Increasing participation in computer activities using eye-gaze assistive technology for children with complex needs

Figures & data

Figure 1. The study procedure and measurements at each time point. Note. T1= the beginning of the baseline phase. T2= before the intervention started. T3= at the three-month intervention, T4= at the six-month intervention, T5= one-month after the intervention ended. GMFCS = Gross Motor Function Classification System; MACS = Manual Ability Classification System; CFCS = Communication Function Classification System; GAS = Goal Attainment Scaling; COPM = Canadian Occupational Performance Measure. The study began with a workshop for therapists and participant recruitment. Then, the included participants were involved in a procedure, with a two to four-week baseline, followed by a six-month intervention and a one-month maintenance phase. The figure also presents the measurements conducted from T1 to T5.

Table 1. Participant characteristics, baseline and intervention context.

Demographic characteristics							Baseline information		Intervention context
Name, age, gender	Diagnosis	GMFCS, MACS	Cognition/ Epilepsy	CFCS	Vision/Hearing	Eye control skills: Accuracy (%), Time on Task (seconds) ^a	Baseline period	Eye-gaze device at inclusion	Main supporter/ therapist	Place
LiHao 5y7m, male	Dyskinetic CP	V, V	UI/Yes	IV	Myopia, strabismus/mild impairment	8.33%, 22.9s	14 days	Eye Tracker 4 C	Mother/PT	Home
ChiaYu 6y2m, female	Neurometabolic disorder, post gene therapy	V, V,	UI/Oculogyric crisis	V	Normal/normal	11.11%, 14.99s	17 days	Eye Tracker 4 C	Special education teacher/PT	Special class in mainstream school
ShuWen 3y8m, female	Dyskinetic CP	V, V,	UI/none	IV	Normal/normal	27.78%, 13.01s	20 days	No	Mother / SLP, PT	Home
YiFen 4y8m, female	Dyskinetic CP	V, IV,	UI/none	IV	Hyperopia, strabismus/normal	5.55%, 13.94s	23 days	No	Mother, special educator / OT, SLP	Home, once a week in the child development centre

Note. CP = cerebral palsy. GMFCS = Gross Motor Function Classification System. MACS = Manual Ability Classification System. UI = unspecified impairment. CFCS = Communication Function Classification System. PT = physiotherapist. OT = occupational therapist. SLP = speech-language pathologist.

^aEye-control skills measured by Compass Aim test [43]. Accuracy (%) was calculated using the number of selected targets divided by total 36 targets from three trials. Time on tasks (seconds) was the median value (in seconds) to successfully select a target.

Table 2. The EGAT intervention content.

EGAT intervention	EGAT devices and service delivery
What (Materials) Devices Software	Tobii PCEyeMini + laptop, adjustable table stand HelpKidzLearn or Look to Learn with different play activities Communicator 5 with adapted communication/learning/leisure pages
Who Direct support to participants Service providers Coordinator	Parents and/or teachers Therapists (PT, OT, SLP) The researcher
What (Procedure) Service delivery	Preparation: Workshops for service providers (14 h in two days), including instructions and practicum on EGAT use The researcher collected information related to the service.	Intervention activities and procedure: 1. Planning meeting • Team set individualised goals and developed intervention plan for implementing EGAT at home or in school/centre 2. Individual support • Parents/teachers were trained to set-up EGAT and software use; an EGAT manual was provided. • Parents/teachers implemented intervention plan with team support for technical, pedagogical and gaze-control problems 3. Follow-up meeting • Team jointly evaluated goals and modified strategies to meet a child’s motivation, needs and progress
How	Individually delivered
Where	Home or school/child centre
How much (services)	Planning meeting: 1 time Individual support to parents/teachers: Twice a month, total 12 times Follow-up meeting: 1 time
How much (use)	Daily use recommended

Figure 2. Duration of participation in computer activities for each participant. Note. Data were aggregated from daily to weekly average after 50 days because of space constraints. Zero performance days of data mean that the computer was available, but the participants did not use it. A hatch mark (//) indicates interruption (that is days when the intervention was usually followed but there was no opportunity because the computer was not available to the children). Horizontal solid line (blue) = level (mean) at each phase. Horizontal dash line (red) = split middle trend line at baseline. This graph displayed that ChiaYu, ShuWen, and YiFen showed a clear level (mean) change from baseline to the intervention phase, and the immediacy of effects was evident. LiHao only showed a small level change across phases, and there was no immediacy of response to the intervention.

