Research in Developmental Disabilities 35 (2014) 1963–1969
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Research in Developmental Disabilities
Increase in physical activities in kindergarten children with cerebral palsy by employing MaKey–MaKey-based task systems Chien-Yu Lin a,*, Yu-Ming Chang b a
Department of Special Education, National University of Tainan, 33, Section 2, Shu-Lin Street, Tainan 700, Taiwan, ROC College of Digital Design, Southern Taiwan University of Science and Technology, No.1, Nantai Street, Yongkang District, Tainan City 710, Taiwan, ROC
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 April 2014 Received in revised form 21 April 2014 Accepted 22 April 2014 Available online
In this study, we employed Flash- and Scratch-based multimedia by using a MaKey– MaKey-based task system to increase the motivation level of children with cerebral palsy to perform physical activities. MaKey MaKey is a circuit board that converts physical touch to a digital signal, which is interpreted by a computer as a keyboard message. In this study, we used conductive materials to control this interaction. This study followed single-case design using ABAB models in which A indicated the baseline and B indicated the intervention. The experiment period comprised 1 month and a half. The experimental results demonstrated that in the case of two kindergarten children with cerebral palsy, their scores were considerably increased during the intervention phrases. The developmental applications of the results are also discussed. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Interaction Cerebral palsy MaKey MaKey Conductive materials Single-case design
1. Introduction Cerebral palsy is a permanent neurodevelopmental disorders. Beyond motor function impairment, it also compromises cognitive, visual, hearing, and verbal functions (Huang, Pan, Ou, Yu, & Tsai, 2014), because of these limitations, physical activities are quite important. Recently, with technological advances, technology has become applied for special needs individuals (Kagohara, Sigafoos, Achmadi, O’Reilly, & Lancioni, 2012), but one challenge in human–computer interaction is to design systems that users find appealing as well as usable (Bonnardel, Piolat, & Bigot, 2011). As such custom designed assistive technology for people with disabilities is always too costly to promote, Friederich, Bernd, and De Witte (2010) stated that professionals often use selfmade tools to fill this gap. To operate human–machine interface systems effectively, efficiently, and safely, much research has addressed human performance, technological possibilities (Carvalho, dos Santos, Gomes, Borges, & Guerlain, 2008), significant technical improvements including more user-friendly input mechanisms, and a more general procedure (Seeber et al., 2011). Therefore, this study focuses on easy learn features on the interface and interaction. Despite their facilitative features, the overall effectiveness of these keyboards may be negligible and/or their use may be very tiring for participants who exhibit particularly serious motor disabilities (Lancioni et al., 2011), although many
* Corresponding author. Tel.: +886 62133111#744. E-mail address: [email protected] (C.-Y. Lin). http://dx.doi.org/10.1016/j.ridd.2014.04.028 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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C.-Y. Lin, Y.-M. Chang / Research in Developmental Disabilities 35 (2014) 1963–1969
multi-screen designs have changed the method of operating the screen, using only the finger to touch the screen and control it, specific participation in more vigorous leisure activities has proven to improve participants’ physical fitness and adjustment to a life with disabilities. As the majority of leisure pastimes available for people with severe physical limitations is often extremely limited (Lotan, Yalon-Chamovitz, & Weiss, 2009), such leisure activities are not useful for people with severe physical disabilities. People with physical disabilities experience limitations in fine motor control, strength, and range of motion. These deficits can dramatically limit their ability to perform daily tasks independently, such as dressing, hair combing, and bathing. These deficits can also reduce participation in community and leisure activities (Chang, Chen, & Huang, 2011). Participation in leisure activities is a fundamental human right and an important factor in quality of life. Many people with intellectual disabilities also have physical difficulties that prevent them from using standard computer control devices. Custom-made alternative devices for those with special needs are expensive, and the low unit turnover makes the prospect unattractive to potential manufacturers (Standen, Camm, Battersby, Brown, & Harrison, 2011). Just as the art games on console systems such as Microsoft Xbox, Nintendo Wii, or Sony PlayStation offer fun but also function as rehabilitation treatment, therapeutic systems could be used the business device (Ding et al., 2013). Recently, efforts have been made to assess new method, MaKey MaKey is an invention kit containing a printed circuit board running Arduino Leonardo firmware (Aron, 2012). It uses the human interface device (HID) protocol to communicate with the computer, and it can transmit key presses. The use of the MaKey MaKey board to create a novel game controller to control different types of Flash or other games could become a new platform for improvising tangible user interfaces. It enables people to make nature-based interfaces, it is compatible with all software, and it does not require the user to program or assemble electronics (Collective & Shaw, 