Keywords

1 Introduction

Performing morning routines represents a considerable challenge for children with neurodevelopmental disorders, such as ADHD or ASD [1, 6]. ADHD is characterized by attention and/or impulsivity and hyperactivity difficulties that affect various spheres of life (social, academic, etc.) [7]. As for autistic people, significant difficulties in communication and social interaction are observed, as well as restricted or repetitive behaviors, interests, and activities [8]. Both children with ADHD or ASD frequently exhibit deficits in executive functions, working memory, or emotional and behavioral self-regulation, which can lead to serious difficulties when it comes to performing morning routines [1, 2, 9]. More specifically, those deficits may reduce children’s 1) ability to plan a routine coherently, 2) motivation to engage in or continue the routine and 3) tolerance for delayed gratification. Moreover, working memory can affect the execution of the routine, notably when the child forgets to perform some steps or loses track of what he/she is doing [10].

Consequently, for these children, performing morning routines requires considerable daily supervision by the parents. They must provide consistent instructions and frequent reinforcement to support their child. However, these interventions can require substantial energy and be burdensome for many families [1]. Parents thus feel overwhelmed and exhausted when performing these routines. In fact, Johnston and Mash [11] demonstrated that parental stress may affect parent-child relationship, notably because of a decrease in positive interactions and an increase in negative comments toward children.

To support children and their parents, several traditional intervention tools, such as token systems and visual schedules, are currently used. Though, Bimbrahw et al. [3] reported that these strategies are not effective for all children and still require large investments of time by the parents. In this regard, technology may represent a promising and novel solution to support interventions with children who have ADHD or ASD [3, 12, 13]. Technology may help improve their development, provide new learning opportunities, and increase their autonomy [14]. Actually, few educational technologies are available to help children with ADHD or ASD perform their daily activities.

2 Objectives

This pilot study aimed at developing a digital solution to support children with ADHD or ASD in performing morning routines. To help empower children, a Beta version of the STORM prototype was given to each family. Three objectives were pursued to describe parents and their child’s experience of using the prototype:

  1. 1.

    Identify the acceptance level of the STORM prototype, including perceived usefulness and user-friendliness;

  2. 2.

    Explore the children’s and their parents’ perceptions of the effects of using the prototype on the completion of morning routines;

  3. 3.

    Document the frequency of everyday use of the prototype as per the proposed approach.

3 Method

For these objectives to be met, a descriptive mixed design was used. Because this research sector is relatively new, qualitative research tools were appropriate for learning about the users’ perceptions regarding the effects of the game but also of its user-friendliness. The addition of quantitative data collection tools made it possible to quantify the effects of using the product but also to see if its use in a real-life setting matched the designers’ predictions. The various methodological aspects of the study are presented in the following subsections.

3.1 Sample

Purposive sampling was used to recruit participants through a private clinic near researchers’ city. To participate, children had to meet the following inclusion criteria:

  • Be diagnosed with ADHD and/or high-level ASD;

  • Be between 6 and 12 years old;

  • Attend a regular school;

  • Have two parents living at the same address or one parent with exclusive custody of the child;

  • Speak French.

Five families with children between 6 and 12 years old with a diagnosis of ASD or ADHD were recruited to use the prototype each morning for a two-week period.

3.2 Materials and Intervention Process

During the study, parents and children had to use the STORM prototype each morning on a two-week period. The prototype included: 1) a digital tablet that contained the video game for the child and the morning routine management interface for the parent, and 2) a smart watch for the child. On the watch, an avatar would appear at the beginning of the morning routine to inform the tasks he/she had to perform (e.g., eat, brush his/her teeth). The child then had to “check off” the accomplished tasks on the watch and the parent had to confirm its completion on the tablet. If the child completed 80% of the routine and the parent approved it, the child was then rewarded with a power that allowed him/her to access a new mission in the video game. This procedure was intended to make the morning routines more pleasant for the child by making him/her part of the mission, and also for the parents, by reducing negative interactions by giving them more of a motivator role where he/she would be encouraging their child. Throughout the process, the parent received technical assistance to make sure the prototype was working properly.

