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Playful Tray: Adopting Ubicomp and Persuasive Techniques into Play-based Occupational Therapy for Reducing Poor Eating Behavior in Young Children

UBICOMP 2007

Dori Lin, Hao Chu, Arthur Chen, Jane Hsu, Polly HuangGraduate Institute of Networking and MultimediaNational Taiwan University

Jin-Ling Lo, His-Chin ChouNational Taiwan University Hospital

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Child Behavior Training

• Child behavior training as important but challenging parental responsibility– Potty training, tooth brushing, self-dressing,

cleaning room, slow eating (focus of this work)

• The most common form of parental persuasion is verbal persuasion.– “if you don’t finish your food, you are going to sit

here for the rest of your life”.

• Effective and Why not?– Verbal persuasion alone lacks proper incentive

to motivate child

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A Case Study: Child Mealtime Behavior• Target child long mealtime problem (over 30 minutes)

– Affect the participation of daily activities– Negative parent-child interaction

• Dinner time supposed to be valuable family time together

• Common scenario: A child refuses to eat -> Mother upset -> Mother force feed -> Child upset

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Play-based Occupational Therapy

• Pediatric occupational therapy (O.T.)– Leverage the desire of children to play to induce their behavior

change willingly. • A child may not like to sit & eat dinner, but likes to play.

• Add playfulness (game) into the eating activity

– Effective – full of toys in pediatric O.T. clinic.

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Play-Based O.T. Limitations

(1) Children treated in clinics during regular office hours (NTU Hospital)– Many child behavior problems not observable to therapists

• Eating (dinner time), sleeping (night time), etc.

• Effective treatment is difficult.

(2) Train general performance skill rather than specific functional skill– Hand scoping skill vs. eating skill– Improvement in general performance skills may not translate into

specific functional skills

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UBICOMP Opportunities

• Embed digital technology into a child naturalistic living environment– Sensing to observe child behavior anytime, anywhere– Game playing to influence child behavior anytime, anywhere

• Occupational therapist perspective: – From treatment clinic– To the child actual living environment (functional behaviors)

• UBICOMP perspective:– From sense and track behaviors – To engage children to change behaviors

• Also called Persuasive technology (by Fogg and others)

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• Sensing– Weight sensors underneath tray

detect child eating actions– Eating actions are game input

• Playing– An interactive game of coloring a

cartoon character– To fully color the cartoon character, a

child is motivated to eat.

• Is this design successful?

Playful Tray Prototype 1: Coloring Game

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Why not?

Show prototype #1 to our pediatric O.T. partners, their feedbacks are two questions:

• Do you think the child would pay attention to playing the game or eating (enjoying) food?

• What would happen if parents take away the tray after a while?– Intervention (Effective) – Post (Ineffective)

Guess their opinions from their questions …

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Play-based Occupational Therapy Model• Treatment program is about designing a play activity (thr

ee elements).

Volition Performance Habituation

Bring enough enjoyment to attract a child to participate in the target activity.

Ensure a child will have a successful experience. Set appropriate level of difficulty.

Apply reinforcement to reward good performance, so increase change of repeating desirable behavior. Enough times to become a habit.

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Design Consideration

• Attention (Child)– Split between playing and eating– Game playing (secondary) not overtaking eating (primary, target)

• Enjoyment (Game)– Bring just enough fun to attract children to eating

• Engagement (Game)– Simple (Not all young children can learn to operate complex devices)

– Use natural eating actions as game inputs • Child must eat to continue playing (eating becomes self-inforced)

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Prototype 1: Problems

• Disengagement– Grabbed too much attention & distract children from proper

eating.

• Gobbling– Impatient children ate too quickly (to color cartoon character).

• Single weight cell is sufficient– Food is served in one bowl to a young child (at home or school).

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Prototype 2: Racing Game Tray

For placing the bowl Weight sensing surface

Palm-top PC with touch screen

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The Racing Game

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The Racing Game

• No reward for eating too fast

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Racing Game Tray: Feedbacks

• Tray was too thick (3 cm)– Inconvenience for young children with short arms

• Playing the same game boring– Download new games

• Expensive• Difficult to wash

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Placemate skin Weight sensing module Mobile Phone

Prototype 3: Mobile Penguin Fishing Tray

50% Thinner (1.5 cm)Light, foldable, washable, changeable

Bluetooth mobile phone accessory

Download new gamesOnly buy the skin & weight sensing model

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Install weight sensing module

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Child selects a penguin to compete in a fishing game.

Game start

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Each bite causes one penguin to get a fishThe penguin getting more fish at the end winsChild is motivate to help in order to help penguin to win.

Game start

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Pilot User Study on Prototype #2

• Conducted by our pediatric O.T. team• Subjects: four young children with reported

long mealtime problems (30 min to over 1 hr)

Children Age Diagnosis

A 7 Asperger’s Syndrome

B 5 High function autism

C 5 Asperger’s Syndrome

D 4 No specific diagnosis

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User Study Procedure

1. Child’s Mealtime Behavior Checklist

2. Interview - to clarify behavioral details

3. Record eating activities without the tray

4. Record eating activities with the tray within 1 week

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Measurement method

• Code behaviors of both children & parents from taped videos

• Our eating coding behavior table was modified from Moore.– Self-feeding (Positive, Negative)

• Child active feeding or related behaviors

– Interaction (Positive, Negative)• Actively initiated behaviors and synchronous responsive behaviors

of the feeding partners

– Social• Toward a feeding partner but unrelated to feeding

– Positive (promote self-feeding); Negative (interrupt self-feeding)

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(1) Self-feeding: a child place food into his/her own mouthMother Child

Positive: A mother allows or promotes self-feeding, such as verbal encouragement, praises, etc.