2012); furthermore, educators are finding ways to increase students’ motivation, one of which is making a task more enjoyable (Sun & Han, 2013). With the progress of technology, the input interface from the traditional mouse and keyboard has evolved to the touch screen. Although the special nature of touch screens focuses on easier user operation and learning (Wu, Lin, & You, 2011), it might not be well suited for people with physical disabilities. The MaKey MaKey, however, uses high resistance switching to detect when a user makes a connection, even though the materials are not very conductive. This study used aids for children with disabilities; compared with the expert device, the advantage of the MaKey MaKey is its low cost and the fact that this kit could be redesigned with relatively more conductive materials for children with physical disabilities to expand their activities. Physical activity is an effective intervention for improving physical complaints (Mirandola et al., 2013), enhancing cognition (Erickson et al., 2011), and improving body alignment and function (Howden et al., 2013). Physical activity may have a prognostic benefit (Hogg, Grant, Garrod, & Fiddler, 2012) and improves both balance and performance (Chou, Hwang, & Wu, 2012). For people with cerebral palsy, physical activity is a good strategy for maintaining the muscle flexibility. Motivation is a strong intervention, enabling participants to benefit from more frequent bodily activity. 2. Method 2.1. Participants This study recruited two participants, both of whom are children studied at self-contained class room in kindergarten. We obtained formal consent from their parents for this study designed to enhance the frequency of the participants’ physical activities. Helen studies in kindergarten, and is a 5-year and 9-month-old female. Her condition is severe physical disabilities, with cerebral palsy convulsions. Her hands and both legs cannot operate a mouse button because of lack the motivation of physical activities; all of her limbs involuntarily twitch, and so she must sit on a customized Kinder chair and be strapped into her H-harness to remain stable. Her upper arms and forearms could move, but her legs move weakly, and so she always sits on the customized Kinder chair and lacks the initiative to exercise. Jay also studies in kindergarten, and is a 3-year and 8-month-old male. His condition is moderate multiple disabilities, with both legs weak and low vision. He always sits on chair. If he stands, he always uses a walker for support. He could lift his legs, but also lacks the initiative to strengthen his legs. 2.2. Apparatus, material and setting The study tested the experiment at a self-contained class room in kindergarten. The input device used in this study is the MaKey MaKey and wood pulp fiber. The MaKey MaKey is a device that promises to turn anything even slightly conductive into a key or mouse button. The principle is clipping two objects to the MaKey MaKey board, which then makes a circuit, and MaKey MaKey sends the computer a keyboard message. Wood pulp fiber is a type of cloth that offers flexibility and high conductivity (Chu, Zhang, Liu, & Leng, 2014) and feels softer than aluminum foil; it was originally used in clean kitchenware, so it is easy to obtain at a supermarket and priced less than $1 USD. This study focused on how to use conductive materials as an intuitive input interface. Makey Makey was connected to a notebook computer on which the interactive Flash- and Scratch-base multimedia were installed with Microsoft Window 7. The configuration of the study is shown in Fig. 1. The Makey Makey connected with one
[(Fig._1)TD$IG]
C.-Y. Lin, Y.-M. Chang / Research in Developmental Disabilities 35 (2014) 1963–1969
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Fig. 1. The configuration of this study.
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Fig. 2. The experimental setup.
participant and conductive materials. At the beginning, there is a prepared multimedia show on the screen for 5 s, then on the pause situation. When the participant touches the conductive material again, the multimedia plays for 5 s, after which the multimedia pauses. When the participant touches the conductive material, it creates a conductive loop, which then starts the play function. Because the participants are two children with physical disabilities, and they respond more slowly than normal children, the operating process time was set to 1 min. The intervention materials design by Flash and Scratch technology (Brennan & Resnick, 2013; Brennan, Resnick, & Monroy-Hernandez, 2010; Monroy-Herna´ndez & Resnick, 2008) to set up the multimedia pauses automatically every 5 s, and so the multimedia could not play anything unless the participant touches the conductive material. The goal was to identify how many times the participant applied his/her physical strength to touch any part of the conductive material as a physical activity. Helen could sit on her Kinder chair; her upper arms are weak, so this study put wood pulp fiber on the edge of her table, focused on giving her motivational training to stretch her arms to touch the wood pulp fiber. Jay sat on a chair, and this study set wood pulp fiber on the floor, requiring that he lift his legs to touch the conductive material, and so focused on giving him motivational training to move his legs. 2.3. General procedure This study examines the effect of interactive multimedia training on operating a computer to help people with physical disabilities engage in physical activity. The input interface is low-cost conductive materials with a computer and MaKey MaKey. Fig. 2 depicts the experimental setup.