3.3 Measuring Instruments

For these objectives to be met, various measuring instruments were used. Four semi-structured interview canvases were created and used with parents and children. In separated rooms, the interviews were conducted before and after the testing of the solution. They pertained notably to the conduct of the morning routines and the experience of using the solution. The BSFQ [4, 5] was also administered to the parents before and after the test. Total score varied between 0 (absence of dysfunction in the child during the performance of the morning routine) and 60 (high level of dysfunction during the performance of the morning routine). Finally, for the third objective, analytics was installed within the game to collect information on the child’s playing habits (e.g., tasks performed by the child, duration of the game sessions, timing of usage).

3.4 Analyses

The qualitative interviews were transcribed into verbatim and then analyzed using NVivo software to extract emerging categories. For the quantitative analysis, descriptive-type statistical analyses were used to analyze the analytics data and a Wilcoxon test was conducted for the BSFQ results in order to verify if any improvements or changes in the child’s behaviors were observed during the performance of the morning routine.

4 Results

Results obtained within this study are presented into five sections: 1) Participants description; 2) Conduct of the morning routine during the test; 3) Factors influencing the conduct of the routine during testing; 4) Results of the BSFQ; and 5) User experience.

4.1 Participant’s Description

Five families participated in this research project. The average age of participating children is 7.8 years old. They all had been diagnosed with ADHD, and two had ASD as well (see Table 1 for more details). All participating parents mentioned using technology at least two hours per day in their personal lives. They thus felt that they had the necessary skills to use the technology and said they were comfortable doing so. According to their perceptions, the children used technology daily at varying frequencies.

Table 1. Characteristics of the participating children

4.2 Conduct of the Morning Routine During the Test

All the parents who tested the prototype during the two-week period (F1, F2, F3, F4) spoke of several positive effects. They reported that the tasks were better performed (F2), and the sequence was followed correctly by their child (F2, F3, F4). Two families also said that the routine was executed more quickly (F2, F4; e.g., earlier departure in the morning). However, one of them (F4) specified that certain tasks were sometimes performed too quickly by the child, who was eager to carry out his/her mission.

I remember…let’s say that he was brushing his teeth, well, sometimes he would go a bit fast, because he was excited, he was anxious to go play. … If the game stimulated him to do it a little bit longer, it would be even better. (Father, Family 4)

In fact, all the families reported a reduction in parental supervision, notably in the number of repetitions required during the morning routine (F1, F2, F3, F4). They all found the child more cooperative (F1, F2) and felt less need to get angry with him/her during the morning routine (F2, F4).

And he is extremely cooperative, and I don’t know if it’s the effect of the watch or of the game, but he is very cooperative; when I would say something, he would say, “Yes, Mom.” And he would go. (Mother, Family 2)

Furthermore, the parents noticed a reduction in negative interactions as well as an increase in positive interactions within some families (more time to discuss and reinforce the child’s desired behaviors). All the families thus reported that the test had helped improve the family atmosphere (F1, F2, F3, F4) and reduce fatigue for the parents. Regarding the effects on the child, three families mentioned an increase in the child’s enthusiasm and motivation during the morning routine (F1, F3, F4). All the parents (F1, F2, F3, F4) found that their child had demonstrated considerable autonomy because he/she was able to choose the order in which to perform the tasks (F1).

He had the choice, but not the choice; he knows that that’s what the routine is, but he was doing it in the order he wanted. That opened up opportunities for him. (Mother, Family 1)

Some parents noted that their child had a better capacity for attention in the morning. According to two families (F1, F3), the introduction of STORM led to major changes in their child at home and at school alike:

From the first week, it was a complete change. Laurent [fictional name] had his watch all the time and he would do his whole routine. We didn’t have to repeat anything… He would say to me: “This is fun, Mom; you don’t have to repeat things to me.” (Mother, Family 2)

All the children found that using the STORM had a positive impact on the performance of the morning routine. Some said the routine was easier to do (F1, F3, F4), it carried out the tasks more quickly (F2, F3), and was able to do more tasks (F2).

