Computer-based intervention in autism spectrum disorders
Author:
Dr Sven Bцlte - Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
Sven Bölte, Ph.D., is assistant professor and clinical neuropsychologist at the department of child
and adolescent psychiatry and psychotherapy at Johann Wolfgang Goethe-University, Frankfurt
am Main, Germany. He is a senior researcher in autism spectrum disorders and has published
more than 70 original articles, reviews, book chapters and assessment tools in the field. One of
his special interests is computer-based intervention. He recently published the first intervention
study in autism using functional neuroimaging for evaluation
Abstract:
Sven Bölte, Ph.D.
Department of Child and Adolescent Psychiatry
Johann Wolfgang Goethe-University, Deutschordenstr. 50, D-60528 Frankfurt/M., Germany
E-mail: Boelte@em.uni-frankfurt.de or Boelte@telia.com
Tel.: 0049.69.6301.5408 Fax: 0049.69.6301.5843
Individuals who suffer from autism spectrum disorders (ASD) are impaired in reciprocal social
interaction and communicative interchange. ASD are chronically disabling conditions, for which to
date no cure has been found, although some behaviour-based interventions have proven to result
in major quantitative behavioural improvements. Computer technology promises to be of
substantial value in autism intervention. The availability of evaluated computer programs to
facilitate cognitive and social-communicative behaviour in autism spectrum disorders is still
limited. In this article, a review regarding the development and evaluation of computer-based
intervention in autism is given. Recent studies on computer-aided programs aiming to promote
literacy skills, social cognition and emotion recognition are summarized. All studies show
optimistic results, but the problem of limited generalization of accomplished effects is often
discussed. It is concluded that computer-aided treatment of autism houses a large potential for
helping affected individuals to acquire underdeveloped capacities, if certain key elements are
taken into account.
Full Paper:
INTRODUCTION
Pervasive developmental disorders, increasingly also called autism spectrum disorders, are
severe, early-onset neurodevelopmental conditions, primarily characterized by impairments in
social interaction and reciprocal communication. According to the behaviour descriptions of the
syndromes in DSM-IV-TR and ICD-10, a prototypic individual with core autism (299.0; F84.0) may
be very limited in showing interest in people, being empathic, making social overtures,
responding to others and sharing enjoyment or attention. In addition, speech perhaps is delayed
or deviant, eye contact unusual, gesturing and facial expressions poor or awkward. Aside from
the social and communicative features, autism is associated with stereotyped, repetitive,
restricted or bizarre behaviours, activities and interests. The latter includes obsessive ritualistic
patterns, hand and finger or other mannerisms, unusual curiosity in sensory stimuli (e.g. smells,
sounds), being extraordinarily tied to special objects or excessively engaged in specific topics and
self-mutilation.
Although, deficits mentioned here are are less grave in the more able end of the spectrum (e.g.
Asperger’s syndrome), these subjects still suffer from a basic lack in the capacity to socialize, to
hold mutual conversations, comprehend social conventions and grasp concepts like irony and
cynicism. Thus, all ASD are linked to a comparably low level of adaptive behaviour and outcome
in later life (Howlin & Goode, 1998). Best predictors for outcome are speech capacity and IQ in
pre-school age (Gillberg & Steffenburg, 1987).
ASD are qualitatively chronic conditions, for which no complete cure has yet been found. On the
other hand, ASD manifest at a broad range of phenotypes with multiple accompanying
comorbidities and differing trajectories in single cases. Indeed, in a substantial minority of
affected individuals, adaptive behaviour can reach a considerably high level, with independent
living, employment and even stable partnerships in adulthood. Hence, it is evident that most
individuals with autism are not totally blank concerning interpersonal exchange, but do engage in
social participation to a certain degree (Kennedy & Shukla, 1995; McGee, Feldman & Morrier,
1997).
Fundamental social communication deficits are a hallmark of ASD, but it seems that individuals
with autism are able incrementally to learn some basic social behaviours by guidance (Paul,
2003) and that many affected suffer from their lack of social integration (Bauminger &Kasari,
2000).