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The experimental design adopted the ABAB reversal design for the single-case model (Chang, Han, & Tsai, 2013; Neely, Rispoli, Camargo, Davis, & Boles, 2013; Shih, 2013; Shih, Shih, & Luo, 2013). These case designs are a set of research methods for evaluating treatment effects by assigning different treatments to the same individual and measuring outcomes over time, and they are used across fields such as behavior analysis, clinical psychology, and special education (Hedges, Pustejovsky, & Shadish, 2012). The A (baseline phase) was followed by B (intervention phase), a return to the baseline phase, and then a final intervention phase. In this study, the A represented baseline phases and the B represented intervention phases with the MaKey MaKey system. The experiment was divided into four phases: Baseline 1, Intervention 1, Baseline 2, and Intervention 2. Single-case design is a research method involving deliberate assignment of different conditions to the same individual and measurement of one or more outcomes over time (Hedges, Pustejovsky, & Shadish, 2013). Cohen (1988) offered a large (>0.35), medium (0.15–0.35), or small effect size (0.02–0.15), an effect size for predictive regression equations that could indicate the actual effect. The experiment period comprised one months and a half, 2–3 sessions per day, 4–5 days a week, and each session lasted 1 min during which we collected data points. In the first phrase, Baseline 1 (A1), we collected nine data points. In the second phrase, Intervention 1 (B1), the intervention input device was adjusted to the conductive material and used MaKey MaKey as a connecting mechanism to the computer, in the second phase, we collected 21 data points. In the third phrase, Baseline 2 (A2), withdrawal of the device and multimedia, we collected nine data points. In the fourth phrase, Intervention 2 (B2), the intervention setup just like B1, we collected 24 data points, the trend remained stable, and thus the experiment ended.
3. Results The data collected from the four phases were graphed, with the x-axis indicating the four phases and points scored in each, and the y-axis represents the number of times the participant touched the correct conductive materials and obtained feedback. 3.1. Helen’s result Helen finds taking and operating items with her arms difficult. When she stretched her arm 30 cm to the table’s edge so that she could touch the conductive materials, the multimedia played, after playing for 5 s, it paused, making Helen stretch her arm again to execute the play function. Fig. 3 reports Helen’s data. In Baseline 1 (A1: 9 sessions), the mean for each session of Helen was low; the mean score at A1 was 1.11, with a range of 0–2 in 1 min. The results of Baseline 1 (A1) indicated that Helen lacked motivation for physical activities as she maintained a static position sitting on her customization Kinder chair. When the experiment proceeded to Intervention 1 (B1: 21 sessions), the mean score was 7.05, with a range for 5–9 in 1 min, indicating different stability in B1. Helen achieved higher scores in B1 than A1. In B1, Helen understood that when she stretched her hand to touch the wood pulp fiber, she could watch the multimedia and listen to the sound; 5 s later, when the multimedia paused, if she stretched her hand again to touch the wood pulp fiber, she could watch the multimedia continue. In Baseline 2 (A2: 9 sessions), this study withdraw the intervention, and the data indicated that the mean in A2 reverted to that of A1, the mean score at A2 was 1.00, with a range of 0–2 in 1 min. The results of A2 indicated that upon withdrawing the intervention, Helen again lacked the motivation for physical activities; absent the attraction motivating her perform physical activities, she sat immobile on her Kinder chair just as before. [(Fig._3)TD$IG]
Fig. 3. Reports of Helen’s data.
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Fig. 4. Reports of Jay’s data.
