Multi-Touch Collaborative Gesture Recognition Based User Interfaces as Behavioral Interventions for Children with Autistic Spectrum Disorder: A Review

This paper addresses UI (User Interface) designing based on multi-touch collaborative gesture recognition meant for ASD (Autism Spectrum Disorder) - affected children. The present user interfaces (in the context of behavioral interventions for Autism Spectrum disorder) are investigated in detail. Thorough comparison has been made among various groups of these UIs. Advantages and limitations of these interfaces are discussed and future directions for the design of such interfaces are suggested.

. The symptoms of Autism start to appear before the child is three years old [1].
The disorder is hence diagnosed and cured in the early childhood. If not done so, the child takes the impairments along to his adulthood. This hinders his practical life up to the point that the disorder takes severe shapes. A survey done in the year 2010 tells that the ratio of children with ASD has risen to 1 in 88 in the US [2]; while an incidence rate of 1,755 ASD cases was extrapolated for the population of Pakistan [3].
Multi touch screens are an innovation to the world of technologies for Autistic support. Contrary to the traditional interfaces, a user can utilize the graphical interface with a natural way of interaction with multi touch screens. They also support multi-user interaction. Therefore, multi-touch-enabled UIs prove exceptionally benefitting in the enhancement of social skills among Autistic children.
This paper focuses on exploration of the aptitude of multitouch UIs with collaborative gesture recognition to engage children with ASD in social activities. This is intended to achieve an approximate figure of how applications with these UIs are able to enable the ASD affected children to work in partnership, be social, express their feelings and opinions and to approach a normal life till they get to their adulthood.
The rest of this paper is organized as follows: Section 2 describes the methodology followed to conduct this analytic study, 2.1 briefs about the necessary notion of requirements and expectations of the targeted users; i.e. the children. This section also explains the type of interfaces being designed under the umbrella of CCI. Furthermore, Section 2.2-2.7 discuss the on hand literature on UI development, with special reference to ASD specific applications and related UIs. Findings of the analysis are summarized in Section 3; while, Section 4 concludes the scrutiny by giving the results and deductions of the aforementioned study.

MATERIALS AND METHOD
The objective of this study is to gain an insight and understanding of the trends of UI designing in terms of multi-touch UIs with collaborative gesture recognition. It also aims to aid in social collaborative treatment of ASD affected children. To achieve this, a careful analysis of the available literature was done. The information gathering was initially aimed at reviews done in various dimensions in this regard. It later converged to individual UIs designed for different commercial projects and multitouch applications to support the treatment of children with Autistic conditions. The UI design strategies that have been surveyed and the reviewing methodologies are summarized in Fig. 1. Relevant data were finally collected from selected papers. Section 3 of this paper summarizes this data.

ASD Specific Requirements of A CCI User Interface
CI has been a distinctive area in HCI research since 2002 when the need of a structured community for Child Interface Design was first spotted [5]. CCI has now gained the status of such a broad field in itself that it has recently been recognized as an IFIP (International Federation for Information Processing) work group [5].

Multi-Touch Collaborative Gesture Recognition Based User Interfaces as Behavioral Interventions for Children with Autistic Spectrum Disorder: A Review
Mehran Attempts have already been made by researchers in this field to divert the attention of HCI experts towards easy use of search engines and digital libraries by children [6].
The main idea behind this work was the use of a graphical interface design for a system with information visualization. The survey done in [6] shows that the use One such piece of work has been composed in [7], which has focused on the responses from a group of deaf children using a computer game application. The conclusions made by the authors of [7] point out that children are adjustable with interfaces they are not so familiar with. They also point out that in the contrary they expect intuition and more innovation in the technology that lets their creativity be refined. This challenge is note-worthy when seen in the perspective of special children like disabled due to physical or mental diseases, specifically Autism.
Why do children with ASD find using software and gadget based activities more interesting than socializing with friends and peers? The answer to this question has been found in literature when researchers first started on the voyage to solve the ASD challenges with technology.
One answer has been found in [8]. According to this, the reason behind ASD affected children's inclination towards technological learning is that they get freedom and solitude in such activities; they do not have to interact much with other people. It is therefore a plus point in their treatment. Research has already proved that involving technology is helpful to a great extent in the development of children affected with ASD.