INTERVENTIONS FOR AUTISM SPECTRUM DISORDERS
The interventions offered for autism are numerous. However, if approaches which lack sufficient
empirical support are subtracted,, the number of treatments quickly becomes relatively clear
(Bölte & Poustka, 2002). Even for some interventions which are favoured by the scientific
community (e.g. Carol Gray’s “Social Stories”), the evidence base is sometimes small.
The fact that ASD are biologically-based psychiatric disordersdoes not imply that behavioural
intervention must be useless. On the contrary, global comprehensive behavioural therapy has
shown to be the most effective in reducing autistic behaviours, while psychopharmacological
treatments have solely demonstratedlimited significance.
A range of medications that have been claimed to have dramatically positive effects on autism
(e.g. secretin) do not hold up in controlled clinical trials (e.g. Chez et al., 2000). A standard
medication is never indicated in autism,because no controlled clinical study has yet convincingly
shown any major effect on the social and communicative symptoms of ASD. On the other hand,
in a variety of cases drugs are beneficial or necessary in the handling of extremely stereotypical
behaviour, self-injury, temper tantrums and co-existing problems such as epilepsy, restlessness
andhyperactivity or depressive episodes.
There is now a rich literature on the utility of several global and circumscribed behaviour-based
interventions for ASD (Rogers, 1998). Reviewing the literature of behaviour-based interventions
for children (< 8 years) with autism between 1996 and 2000, Horner et al. (2002) found
reductions by up to 90 % on all kinds of problem behaviour. Decreases of 80 % or greater were
reported in half to two thirds of the studies.
However, large-scale and thoroughly designed long-term and comparative treatment studies are
still rare and more data are required to explore the mechanisms and efficacy in depth. Moreover,
such treatments may not reach all children within the autisticspectrum (Smith et al., 1995). Even
for the well-known and widely applied models (e.g. ABA, TEACCH) more scientific data needs to
be collected.
On the basis of existing research, some general principles have emerged, being integrative parts
of most successful programmes to improve the social behaviour of individuals with autism (Table
1). Several literature reviews (e.g. McConnell, 2002) have pointed out that training in multiple
settings (home, school, clinic) and by different facilitators (parents, teacher, therapist), prompting
and reinforcement of social interaction and later fading of support, peer mediation, extensive
rehearsal, transparency and predictable structure of the training and the environment, as well as
prior functional, do favour the benefit of treatment.
Those principles can be realized through different avenues of intervention. Four general
strategies can be distinguished in behaviour-based intervention in ASD. First, procedures that
increase the probability of functional behaviour appearing by contingently reinforcing it, perhaps
with prior modelling. Second, procedures to minimize reinforcement of aversive behaviour. Third,
procedures targeting the minimimalization of aversive stimuli in the environment and the daily life
of autistic subjects to prevent dysfunctional behaviour. Fourth, strategies trying to modify
behaviour by instruction and self-management.
Table 1. Characteristics of successful behaviour intervention in autism spectrum
disorders
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Training in multiple settings (home, school, clinic)
Multiple facilitators (parents, teacher, expert)
Prompting, reinforcement and fading
Peer mediation (especially educated peers)
Extensive rehearsal
Transparency and predictable structure of training/environment
Prior functional analysis
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Excessive behavioural patterns, like stereotypic, disruptive and self-injurious behaviour have
apparently been investigated the most among the symptoms often encountered in ASD. This is
perhaps because these patterns can appear more dramatic than the social and communicative
problems in the first place and more accessible through functional analysis. Moreover, they can
absorb a lot of time and prevent autistic children from showing adaptive behaviour. In the case of
severe auto-mutilation, such features may even be a serious threat to the child’s health, requiring
urgent action. There is evidence for an inverse relationship between stereotypic, restricted and
pro-socialbehaviour (e.g. Koegel et al., 1992).