I felt good, let’s say, when the watch told me…and when it was my mother, I was like more stressed, so I would give up a little bit. (Children, Family 3)

4.3 Factors Influencing the Conduct of the Routine During Testing

According to the parents, many factors motivated the child during the study. Two families reported that gaining powers was a major motivator (F1, F4). Another said the video game in itself was an effective motivator for their child, while a second one stated that their child was more motivated by the watch than by the video game and the powers.

He was more motivated, because there was a game at the end. He was in the category of people who are perfect for that; it affected him right away… He would really try to have his privilege; he really wanted the reward that the game would give him. (Father, Family 1)

4.4 Results of the BSFQ

Table 2 presents the participants’ total BSFQ scores by measurement time at the Wilcoxon test. For all the participants, the BSFQ scores decreased an average of 22 points between pre-intervention and post-intervention. This result shows an overall improvement of the children functioning in the performance of their morning routine. However, it should be noted that Family 5 encountered technical issues when using the solution (details in the next section) so they made little use of the prototype. In fact, the lowest decrease was in this family, whereas Family 4 had the most notable improvement.

Table 2. Families’ total BSFQ scores by measurement time

4.5 User Experience

The results of this pilot study showed that the parents and children had a good perception of the video game application and the avatar in the STORM prototype. Parents said they appreciated that the STORM prototype worked almost on its own and did not entail supplementary management of the morning routine, contrary to traditional methods (e.g., token system), which can be demanding and require a considerable amount of their time. Nonetheless, despite positive comments from parents and children, the use of qualitative and quantitative data provided a better understanding of the context of use of the prototype. Indeed, the data collected by the analytics showed that some families did not use STORM the way the designers and researchers had originally recommended. A diversity of product usage experiences by the five families was observed. This can be explained notably by the presence of technical glitches that influenced the usage. However, some usage patterns could still be observed. The results showed that three of the five families (F1, F3, and F4) used the STORM application in accordance with the proposed procedure. Figures 1, 2, 3, 4, 5, 6, 7, 8 and 9 presents the results for each of the five families.

Fig. 1.
figure 1

Number of tasks marked as completed by the child and validated by the parent for the Family 4.

Fig. 2.
figure 2

Total child’s play time (in minutes) of Family 4

Fig. 3.
figure 3

Number of tasks marked as completed by the child and validated by the parent for the Family 1.

Fig. 4.
figure 4

Total child’s play time (in minutes) of Family 1

Fig. 5.
figure 5

Number of tasks marked as completed by the child and validated by the parent for the Family 3.

Fig. 6.
figure 6

Total child’s play time (in minutes) of Family 3

Fig. 7.
figure 7

Number of tasks marked as completed by the child and validated by the parent for the Family 5.

Fig. 8.
figure 8

Number of tasks marked as completed by the child and validated by the parent for the Family 2.

Fig. 9.
figure 9

Total child’s play time (in minutes) of Family 2

Family 4 adhered perfectly to the expected usage. Four tasks were thus performed by the child and validated by the parent every day, as shown in Fig. 1. In fact, this was the family that reported the most positive effects on their child during the study. For playing time, peaks were observed (more than 20 min of playing time per day) at the mid-point and at the end (Fig. 2). A slight increase in playing time was also observed in the second week. It thus seems that the first week was a time to get a grasp on the game related to the routines.

For Family 1, the child performed routines as expected most of the time. Even if he didn’t systematically mark tasks as completed, parents validated them for him. However, parents also omitted the validation during two days of the experimentation, but they caught up in the delayed validation the following day (Fig. 3). In the interviews, the parents explained this situation notably by the presence of technical issues related to the prototype. For this family, there was substantial variability in playing time, with a 60-minute peak during the second week (Fig. 4).

