musical instruments played and chosen by the therapist/parent from the library (two difficulties) | (lev.1, 2) IM | 9.2 [0–22] |
Joint attention games
| |||
Follow the therapist’s pointing | Identification of the object indicated (verbally, visually or pointed) by the therapist on the video and chosen from the library (six difficulties and eight categories of stimuli) | (lev.1) RC 1, 4 (lev.2) JA 2, 4, 6 | 32 [0–109] |
Cooperative drawing—connect dots | The therapist and the child cooperate to complete a figure shown on the right, by clicking on the corners of the figure itself (two difficulties and four categories of stimuli) | JA | 48.6 [1–124] |
Bake a recipe | The child cooks a recipe by clicking and dragging into a bowl the ingredients chosen by the therapist/parent from the library of recipes (11 categories of stimuli) | JA | 13 [1–16] |
Receptive communication | The child identifies the objects described by the therapist/parent and chosen from the library (three difficulties and five categories of stimuli) | (lev.2) RC 5, (lev.1) RC 6, (lev.1) RC 4 | 53.4 [4–112] |
Automatic extraction of parameters from the serious game
Clinical measures
Statistical analysis
Game type (variable, n = events) | N | Time effect | Difficulty level effect | Number of items effect |
---|---|---|---|---|
Imitation games | ||||
Imitate free drawing (Imitation score per drawing—n = 562) | 13 | Imitation score increases with session (β = 0.02, p = 0.036)* | NA | NA |
Imitate step by step drawing (Imitation score per drawing—n = 198) | 13 | No effect (β = 0.13, p = 0.089)* | NA | Imitation score increases with the number of steps (β = 0.27, p = 0.047)* |
Imitate speech (Imitation score per words or sentences—n = 315) | 13 | No effect (β = 0.014, p = 0.61)* | No effect (β = −0.21, p = 0.328)* | No effect (β = −0.029, p = 0.72)* |
Imitate sounds (Imitation score per sounds—n = 452) | 13 | Imitation score increases with session (β = 0.037, p = 0.019)* | Imitation score decreases when increasing severity (β = −0.31, p = 0.014)* | No effect (β = 0.05, p = 0.41)* |
Imitate actions (Imitation score per actions—n = 161) | 13 | Imitation score increases with session (β = 0.11, p = 0.039)* | No effect (β = 0.089, p = 0.86)* | No effect (β = −0.43, p = 0.18)* |
Imitate actions and build (Imitation score per contruction—n = 227) | 13 | Imitation score increases with session (β = 0.149, p < 0.001)* | No effect (β = 0.266, p = 0.47)* | Imitation score decreases with the number of cubes (β = −0.1′, p = 0.0176)* |
Guess the instrument | 13 | Bug | Bug | Bug |
Joint attention games | ||||
Follow the therapist’s pointing (RT for good answers—n = 681) | 13 | RT decreases with sessions (β = −0.0045, p = 0.048)** | No effect (β = −0.014, p = 0.247)** | No effect (β = 0.0057, p = 0.428)** |
Cooperative drawing—connect dots (RT—n = 449) | 13 | RT decreases with sessions (β = −0.024, p = 0.045)** | NA | No effect (β = 0.0035, p = 0.51)** |
Bake a recipe (TCT—n = 748) | 14 | RT decreases with sessions (β = −0.021, p < 0.001)** | NA | NA |
Receptive communication (RT for good answers—n = 225) | 14 | No effect (β = −0.002, p = 0.776)** | RT is faster in easy versus difficult condition ( = −0.17, p = 0.021)** | NA |
Results
Acceptability and parental stress
T0 = Baseline | T6 = Outcome at 6 months | |||
---|---|---|---|---|
Experimental group (N = 14) | Control group (N = 10) | Experimental group (N = 14) | Control group (N = 10) | |
ADOS, mean (±SD) | ||||
Communication score | 3.6 (±1.7) | 4.5 (±1.5) | 2.9 (±2.1) | 3.7 (±1.6) |
Interaction score | 7.2 (±2.4) | 9.3 (±2.6) | 6.3 (±2.8) | 7.3 (±2.9) |
Total score | 10.8 (±3.6) | 13.8 (±3.5) | 9.2 (±4.6) | 11 (±4.1) |
Cognition WISC3/WPPSI | ||||
VIQ | 103.1 (±14) | 100.8 (±25.9) | 107.2 (±22.8) | 102.4 (±26.6) |
PIQ | 96.1 (±24.8) | 96.4 (±24.5) | 104.4 (±19.9) | 98.1 (±24.5) |
Speed | 93.5 (±12.6) | 90.6 (±16.2) | 97.4 (±15.3) | 90.7 (±21.9) |