Even though there might be a surplus of studies on the efficacy of behaviour-basedreduction of
stereotypies in autism, the treatment of social and communicative deficits is, at long last, the main
interest of intervention in ASD. Within this array of intervention efforts, a mounting number of
approaches focus on the teaching of social skills and Theory of Mind (ToM) -abilities in older and
more able people with ASD, particularly individuals with Asperger 's syndrome and highfunctioning autism.
Unfortunately, for this quite large group of affected subjects, adequate intervention methods have
been rather neglected in the past. Typically, in social skills approaches, instruction-based
intervention, self-monitoring and perception, topic-centred peer- mediated group activities, video-
modelling, explicit teaching of ToM competencies (Ozonoff & Miller, 1995; Hadwin et al., 1996)
and social conventions are pivotal techniques.
In their intervention guidelines for students with Asperger's syndrome, Klin and Volkmar (2000)
also stress the need to improve pragmatic conversational rules and prosody.
COMPUTER TECHNOLOGY AND AUTISM SPECTRUM DISORDERS
There is no doubt that computers have revolutionized the world. Also for clinical child and
adolescent psychology and psychiatry, the introduction of computer technology has meant a
considerable change regarding assessment and intervention.
In the past few years, computers have become tools with which more and more people are
experienced and prices have fallen to a broadly affordable level. There are numerous areas
where the application of computers in research and practice are potentially useful. Not to mention
the Internet as an extraordinary source of communication between experts and parents.
In diagnostics, computer-based psychometric testing and expert systems are already well
established. For some psychiatric disorders, also, the use of computer programs for training
purposes is becoming a standard procedure, e.g. computer facilitated programs to increase
phonological awareness, reading and spelling skills in learning disorders.
However, well-standardized and evaluated treatment programs are still scarce. In the latest
edition (4th) of the leading textbook “Child and Adolescent Psychiatry” by Sir Michael Rutter and
Eric Taylor (2002), the index of the book comprising 1209 pages does not include a single
reference to computer-based intervention.
Although improving, the research on, and development of, specific computerprograms for the
treatment of ASD is still in its infancy. Already over twenty years ago, Panyan (1984) emphasized
why computers may be particularly appropriate for individuals with autism. For instance, he
pointed out the computer’s role in improving the motivation and co-operation of autistic
individuals. Indeed, later studies have consistently shown that subjects with autism displayed
more interest in computers than in toys and preferred computer instruction when alternatively
offered a personal instruction (Bernard-Opitz et al., 1990; Chen & Bernard-Opitz, 1993).
Furthermore, people with ASD do not just seem to be more attentive or less resistant to
computers (Williams et al., 2002) than to teachers, but also show a superior learning result
(Moore & Calvert, 2000).
These results are promising, but the use of computer for therapy matters has also raised
legitimate concerns. The core critique is that computers could enhance social withdrawal and
obsessive behaviour. Although there is a certain risk of such a consequence, computer
intervention has never been intended as a substitute but rather as a supplement to intervention
involving people. In fact, some studies have also reported that the support of assistants is crucial
for effective computer learning (e.g. Jordan & Powell, 1990a/b; Romanczyk et al., 1992).
Overall, there are multiple advantages of computers for intervention settings (see Table 2),
indicating that it would be negligent not to see them as an opportunity for treatment practice. For
instance, as subjects with autism probably have problems in automatically ignoring irrelevant
stimuli and forming a globally meaningful gestalt perception, computers may be a good medium
to present optimal, adaptive learning contexts for each child, with the option slowly to increase the
level of complexity.
Computers give predictable responses, are “fair” (all users are treatedequally) and do not
demand swift in vivo social behaviour that could overtax people with autism. Via computers, a
wide range of social and communicative behaviours can be trained in protected and safe virtual
realities, to prepare for development in real-life situations. Last but not least, tasks can be
repeated without fatiguing the trainer.