Positive: A child attempts self-feeding, such as holding utensils, putting food into mouth, etc.

Negative: A mother discourages, disallows, or interrupts self-feeding, such as pushing the child’s hands away, telling the child that she will feed the child, etc.

Negative: A child rejects self-feeding, such as saying “no” or pushing away given food.

(2) Interaction: Actively initiated behavior and the synchronous responsive behavior of the feeding partner

Mother as the actor Child’s responsive behavior

Positive: A mother attempts to arouse a child’s interest, such as talking about food, models, food games, etc. A mother refocuses the child’s attention on food when the child is distracted.

Positive: A child accepts food when it is offered, or self-feeds food.

Negative: A child ignores the mother’s cue, refuses, or walks away from the mother’s cue.

Negative: A mother intrusively attempts to direct feeding, such as force-feeding the child, holding a child’s head, body, or hand, and threatening the child.

Positive: A child responds by self-feeding.Negative: A child ignores the mother’s attempts,

refuses, or walks away from the mother’s attempts.

Mother’s responsive behavior Child as the actorPositive: A mother synchronously responds to pro

mote continuous feeding, such as interpreting a child feeding cues, responding to a child’s needs, etc.

Positive: A child initiates an attempt to eat, such as looking at food, talking about food, requesting food/drink, or touching food.Negative: A mother synchronously responds to int

errupt the child’s feeding.Positive: A mother synchronously responds to pro

mote continuous feeding, such as interpreting the child feeding cues, responding to the child’s needs, etc.

Negative: A child shows disinterest, discouragement, or stops eating or chewing.

Negative: A mother synchronously responds to interrupt the child’s feeding.

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Measurements (with vs. without the tray)

• Mealtime duration• Child on-task / off-task behavior ratio• Parent on-task / off-task behavior ratio • Parent positive / negative behavior ratio

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Mealtime duration

0

10

20

30

40

50

A B C D

Participants

Mea

ltim

e du

ratio

n (m

in) without the tray

with the tray

Result: Mealtime Duration

• (A:23, B:40, C:41, D:25) -> (23, 25, 29, 9) • Except for Child A, children B, C, D all had reduced meal

time from 29% ~ 64%.

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Measurements (with vs. without the tray)

• Mealtime duration• Child on-task / off-task behavior ratio

– On-task behaviors: positive behaviors– Off-task behaviors: negative + social behaviors– High ratio is good.

• Parent on-task / off-task behavior ratio • Parent positive / negative (P/N) behavior ratio

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0.8~1.6

2.3~5.9

Child On-task/Off-task Behavior Ratio

Child behavior

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

A B C D

Participants

On-t

ask

/Off

-task

behavio

r

without the tray

with the tray

• Improvement in all children– Children were more focused on self-feeding with the playful tray

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Measurements: with vs. without the tray

• Mealtime duration• Child on-task / off-task behavior ratio • Parent on-task / off-task behavior ratio

– On-task behaviors: positive behaviors– Off-task behaviors: negative + social behaviors– High ratio means good improvement.

• Parent positive / negative behavior ratio

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0.5~1.1

0.8~2.3

Parent On-task/Off-task Behavior Ratio

Parent behavior

0.0

0.5

1.0

1.5

2.0

2.5

A B C D

Participants

On

-task

/Off

-task

beh

av

ior

without the tray

with the tray

• Improvement of all parents– Parents were also more focused on the feeding task with the pla

yful tray.

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Measurements: with vs. without the tray

• Mealtime duration• Child on-task / off-task behavior ratio • Parent on-task / off-task behavior ratio• Parent positive / negative behavior ratio

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0.79~4.00

4.30~30.00

Result: Parent P/N Ratio

• Less negative & more positive interaction between parent-child.– A positive interaction cycle of parent giving encouragement and

children responding with positive self-feeding behaviors– Mealtime experience can be good.

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Limitation

• Pilot user study results were encouraging but not conclusive– Lack long-term user studies involving more children– Lack post-intervention study

• What happened when taking away the tray? • For O.T., success = improvement from posttest to pretest.

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Conclusion

• This work demonstrates a case study of adopting UBICOMP technology in play-based occupational therapy for children– Pilot user study results were encouraging

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Ongoing & Future Work (Children have lots of

behavior problems)

• Playful toothbrush– Tooth brushing behavior– Sensing: camera vision to recognize brushing motions– Playing: an game of cleaning dirty teeth

• Mug-Tree– Regular water drinking habit– Sensing: tilt sensor to detect drinking actions.– Playing: watering a virtual tree

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Many Thanks

• Reviewers for their insightful comments• Our shepherd Sunny Consolvo• Keng-hao Chang on helping to create the first prototype

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Thanks

Q & A

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0.80~13.33

6.95~19.00different food types (rice/ dumpling→easy to eat → less self-feeding actions) ↑

Result: Child P/N Ratio

• Child negative behaviors decreased