Working memory | 107.6 (±21.5) | 97.8 (±28.2) | 107.4 (±23.6) | 99.2 (±27.6) |
Total IQ | 98.8 (±20.1) | 96.3 (±22.7) | 107 (±20.8) | 98.9 (±25.8) |
Vineland, mean (±SD) | ||||
Communication score | 88.2 (±16.7) | 86.2 (±13.9) | 79.6 (±11.5) | 82.8 (±6.5) |
Daily living | 84.3 (±13.4) | 85.4 (±14.7) | 79.4 (±5.5) | 83.6 (±10.8) |
Socialization | 79.5 (±10.3) | 80.1 (±11.9) | 78.3 (±10.7) | 85.3 (±8.4) |
SCQ, mean (±SD) | ||||
Total score | 11.6 (±7.7) | 11.5 (±7.2) | 10 (±6.3) | 8.6 (±7) |
CBCL T score, mean (±SD) | ||||
Withdrawn/depressed | 62.8 (±9.9) | 62.9 (±9.5) | 60.9 (±8.6) | 60.6 (±9) |
Somatic complaints | 56 (±7.7) | 59.5 (±7.5) | 54.7 (±7.6) | 57.5 (±8.3) |
Anxious/depressed | 62.8 (±8.1) | 61.2 (±9.3) | 60.5 (±7.6) | 58.6 (±10.5) |
Social problems | 68.5 (±6.5) | 66.7 (±7.4) | 63.8 (±7.3) | 60.8 (±8.2) |
Thought problems | 61.1 (±10.8) | 66.7 (±8.4) | 59.8 (±10.8) | 61.2 (±9.5) |
Attention problems | 65.1 (±9.1) | 67.4 (±9.1) | 63.6 (±9.7) | 61.1 (±9.7) |
Rule-breaking behavior | 58.6 (±7.4) | 58.1 (±6.1) | 56.5 (±6.3) | 57.4 (±6.2) |
Aggressive behavior | 60.4 (±6.5) | 64.4 (±9.2) | 57.8 (±6) | 61 (±8.5) |
Internalizing | 62.5 (±9) | 63 (±8) | 60.2 (±9.5) | 59 (±10.3) |
Externalizing | 59.1 (±8.1) | 61.7 (±7.1) | 57.7 (±7.7) | 55.9 (±11.8) |
Total | 63.9 (±8.4) | 66.5 (±7.3) | 61.2 (±8.3) | 60.5 (±11.3) |
PSI, mean (±SD) | ||||
Parental distress | 31.6 (±6.9) | 32.9 (±8.2) | 28.3 (±9.4) | 27.6 (±6.5) |
Dysfunctional interaction | 31.5 (±5.7) | 37.3 (±6.4) | 26.8 (±8.8) | 28.3 (±7.4) |
Difficult child | 37.2 (±7.3) | 39.2 (±7.2) | 29.4 (±7.3) | 30.3 (±8.2) |
Total stress | 100.7 (±15) | 105.8 (±13.6) | 85.5 (±22.6) | 86.2 (±20) |
Children’s performance across sessions and games in the experimental group
Improvement of clinical measures in the experimental versus control groups
Group effect | Time effect | Group × time interaction | |
---|---|---|---|
ADOS, mean (±SD) | |||
Communication score | −0.93 (p = 0.22) | −0.8 (p = 0.016) | 0.16 (p = 0.7) |
Interaction score | −2.07 (p = 0.071) | −2 (p = 0.008) | 1.07 (p = 0.25) |
Total score | −3.01 (p = 0.082) | −2.8 (p = 0.001) | 1.23 (p = 0.21) |
Cognitive level (WISC3/WPPSI) | |||
VIQ | 2.3 (p = 0.8) | 1.7 (p = 0.63) | 2.5 (p = 0.59) |
PIQ | −0.33 (p = 0.97) | 1.7 (p = 0.64) | 6.66 (p = 0.16) |
Speed | 2.99 (p = 0.69) | 0.11 (p = 0.98) | 3.7 (p = 0.53) |
Working memory | 9.85 (p = 0.42) | 2.14 (p = 0.49) | 2.87 (p = 0.56) |
Total IQ | 2.5 (p = 0.8) | 2.55 (p = 0.46) | 5.61 (p = 0.23) |
SCQ, mean (±SD) | |||
Total score | 0.071 (p = 0.98) | −2.9 (p = 0.054) | 1.33 (p = 0.49) |
Vineland: mean (±SD) | |||
Communication score | 8.6 (p = 0.14) | 3.2 (p = 0.27) | −5.2 (p = 0.17) |
Daily living | 4.89 (p = 0.34) | 4.2 (p = 0.19) | −3.06 (p = 0.46) |
Socialization | 1.2 (p = 0.79) | 7 (p = 0.033) | −6.29 (p = 0.13) |
CBCL T score: mean (±SD) | |||
Withdrawn/depressed | −0.54 (p = 0.99) | −2.3 (p = 0.22) | 0.38 (p = 0.88) |
Somatic complaints | −3.5 (p = 0.3) | −2 (p = 0.2) | 0.69 (p = 0.73) |
Anxious/depressed | 1.57 (p = 0.68) | −2.6 (p = 0.1) | 0.37 (p = 0.86) |
Social problems | 1.83 (p = 0.58) | −5.89 (p = 0.04) | 1.14 (p = 0.64) |
Thought problems | −5.58 (p = 0.23) | −5.44 (p = 0.12) | 4.11 (p = 0.37) |
Attention problems | 2.32 (p = 0.56) | −6.3 (p = 0.011) | 4.84 (p = 0.12) |
Rule-breaking behavior | 0.47 (p = 0.87) | −0.67 (p = 0.64) | −1.42 (p = 0.46) |
Aggressive behavior | −4.46 (p = 0.18) | −3.44 (p = 0.054) | 1.23 (p = 0.59) |
Internalizing | −0.54 (p = 0.89) | −4. (p = 0.018) | 1.77 (p = 0.4) |
Externalizing | −2.62 (p = 0.48) | −5.8 (p = 0.01) | 4.41 (p = 0.12) |
Total | −2.58 (p = 0.5) | −6 (p = 0.013) | 3.2 (p = 0.28) |
PSI, mean (±SD) | |||
Parental distress | −1.51 (p = 0.65) | −5.55 (p = 0.037) | 2.19 (p = 0.5) |
Dysfunctional interaction | −2.13 (p = 0.5) | −5.68 (p = 0.065) | 0.61 (p = 0.87) |
Difficult child | −2.67 (p = 0.4) | −9.59 (p < 0.001) | 1.8 (p = 0.41) |
Total stress | −6.4 (p = 0.42) | −20.92 (p = 0.002) | 5.7 (p = 0.47) |