Table 2. Advantages of computer usage in autism
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Highly motivating (preferred education form)
Possibility of only presenting relevant (limited) information
Material can be selected to match cognitive ability
Freedom from social demands
Fair medium
Provision of consistent and predictable responses
Rehearsal without trainer fatigue
Active control over the pace of learning
Multiple virtual real-world simulations possible
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COMPUTER PROGRAMS IN AUTISM INTERVENTION
Since the 1960s, the utility of computers to facilitate adaptive behaviour in autism has been
investigated (Ferster & DeMyer, 1961; Colby, 1973; Russo et al., 1978). At first, studies were
relatively optimistic but did not lead to straightforward furtherdevelopments. In recent years, more
elaborate programs and evaluation studies of computer-aided intervention have become
available, focusing on literacy as well as social communicative skills and emotion detection (Table
3).
Literacy
From a Scandinavian group, various publications are available regarding the training of reading
and spelling skills in autism. Heimann et al. (1995) examined the utility of an interactive
microcomputer program called “Alpha”. Three groups of children were taught reading and
communication skills: 11 autistic children, 9 children with mixed handicaps (cerebral palsy,
learning disabilities) and 10 normal pre-school children. The children received a computer
instruction comprising a series of animated nouns and verbs in sentence creations, in addition to
their regular reading and writing lessons. After familiarization, the groups had 20 sessions of 30
minutes training over a period of three months. A pre-test (after familiarization), and two posttests (at the end of training, after six months) were performed, including reading samples,
sentence imitation, sound synthesis and ratings of communication and autistic symptoms.
Moreover, videotaping of the children’s communicative behaviour was carried out (start and posttest 1). The autistic group showed significant gains on the measures for reading and phonological
awareness during the intervention, but not at follow-up. The study concluded that the program is
valuable in teaching communicative behaviour in autistic and otherwise disabled children, but that
the treatment should be individualized and monitored in clinical practice.
The same research group (Tjus et al., 1998) also evaluated another multi-media program (“Delta
Messages”) for enhancing literacy skills in children with autism. Thirteen autistic children received
training with the Delta Messages program, as a supplement to their regular reading and language
lessons. No control groups were included. Fifteen training sessions of 15 to 30 minutes were
carried out over three to four months. The authors report substantial gains on the scales applied
to ensure effect during the treatment and partially at follow-up. Tjus et al. (2001) also conducted
an in-depth look at the videotaped teacher-child interactions during the training program.
According to their observations, the children with autism exhibited a significant increase in verbal
expression, enjoyment and willingness to seek assistance during the course of the training. There
was a tendency for individuals with higher language ability to get more help and attention than
children with low communication skills.
In a well-designed pilot study, Williams et al. (2002) observed the development of eight autistic
pre-school children’s reading skills during specialist teaching. The focus of the study was on the
comparison of computer-instructed learning versus book-based learning. An observation
schedule to register autistic behaviours was developed and tested for sufficient interrater
reliability (kappa = .68). Participants were roughly matched according to ratings in the Autism
Diagnostic Interview-Revised (Lord et al., 1994). The probands were randomly assigned to the
computer or book condition and then crossed over after half of the training (10 weeks). By the
end of the training, four of eight probands, who could not read prior to the intervention, could
recognize and read out loud at least three words. Findings showed that all eight children were
more able to focus when in front of the computer. On average, the children were three to four
times more attentive to the computer than to the book teaching. Interestingly, communicative
behaviour (pointing, gesturing, showing) was also dramatically higher in the computer condition,
while at the same time stereotypic behaviour decreased.
Social cognition and emotion perception
Swettenham (1996) examined the usefulness of a computer-based training version of the classic
Sally-Anne false belief task to teach the understanding of basic Theory of Mind abilities. The
effect of the program on three groups was recorded: eight healthy children, eight children with
Down’s syndrome and eight children with autism. Only probands were included for the study who
had initially failed to pass several false belief task scenarios. After the computer-aided training
,all three groups were able to pass the close transfer false belief task (Sally-Anne). However,
only the children with autism were still unable to solve the distant transfer false belief tasks
following the training. Overall, the results indicate limited effects of the program. Especially,
generalisation of training effects could not be found. Thus, the authors speculate, the autistic
children had not really learned to understand the ToM problem, but had developed an alternative
coping strategy to pass the Sally-Anne task.
