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1 CRITICALLY APPRAISED PAPER (CAP) Kim, E. S., Berkovits, L. D., Bernier, E. P., Leyzberg, D., Shic, F., Paul, R., & Scassellati, B. (2013). Social robots as embedded reinforcers of social behavior in children with autism. Journal of Autism and Developmental Disorders, 43, CLINICAL BOTTOM LINE: Children with autism spectrum disorders (ASD) frequently display deficits in social interaction and social communication, which can severely affect their functional independence in activities of daily living and their participation in meaningful occupations. Many occupational therapy interventions attempt to address social deficits through play activities targeting specific prosocial behaviors (e.g., sharing, reciprocal communication). Evidence suggests that embedding social interaction into motivating activities can stimulate greater social initiation, nonverbal orientation to a partner, and positive affect in individuals with ASD. This study s findings indicate that the presence of a social robot motivates and facilitates social interaction with another person by eliciting speech directed socially toward an adult partner. Although further research should address the long-term benefits of social robots with children with ASD, this study indicates the positive short-term effects that interaction with a robot can have on social behaviors. Because social robots represent novel technology items, their use as an embedded reinforcer presents a potential avenue for occupational therapists to motivate clients participation in social skills and communication interventions. As pediatric occupational therapists continue to seek out interventions and supplemental tools to refine their practice, they should consider including social robots as an instrument to enhance their scope of practice and facilitate social interactions among individuals with ASD. Because robotic technology can be used in a variety of practice settings, occupational therapists should consider adding this tool to augment human-delivered social and communication skills therapy interventions with people with autism. RESEARCH OBJECTIVE(S) List study objectives. To answer the following questions: In children with ASD, what is the effectiveness of social robots as embedded reinforcers of social behavior? 1

2 What are the beneficial effects of social robots on social behaviors across a broad range of children with autism? To what extent do social robots elicit social engagement directed toward the robot itself and motivate or facilitate social interactions with another person? DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Randomized controlled trial; crossover experiment SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Participants were recruited from two continuing studies at a university-based clinic that specialized in treatment, assessment, and planning for children with ASD. On volunteering, participants were chosen to take part in the study on the basis of the inclusion and exclusion criteria listed below. Inclusion Criteria Chronological age of 4 to 12 years and a previous diagnosis of high-functioning ASD, which was defined as having an IQ of 70 or above and verbal fluency that included utterance production of three or more word phrase utterances. Exclusion Criteria Below-threshold IQ measurement, failure to meet Autism Diagnostic Observation Schedule criteria for ASD SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 24 #/ (%) Male 21 (87.5%) #/ (%) Female 3 (12.5%) Ethnicity Twenty participants were non-hispanic White, 2 were non-hispanic Black, and 2 were Hispanic or Latino. Disease/disability diagnosis 20 met ADOS criteria for autism, 4 met Autism Diagnostic Observation Schedule (ADOS) criteria for ASD INTERVENTION(S) AND CONTROL GROUPS Group 1: Adult interactional condition Brief description of the intervention How many participants in the group? Where did the Semistructured condition in which children manipulated multicolored, interlocking blocks with an adult, with a confederate present to guide the participant and adult in several interactions 8 At a 3-ft square table, with the participant and confederate sitting at 2

3 intervention take place? Who Delivered? How often? For how long? adjacent sides and the adult interaction partner at other side of the table Adult confederate, whose role was to guide the participant through an ordered, standard set of activities and cognitive probes through instruction, direction of when to deliver cues and affirmations, and questions to the adult One time; order determined by random assignment but then rotated through each of three conditions 6 min Group 2: Robot interactional condition Brief description of the intervention How many participants in the group? Where did the intervention take place? Who Delivered? How often? For how long? Semistructured condition in which children manipulated multicolored, magnetically linking tiles with Pleo robot, an affectively expressive toy dinosaur robot that was preprogrammed with 10 socially expressive behaviors (motor movements and speechlike vocal recordings). A confederate was present to guide the participant in several interactions, and the robot was manipulated with a real-time remote control operated by an adult interaction partner in the room (hidden by a clipboard). 8 At a 3-ft square table, with a participant and confederate sitting at adjacent sides and the adult observer with remote in a corner of room Adult confederate, whose role was to guide the participant through an ordered, standard set of activities and cognitive probes through instruction, direction of when to deliver cues and affirmations, and questions to the robot One time; order determined by random assignment but then rotated through each of three conditions 6 min Group 3: Computer game interactional condition Brief description of the intervention How many participants in the group? Semistructured condition in which participants moved and turned tangrams by dragging or tapping; a confederate was present to explain the goal of the tangrams game and show the participant how to use the touch-screen system to manipulate tangrams but then stopped initiating conversation with the participant, unless a request was made 8 3