Multi-Touch UIs for Behavioural Interventions in the Treatment of ASD: Review and Discussion
An influential attempt on the development of an interface helping Autism patients to interact more with their peers has been found in [9]. The need arose since children affected by Autism are less fond of socializing with peers, as compared to the normal children. This interface has been designed for the sake of improving such children's social life and their interaction with class mates and friends [9]. The main objective of the concerned UI designers has always been to let the child engage in a certain socializing activity without letting him get aware with the purpose of it. This is mandatory as children with the Autism tend to become aggressive when they are forced to respond and get social with their peers. In order to make this, the interface designing needs to be highly specialized and HCI enabled to let the child be grasped in the activity without aggravating him. The study conducted in [9] is a comparative analysis of an

User Interfaces Supporting Autism Advocacy Over the Web
The inspiration to use collaborative gesture recognition lessons and more intelligent gaming interface development for the ASD affected children. The authors of [10] have also done a survey on their project and found a satisfactory rating by the respondents. Another such survey has been found in [11] in which the main objective was to investigate the usefulness of a web-based portal i.e. the IAN (Interactive Autism Network). At one place, this online registry has made the diagnosis and treatment of ASD affected children easier for the parents; at the other place, it has bridged the gap between researchers and families related to ASD. One of such online polls has been shown in Fig. 3.
Virtual communities and online discussion forums such as Wrong Planet [12] help an Autistic individual socialize on his own. The most constructive feature in such UIs is that the Autistic individual feels free to communicate with the world, without any social anxiety and with much engrossed empathy. Another such forum named as Together for Autism (developed in 2009) has an objective similar to [12] with around 14,000 posts and 24,000 members including Autistics and their parents. Here, they discuss the difficulties they face and get awareness about concerned health issues and other socializing problems.
One other attempt was narrated in [13], describing a blog created by a bunch of high functioning Autistics. The study shows the good that the web can do in development of such individuals. These people discuss their uniqueness in their blogs, highlighting the optimism of their minds in spite of the mental incompetence that they suffer. Other such blogs and online communities have been discussed in [14,15]. One of these blogs is named as "We go with him" where the mother of a 10-year old Autistic describes her happy experiences when her child progresses and tries to gain 'joint attention' with elders and grandparents. One such review has also been found in [16], where the authors have discussed the pros of Autism Advocacy for Autistic children and their parents.
Moreover, researchers like the authors of [17] have developed user interfaces having online surveys for parents of the Autistics. These surveys provide convenience to the parents and help them gain detailed feedback about the related issues.
Among the negative consequences that come sidewise with the benefits of web-based UIs is the fact that inappropriate information travels over the web as easily as does the useful information. Scams and advertisements of expensive Autism treatments also travel through the UIs using web. This misleads the parents of Autistic children [18]. Yet another issue that has risen due to the UIs that involve web is that of splintering within the Autism society. One such matter has been addressed in [19]  pilot study of this work has been described in [21]. In this user-centered approach of work, they have presented the prototype of an audio-augmented paper that can be used to record and play the child's discussion with his therapist. This is shown in Fig. 4. The sheet-of-paper based interface consists of two tags of record and play. These tagswhen hidden under the user's hand while drawing on the paper -let the computer record and play the user's voice.
This activity helps therapist in keeping the user engaged without his awareness of being treated. Meanwhile, play back of the child's own voice helps to auto-treat the ASD disorder. Results gained from the prototype testing showed that such an interface is beneficial to help the child cope with his hesitation. At the same time, it helps the therapist to control the child's attention, cooperation and to get improved results in the treatment.
According to the review done on multi-touch  [22].
The interface developed in [22] works in a fashion similar to [21] that is to record useful information and analyze the ASD subject's behavior while delivering the training.
The proposed prototype, thus aims to help the trainer cum therapist to foster the child's attention on the trial analyze the child's responses simultaneously. This makes the activity prone to errors, due to which research in CCI for Autistic children has found one of its routes oriented in this direction. According to the analysis done in [22], touch based UIs suit best to children with ASD and they find such applications more interesting than others. The  [23].

Mehran University Research
With DTT, the Autistic child gets help in learning attention, imitation and working skills. The methodology followed in DTT helps the trainers in accurate data collection due to the systematically outlined procedure that they have to follow. This way, it becomes easier for them to record and monitor the child's progress [24].
DTT provides the ASD affected child with better learning habits, focusing more on his tolerance to demands which occur to him because of his aggressiveness. The ease that DTT provides for group learning makes it easier and habitual for the Autistic child to get mixed with peers in a group. This boosts his socializing and interacting skills.
The UI discussed in [12], is effective in terms of engaging the child in learning with a lesser use of sensors. A pronounced shortcoming of this attribute is noncollaborative allowance. This leads to the child's annoyance out of the lack of multiple features and space on screen. The authors of [25] have discussed the consequences of misapplication of DTT. According to them, the mistakes usually occur in the timing of trials, insufficient optimistic support by the trainers for the correct responses of the Autistic child and unnecessary pessimistic consequences for incorrect responses. To overcome this issue, [26] has presented a solution that specifies that the training sessions should be generalized so that multiple trainers could use the UI. It also states that there should be multiple environments to get a more realistic and better response on the average.