Silver and Oakes (2001) carried out a randomized controlled trial to evaluate the effect of a
computer program entitled “Emotion Trainer”, developed to train individuals with autism and
associated disorders to recognize and predict the emotions of other people.
Two randomly allocated groups of 11 adolescent children with infantile autism or Asperger's
syndrome recruited at special schools were examined. One group received emotion recognition
training using the Emotion Trainer in ten 30 minutes sessions over two to three weeks, while the
other group did not get any computer training. The program consists of four modules showing
facial expressions in a number of situations,which are connected to specific tasks, e.g. decide
whether a situation would make a person angry, happy, sad or afraid. Group comparisons
showed a substantial reduction in errors made in the emotion tasks of the computer program
during the training phase. In addition, the trained probands were assessed pre- and postintervention using three independent outcome measures - namely judging facial expression
photographs, cartoons depicting emotion-laden situations and non-literal stories - and they
improved on all three criteria, compared to the control group.
Bernard-Opitz et al. (2001) presented eight social problems on a computer to eight pre-school
children with autism and eight matched normal children. In six probe and 10 training sessions, the
participants were instructed to find solutions to animated social problem scenes. Children could
choose from a range of given solutions or provide own. In the training sessions, the standard
problem solutions were carefully described by the trainer and then illustrated via a computer. The
latter was not the case in the probe sessions. Compared to matched peers, autistic children
produced markedly fewer alternative problem solutions in the probe and training sessions.
Nevertheless, a steady increase of ideas was present during the probe sessions. The authors
concluded that computers were useful tools to teach social problem solving to young children with
autism and normal peers.
Bölte and colleagues (2002, 2006) report the development and evaluation of a computer-based
program to teach and test the ability to identify facially expressed basic emotions on different
levels, called the “Frankfurter Test und Training des Erkennens von fazialem Affekt” (FEFA). It
uses the cross-cultural concept of seven fundamental emotional states (happy, sad, angry,
surprised, disgusted, fearful, neutral) by Paul Ekman and colleagues (Ekman, Friesen, &
Ellsworth, 1972) for judging emotion in photographs of whole faces and eye regions, respectively.
The FEFA-training module comprises about 500 facial emotion teaching items on three
description levels. On level 1, the test and the training module use comparable stimulus material,
but correct judgments in the training section are followed by visual and acoustical reinforcement.
If the given answer is incorrect, a feedback button appears on the screen. Clicking on the link
leads to an explanation of the item solution (level 2). A further in-depth engagement in the
specific emotion is provided by the opportunity to look at a comic-strip and again choose the
specific corresponding emotion (level 3). The normed FEFA-test module comprises a series of 50
items for faces and 40 items for eyes, showing good to excellent internal consistency and stability
(rt t .89). As one point is given for each correctly classified emotion, the maximum score is 50 for
the face and 40 for the eyes test.
To evaluate the efficacy of the FEFA, a sample of 10 adolescent and adult male individuals with
high-functioning autism or Asperger's syndrome was collected. One half of the sample was
randomly assigned to receive FEFA treatment while the other half of the sample served to control
for possible confounding effects. The training ran over a period of five weeks, consisting of two
hours training a week. To evaluate the effect of the FEFA training module, the test module of the
FEFA was applied. Furthermore, BOLD-fMRI changes in the fusiform gyrus region of the brain
and other regions of interest as well as behavioural facial emotion recognition measures were
assessed before and after training. No significant activation changes in the fisiform were
observed. Trained subjects showed marked behavioural improvements on the FEFA-test, which
were accompanied by higher BOLD-fMRI signals in the superior parietal lobule and maintained
activation in the right medial occipital gyrus.