Table 3. Computer usage at baseline and the intervention phases.

Variable	Phase	Participant
		LiHao	ChiaYu	ShuWen	YiFen
Number of days excluded for analysis	Intervention	29 days: sickness (n = 22), the family was on vacation (n = 7)	75 days: weekends & holidays (n = 47), sick leave or leave of absence (n = 19), broken device (n = 9)	9 days: sickness (n = 2), the family was on vacation (n = 7)	26 days: sickness (n = 13), the family was on vacation (n = 13)
Diversity of activities	Baseline	Play	Play, communication	Play, photos	Play
	Intervention	Play, communication, music/videos, photos, learning, activity calendar	Play, communication, language lesson, maths lesson, photos, music	Play, communication music/videos, photos	Play, communication, music/videos
Frequency:
% days with use,	Baseline	14%, 1	35%, 2	5%, 0.3	4%, 0.3
average use days per week	Intervention	37%, 2.5	71%, 3.1	34%, 2.2	50%, 3.2
Mean duration per use day (min): mean (SD)	Baseline	12.5 (10.61)	14.7 (7.26)	20 ^a	20 ^a
	Intervention:
	Overall	16.2 (11.59)	30.8 (11.71)	29.4 (11.03)	22.8 (8.92)
	From T2 to T3	12.4 (10.13)	24.5 (10.37)	24.6 (9.80)	20.9 (9.09)
	From T3 to T4	21.3 (11.57)	36.6 (9.78)	35 (9.81)	25 (8.31)

^aDuring the baseline, ShuWen and YiFen only used a computer once.

Table 4. GAS scores and the score changes of the performance and satisfaction scales of COPM at T3 and T4.

Name	Number of achieved goals	Categories of goals	GAS score		COPM change at T3		COPM change at T4
			T3	T4	Performance	Satisfaction	Performance	Satisfaction
LiHao	1/2	Goal 1: Engagement in computer play activities	0	+1	7.5	9	7	8.5
		Goal 2: Choose activities to express his wants	−1	−1
ChiaYu	2/2	Goal 1: Choose activities in school lessons and recess time	−1	0	2.3	2	3.3	2.5
		Goal 2: Respond to school learning tasks	−2	0
ShuWen	2/2	Goal 1: Engagement in computer play activities	−1	0	0.8	0.8	2	1.5
		Goal 2: Choose what to do during playtime	−1	+1
YiFen	1/2	Goal 1: Engagement in computer play activities	0	+1	3	3.5	4.5	5
		Goal 2: Choose what to do during playtime	−2	−1

Note. GAS = Goal Attainment Scaling. COPM = Canadian Occupational Performance Measure.

Appendix Individualised content of EGAT use at the beginning and the end of the intervention phase

Name	Beginning of intervention	End of intervention
LiHao	Communication: 2–6 symbols/page; Play, leisure: 2–12 pictures/page; Total 102 pictures/photos/PCS symbols	Communication: 2–6 symbols/page; Play, leisure: 2–12 pictures/page; Learning: 2–9 pictures/page. Total 143 pictures/photos/PCS symbols
ChiaYu	Communication: 2–4 symbols/page; Learning: 1–4 pictures/page; Play, leisure: 3–12 pictures/page. Total 111 pictures/photos/PCS symbols	Communication: 2–6 symbols/page; Learning: 1–5 pictures/page; Play, leisure: 3–12 pictures/page. Total 204 pictures/photos/PCS symbols
ShuWen	Communication: 2–4 symbols/page; Play, leisure: 2–12 pictures/page; Total 62 pictures/photos/PCS symbols	Communication: 2–8 symbols/page; Play, leisure: 4–12 pictures/page; Total 112 pictures/photos/PCS symbols
YiFen	Communication: 2–4 symbols/page; Play, leisure: used Look to learn mostly, other pageset: 2–12 pictures/page; Total 46 pictures/photos/PCS symbols	Communication: 2–4 symbols/page; Play, leisure: used Look to learn, other pageset: 2–12 pictures/page; Total 69 pictures/photos/PCS symbols

Note. PCS = Picture Communication Symbols.

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