INTEGRATION OF COGNITIVE-BEHAVIOURAL THERAPY AND UI DESIGNING
The Story Table interface mentioned in [27] is yet another innovation done specifically for the HFASD affected children. This interface, as proposed by the authors is a cooperation-enforcing interface. It reflects their intercession based attempt to let the subjects interact with each other via the means of a story telling activity. The survey was based on a sample of 6 children aged 8-11years.
The mention of the game suite in the field study done by the authors of [28] is an attempt made explicitly for HFASD affected children. The project under which this study has been done was essentially a multi-dimensional project that was based on a collaborative effort of CBT (Cognitive-Behavioral Therapy) expert therapists and software interface designers. The authors also involved parents and teachers of HFASD affected children in this work.
Their experimental group was based on 8 children, who after being tested came out to be more interactive and collaborative with their peers than before. A new term of 'ecological validity' in computer games was acknowledged in the work in [28]. This -if accounted for in interface designing -has been proved to be a progressive factor in the treatment of HFASD patients. A piece of work related to the same background in interface designing has been found in [29]. This work addresses a UI design model named as SCERTS, which is the acronym for SC (Social Communication), ER (Emotional Regulation) and TS (Transactional Support). This model has basically been derived from an empirical cognitive behavioral therapy based design methodology. The work done in [29] has also addressed the concept of 'ecological validity' with verification of the fact that this perception is helpful in effective user interface designing.
CBT based interfaces are built by developers, specifically to address aggressiveness and intellectual mutilation in Autistic children [30]. Literature shows that interfaces that are built for trainings based on CBT prove to be effective for the Autistic children with anxiety disorders [31]. As far as behavioral therapy based UIs for Autistic adults are considered, the survey performed in [32] shows that CBT has long term positive effects on adults with Autism. This influence includes reduction in symptoms of depression, distrust, sleeping problems, anxiety and agoraphobia.
Among the pitfalls in UIs centered on this technique, the most prominent one is the lack of visual aids, which has been proposed as a modification in CBT [32]. The authors of this case study have found room for implementing visual aids within behavioral treatment to provide better results and to achieve subject's interest to a comparatively higher level. Apart from this modification, the authors of [32] have also identified the need of physical activities within the therapies and involvement of the subject's parents to aid in his/ her treatment.

UIs for Empathy Enhancement in ASD Patients
The next relevant work reviewed is the development of a multi-touch UI based software for the ASD affected children of Chile, with the main focus to support enhancement of empathy in such children [33]. The mentioned software was developed using the UCD (User Centered Design) methodology. A note-worthy point in this approach is that the UI designers have considered, among other factors, Chilean culture as an important element in the design. This cultural feature in the designed application has reflected in the analyzed results given in [27]. According to these results, the designed application serves to be a good learning medium in context of cultural values for the ASD affected children. The Android application proposed in [33] can be downloaded via Google Play from [34].
The interface developed in [33] has been built specifically to develop the skill of empathy in the target children.
According to the authors, when the child learns to

Interactive Verbal Behaviour Approach in UIs with Virtual Agents
The serious game platform named as ECHOE, mentioned in [35] is another attempt made by a group of researchers that used the multi-touch interfacing methodology to design a platform for Autistic Spectrum Disorder patients.   , Volume 35, No. 4, October, 2016 [p-ISSN: 0254-7821, e-ISSN: 2413-7219] 553 correspondence and support that the Autistic child actually needs. The pro-activeness of autonomous agents is necessary for improvement in the Autistic child's motivation and attention seeking abilities.

Mehran University Research Journal of Engineering & Technology
Literature shows the other side of the picture as well; since there also came situations in trainings where the agents increased users' anxiety and affected their performance just as if they were being watched by a real human [44]. One pitfall of virtual agent based user interfaces is that once the child becomes accustomed to his virtual friend, he tends to become isolated from the other world. This phenomenon can be reduced by focusing on the 'talk' that the virtual agent does with the child; with more emphasis on family importance and socializing with classmates and peers. The commercial projects discussed in Table 2  (1) Web based interfaces like the Interactive Autism Network and its online portals are more helpful for the parents/ teachers of autistic children than the children themselves. These UIs are sophisticated enough for mature users but they lack in features that attract Autistic children. Hence, they tend to enjoy serious games more than online portals. Autistic adults are more biased towards web-based interfaces.