Golan and Baron-Cohen (2006) examined the effect of their “Mind Reading” program (BaronCohen et al., 2002) in a sample of adults with Asperger 's syndrome (AS) and high-functioning
autism (HFA). The program is an interactive systematic guide to emotions, including both
complex emotions in faces and voices. Mind Reading comprises 412 human emotions each
illustrated by 6 actors through the face, voice and mimi-stories. The program was evaluated in a
sample of 19 subjects and 22 controls with HFA or AS and 24 normative controls at their homes
for 10 to 15 weeks.
Participants were tested on recognition of faces and voices at three different levels of
generalization. The intervention group improved significantly, but generalization was less
convincing. The authors conclude that using Mind Reading for a relatively short period of time
allows users to learn to recognize a variety of complex emotions and mental states, although
additional methods are required to enhance generalization.
Mitchell et al. (2006) used virtual café and bus scenes for teaching social understanding to six
adolescents with ASD. Participants also watched sets of videos of real café and bus
environments. They were asked to judge where they would sit and explain why. Ten naive raters
independently coded participants’ judgments and reasoning. In direct relation to the timing of
virtual environment use, there were several instances of significant improvement in judgments
and explanations about where to sit, both in a video of a café and a bus. According to the
authors, the results demonstrate the potential of virtual reality for teaching social skills.
In another study by the same group, Parsons et al. (2005) applied virtual environments in
educational contexts for people with ASD. A sample of 12 adolescents with ASD, and matched
comparison participants were studied. Participants were presented with virtual environments to
assess whether they adhered to particular social conventions, such as not walking across grass
and flowerbeds en route to a café, or not walking between two people (involved in conversation)
en route to the bar. Whilst a significant minority of the ASD group adhered to the social
conventions, others displayed substantial “off-task” behaviour and a limited understanding of the
virtual environments. Thus, in addition to their other study, the authors suggest that some
individuals with an ASD, with low verbal IQ and weak executive ability, require extra support to
complete tasks successfully in virtual environments.
BRIEF CONCLUSIONS
Computer technology may be a valuable tool in supporting individuals with autism to enhance
their communicative, social and other abilities. The review of studies on computer programs for
people with ASD presented here demonstrates quite consistently that medium to large
behavioural gains can be expected when circumscribed skills are trained.
Unfortunately, most available programs and corresponding evaluations reportdifficulties in
generalization of effects. However, at least one study using virtual reality (Mitchell et al., 2006) did
not encounter limited generalization. In addition, convincing examples of the utility of virtual reality
for therapeutic purposes have also been presented for other psychiatric problems (e.g. anxiety
disorders; Rothbaum & Hodges, 1999). Therefore, the issue of generalization might be solved by
more elaborated program concepts.
In line with this presumption, Parsons and Mitchell (2002) provide an enthusiastic report of virtual
reality’s potential for social skills training in autism. In their view, computers may be ideal for
practicing socio-communicative behaviour by role-play in a safe environment. They outline crucial
elements for a successful social skill training, which might also be realized (or even better
realized) via a computer. (Table 4).
Table 4. Key elements of successful social skills training (Parsons & Mitchell, 2002)
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Repetition of the target skill or task
Rote learning of social rules
Fading of prompts over time
Verbal instruction/explanation of the social skill
A consideration of how one’s own behaviour impacts on others
Practise skills in realistic settings
The ability to practise the skill across contexts
Role-play of target behaviours
Accessibility and ease of use for schools and teachers
Affordability for home and school environments
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In addition to their list, I believe that the following criteria should be fulfilled: First, social tasks
should be available on a continuum from elementary to complex (a large pool of critical and every
day situations), so that tailored training is possible. Second, the program should be
conceptualized in such a way that it can be applied to single subjects or groups of people. If all of
these aspects can be realized, computer-based programs could emerge as standard procedures
for autism intervention in the future.
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