For Family 3, there was a high level of adherence at the beginning of the test and then a gradual decline in tasks marked as completed by the child and validated by the parent in the second week (see Fig. 5). So, despite performing his routines daily, the child did not systematically enter their execution in the application. A gradual decrease in playing time was also observed (see Fig. 6). In the interview, the parent specified that this drop-in interest was attributable to technical issues.

The profile of Family 5 was characterized by high usage at the beginning and then disinterest for the rest of the experiment. In total, the prototype hadn’t been used for 9 days out of 14 (see Fig. 7). According to the family, positive effects on routine performance were seen at first. However, due to the short time of use, the same difficulties usually encountered resurfaced not long after. In the interview, they said they had to stop using the prototype because of technical issues, the presence of an atypical schedule during those weeks and their child’s lack interest in the type of video game chosen by the designers. Due to these issues, no play time data were provided for this family.

Finally, for Family 2, the data analysis by the analytics showed low adherence to the implementation of the STORM prototype (see Fig. 8). Yet, the post-intervention interviews with the parents suggested the opposite. In fact, the parents reported not having validated the tasks when their child performed them due to a lack of time in the morning. Furthermore, they said the child was very interested in the watch and less so in the video game (see Fig. 9).

In the interview, the child mentioned preferring to wait until the end of the study to ask his parent to unblock all the powers gained over the two weeks. This explains notably why the average playing time was concentrated mainly on the last day. Here is what the parents said in this regard:

He started having fun yesterday. He said: “I must have some powers….” But me, during the week, he didn’t ask me for it. (Parent, Family 2)

It’s funny because I didn’t see him playing so much on the STORM game; I saw him playing a lot; it’s like the watch was just enough to be drawn into it. He didn’t talk that much about unblocking powers. (Parent, Family 2)

5 Discussion/Conclusion

Given the exploratory nature of the study, it was not possible to conduct in-depth statistical analyses for the BSFQ scores and thus quantify whether the gains observed were significant. However, all parents noticed positive effects on their family morning routines when using the prototype. This study showed that the STORM prototype may be a tool with interesting potential for helping children with ASD or ADHD on their morning routines. A study, currently underway with more than 200 families, will make it possible to overcome this limitation and to test the second version of the prototype.

The prototype generated extrinsic motivation for the children, which may have prompted them to perform their morning routines. However, results also show that children were motivated by different reinforcers during the test, which may explain the differences between the participants’ adhesion to the prescribed usage of the STORM prototype. Some derived more enjoyment from using the game or gaining powers while others were more motivated by the avatar’s prompts included in the watch. The motivational aspect thus seems to be an important issue to assess by checking, for instance, the different options available into the product (watch, video game, or a combination of both). Though, the immediate gratification provided by the game that the game provided when a task was performed also seems to have an impact on some children [2]. To maintain their motivation and the novelty aspect, it is thus important for these children that the game be progressive [15, 16]. From the perspective of a longitudinal study, it would also be interesting to document the process of learning the routine, notably when motivation transitions from extrinsic to intrinsic. It would also be interesting to examine the variations in the participants’ gains by type of tool.

Finally, it is possible to believe that perceived usefulness had an impact on the perception of the effects of the STORM prototype and on adherence to its implementation [17]. As shown in the results, the parents who deemed the tool favorable at the pre-test meeting were the ones who reported the most positive effects and who adhered most faithfully to the recommended implementation procedure. Moreover, they even remained committed despite the technical issues encountered. They reported taking steps immediately with technical support when this situation arose. Interest decreased when the second issue occurred; however, usage did not stop completely. Interestingly, a comparison of the results obtained regarding the perceived usefulness of the STORM prototype showed that, of the four families reporting technical issues, only the one having expressed great reluctance quit the testing. It is thus possible to believe that the initial perception of the product influenced the family’s involvement during the study. In fact, this is an important factor in the process of acceptability, acceptance, and adoption of a product. This element shows the importance of limiting the number of technical issues to make sure the participants adhere to the prototype and remain motivated. The product must not be an additional element to manage in the family routine.