RESULTS AND FINDINGS
(2) DTT based UIs are more user-centered than the other four types of UIs studied. This is so because these UIs don't work alone; they rather require the children to involve in a DTT based activity as well. Results from statistical tests done in the various projects show that using these UIs with DTT sessions has made considerable improvement in these sessions.
(3) As compared to DTT-based UIs, CBT-based UIs involve lesser activities. The ultimate meaning of this is that these UIs rely on their own features only. This increases the demand of effective interface designing in these UIs. Authors of the research work discussed in section 2.5 have observed positive changes in their experimental groups. These changes were in terms of problem solving, understanding skills and learning with patience.
(4) Lesser work was found in the domain of empathy enhancement. This is so because the UIs being designed presently have their prime focus on specific impairments. This narrow focus is good in terms of research, but it also indicates that lack of empathy cannot be inter-mixed with other impairments. Explicit work needs to be done for this behavioral impairment.
(5) A wide range of work has been done on UIs with virtual agents to foster verbal behavior approach. As compared to the other four types of UIs, this type is lesser collaborative: it involves a smaller group of children or mostly a single child. This is so because the virtual agent is enough to provide company to the child. Interaction with the reviewed interfaces led to enhanced socializing skills in the experimental group. Moreover, these UIs provide a sense of gesture and emotion recognition in Autistic children.
It is note-worthy here that the study is based on Multitouch collaborative gesture recognition based UIs only. Other methodologies of ASD treatment do exist; for example, the use of Human-Robot Interaction to aid in ASD treatment; however, the current study does not consider these techniques. In order to make the review specific (and HCI-oriented), we have focused on only multi-touch collaborative gesture recognition based UIs. Interventions like tangible UIs and Human-Robot Interactions are unlike our focal point of research, and are wider in their own. It was determined that the literature review be converged to multi-touch based UIs only.  Table  .  o  N   e  v  i  t  a  r  o  b  a  l  l  o  c  h  c  u  o  t  -i  t  l  u  M  d  e  s  a  b  n  o  i  t  i  n  g  o  c  e  r  e  r  u  t  s  e  g  s  t  c  e  j  o  r  P  I  U   m  s  i  t  u  A  f  o  t  n  e  m  t  a  e  r  t  e  h  t  n  i  e  s  U  r  e  d  r  o  s  i  D  m  u  r  t  c  e  p  S  e  r  a  w  d  r  a  h  d  e  t  r  o  p  p  u  S  e  v  i  t  a  r  o  b  a  l  l  o  c  s  u  o  e  n  a  t  l  u  m  i  s  f  o  .  o  N  s  r  e  s  u  L  R  U  t  c  e  j  o  r  P  -n  e  r  e  f  e  R  e  c   .  1 g

CONCLUSION
For decades, technology usage has been an effective tool in the treatment of mental disorders; Autism Spectrum Disorder is one of which. This paper has put in a nutshell, the most recent innovations in terms of UI development for kids with Autism as a result of which they hang back from being social and communicative. Research in this regard has therefore been carefully scrutinized, particularly focusing on UIs with multi-touch support that is able to provide collaborative activities for the concerned children.
After the comparative review, we conclude that research specifically in multi-touch collaborative gesture recognition based UIs, though not fully in the prime, has highlighted marked potential for treatment of ASD affected children. A lot of room is still there for further work in interface designing in this context; some of which has been briefed in section 3 of the paper. The types of user interfaces for behavioral interventions, along with their respective pros and cons have been described. This provides functional points to be noted for the UI designers before starting on the voyage of UI designing for the treatment of behavioral impairments in ASD affected children.

FUTURE WORK
Active research in this domain (during the span of 2011-2015) includes a variety of dimensions in UI development.
One of these is of adaptive user-centered interfaces.
These involve user-centered design methodology. They are adaptive because they integrate characteristics of an Autistic user and then develop an effective user model.
Thus, the special needs of such users are better addressed. Furthermore, multi-touch user interfaces are taking directions to bring Autism treatment home with the advent of home-based behavioral interventions via smart phone based UIs. As far as simplicity in UI development is concerned, work is being done on natural user interfaces for pre-schoolers that lack motor skills.
This school-of-thought of researchers focuses on two aspects: to start Autism treatment as early as possible and to keep the UI simpler for young Autistics, to better understand the targeted skills.
Apart from multi touch tablet and smart-phone applications, another widely accepted innovation is that of robot assisted therapies and tangible user interfaces. Moreover, UI designers are now focusing on a more HCI oriented work so that they may concentrate on even the slighter deficiencies in attitudes of Autistic children.

ACKNOWLEDGEMENT
Authors acknowledge the support provided by