4 Where did the intervention take place? Who Delivered? How often? For how long? At a 3-ft square table, with a participant and confederate sitting at adjacent sides and the adult observer in a corner of room Confederate explained the goal of the tangrams game and showed the participant how to manipulate the objects using a stylus or finger, then stopped interaction unless the participant asked for assistance One time; order determined by random assignment but then rotated through each of three conditions 6 min Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Co-intervention: Timing: Site: All participants were randomly assigned to condition grouping and received all conditions; no order effect was recorded. Same setting used for all three conditions Use of different therapists to provide intervention: Same confederates and adults used in all conditions MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Name/type of Mini digital video camera on stationary tripods measure used: 4

5 What outcome was measured? Is the measure reliable? Is the measure valid? When is the measure used? Number of utterances produced by participants, judgments about to whom utterances were directed YES YES Recordings were analyzed after all participants rotated through each of three conditions. Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Recall or memory bias. Check yes, no, or NR, and if yes, explain. Others (list and explain): Sampling bias: The study included only participants with high-functioning ASD, and the sample population was primarily non-hispanic White. Further research should include a broader sample of ethnic minority groups and levels of functioning. RESULTS List key findings based on study objectives Include statistical significance where appropriate (p<0.05) Include effect size if reported The main effect of interactional condition (robot, adult, or touch-screen computer game) on total number of utterances produced by each participant in each interactional condition was significant (p <.001). Participants produced more utterances during the robot condition (M = 43.0, SD = 19.4) than during the adult condition (M = 36.8, SD = 19.2), and they produced more utterances in both the robot and the adult conditions (p <.001) than in the touch-screen computer game condition (M = 25.2, SD = 13.4). Participants directed significantly more utterances toward the robot, t(23) = 5.40, p <.001, and toward the adult, t(23) = 8.22, p <.001, than toward the touch-screen computer game (M = 0.5, SD = 0.8). \Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. 5

6 Although the results seem significant (p <.05), no discussion of statistical power was provided. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES In bar graphs and written format Was the percent/number of subjects/participants who dropped out of the study reported? YES Limitations: What are the overall study limitations? The authors of the study noted limitations in its sampling and measurement. Even though the sample size was relatively larger in than previous studies, the study included only individuals who were deemed to be high functioning and who could produce adequate speech, which limits the study s generalizability to individuals across the entire autism spectrum. Although this study accurately measured and confirmed utterances made by participants in each of the three conditions, measurements were only made on a quantitative basis, and the authors failed to consider the content of the utterances, which could alter qualitative results of the effectiveness of robot interactions. To that end, the increased production of speech in the robot condition indicates a one-time short-term effect and does not necessarily predict long-term effects of the use of social robots as supplemental therapeutic tools. Although the use of Wizard of Oz robot technology in this study is highly advanced in its automaticity, training in this robotic control paradigm is complex and difficult to master, so future research is needed in automation and customization of robots to address the spectrum of social communication needs of individuals with ASD. Finally, it is unclear to what extent the novelty of the social robot affected the motivation and engagement of participants and whether the increased speech production in these conditions can be generalized to social interactions with familiar and unfamiliar adults. CONCLUSIONS State the authors conclusions related to the research objectives. The findings of this study suggest that social robots may be useful to supplement social skills and communication interventions for children with ASD. Provided proper guidance by an adult 6

7 facilitator, a robot can be used as an embedded reinforcer to elicit greater verbalization compared with other, less-preferred interactions (e.g., an unfamiliar adult human partner). Through the use of utterance recordings, study results show that a sample population of children with ASD spoke more frequently to the social robot than to the adult interaction partner. As an embedded reinforcer, the robot might have heightened recorded verbalizations in the children with ASD through a novelty effect, thus increasing social behaviors. Given the innovative nature of this study, it is unclear to what extent its results can be generalized to social interactions with humans. Because social robots are viewed as engaging technology, it is uncertain whether real-time, uncontrolled human interactions would produce similar effects. It should be noted that the intended use of social robots supplements other intervention techniques and should not serve as a replacement for human interaction and social skills practice. Further research is needed to determine whether increased social interaction with robots translates to increased human social interaction, thus indicating transferrable effects on social communication among individuals with ASD. This work is based on the evidence-based literature review completed by S. Hanlon Myers, OTS, and Sarah-Jeanne Salvy, PhD, Faculty Advisor, University of Southern California. CAP Worksheet adapted from Critical Review Form Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: 7

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