In intervention 2(B2: 24 sessions), the study indicated a difference from A2, the mean score at B2 was 7.38, with a range of 5–9 in 1 min. Helen found the intervention materials, stretched her arm to touch the wood pulp fiber repeatedly, and understood that when she performed this action repeatedly, she could watch the multimedia continue, thus representing an attractive motivation for Helen. In the effect measurement, for A1 and B1, the xt’s p = 0.60 > 0.05, and the intercept effect size f_square = 2.2618. For A2 and B2, the xt’s p = 0.54 > 0.05, and the intercept effect size f_square = 2.2870. The intervention phase demonstrated significantly higher effectiveness than the baseline; A1 and B1 produced a large effect (2.2618 > 0.35), as did A2 and B2 produced a large effect (2.2870 > 0.35), with the interventions producing an immediate effects on Helen’s physical activities. From visual analysis, the correct score significantly increased at the B1 phase, the B2 score results are higher than A2. The effect sizes both are both large effect. The results demonstrated that the improvement between baseline phases and intervention phases was significant (p = 0.00 < 0.05), from the Kolmogorov–Smirnov statistic test, thus, this intervention had significant effectiveness on Helen’s physical activity. 3.2. Jay’s result Because Jay has cerebral palsy with low vision, this study sought to train him to lift his legs and move by himself. He sat on the chair, and we installed conductive materials on the floor so that he must lift and move his legs to touch it; the contents also used the serial multimedia by Flash and Scratch software. After 5 s, the multimedia would pause, motivating him to make the multimedia continue by lifting his legs to touch the conductive material again. Fig. 4 reports Jay’s data. In Baseline 1 (A1: 9 sessions), the mean for each session of Jay was low; the mean score at A1 was 0.78, with a range of 0–2 in 1 min. The results of A1 indicated that Jay lacked motivation for physical activities. When the experiment proceeded to Intervention 1 (B1: 21 sessions), the mean score was 6.67, with a range for 5–9 in 1 min, indicating different stability in B1. Jay understood that when he lifted and moved his legs so that his foot touched the wood pulp fiber, he could listen to the songs (he has low vision, and so he likes focus on sounds); then, 5 s later, when the sound paused, he had strong motivation to lift his leg to touch the wood pulp fiber to continue listening to the songs. In Baseline 2 (A2: 9 sessions), this study withdraw the intervention, and the data indicated that the mean in A2 reverted to A1, the mean score at A2 was 1.22, with a range of 0–2 in 1 min. The results of A2 indicated that Jay also lacked motivation to exercise his legs. In B2 (B2: 24 sessions), the study indicated a difference from A2, the mean score at B2 was 7.54, with a range of 7–10 in 1 min. Jay found that he could control the feedback again; he appeared excited and lifted his legs to touch the wood pulp fiber repeatedly. He understands that when he repeated this action, he could obtain the real-time feedback, which was an achievement for Jay. In the effect measurement, for A1 and B1, the xt’s p = 0.69 > 0.05, and the intercept effect size f_square = 1.8900. For A2 and B2, the xt’s p = 0.64 > 0.05, and the intercept effect size f_square = 2.7679. The intervention phase demonstrated significantly higher effectiveness than the baseline; A1 and B1 produced a large effect (1.8900 > 0.35), as did A2 and B2 produced a large effect (2.7679 > 0.35), with the interventions producing an immediate effects on Jay’s physical activities. The intervention phase demonstrated significantly higher effectiveness than the baseline; thus, the interventions produced an immediate effect on Jay’s physical activity. B1 and B2, the score results are higher than after A1 and A2. The effect sizes both are both large effect. The results demonstrated that the improvement between baseline phases and intervention phases was significant, from the Kolmogorov–Smirnov statistic test, p = 0.00 < 0.05; Therefore, this study suggested a good intervention to motivate Jay to engage in more training for his physical activity.
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4. Discussion This study investigated the use of technology from MaKey MaKey to create a custom-designed, low-cost interactive basic program for an individual diagnosed with physical disabilities, and the study demonstrated that this type of mechanism is useful for motivating and increasing such individuals’ physical activity. This approach could be used as an independent interactive feedback for children with physical disabilities. Helen, at the baseline, always remained in a static situation, but the results of the intervention phases prove the mechanism’s effectiveness. The study interviewed her mother after the experiment, and she also reported that the adjusted interface would be suitable for her child; moreover, she set up the same device and materials at home to train Helen’s other body parts to strengthen muscles. Jay, at the baseline, exhibited no autonomous activities, but the results of the intervention phases proved that creating an intuitive feedback is suitable for him. He found that he could control the multimedia when he lifted his legs and touch the wood pulp fiber, and so the system encouraged him to repeat that physical activity. This study added only wood pulp fiber and MaKey MaKey kit to the original environment, rather than creating a totally new experimental environment for the children. This study was conducted at a self-contained class room in kindergarten, in an environment more familiar than a lab for the children, and their parents and teachers who participated in the study. The participants in this novel program were not only restricted for this two participant; one girl thought to have developmental disabilities also studied in the same class room, and she also enjoyed this study, and participated in the activities on her own initiative. The study involved interaction among teachers, parents, and researchers. This study used conductive materials, a computer, and Flash- and Scratch-based multimedia to create an interactive environment for participants with cerebral palsy who lack motivation to perform physical activities, and we found that this type of intervention could be effective. As related research (Shih, Wang, Chang, & Shih, 2012) used films as a solution to improve motivation and enhance their physical activities, this study also focused on audio feedback because Jay has low vision; we invited him to record his voice, and when he lift and move his leg touch the conductive material, he heard his voice as the feedback, which motivated him to perform the activity repeatedly. The MaKey MaKey interactive technology supports a variety of input materials, such as fruit, water, or anything that could provide a conductive materials as the interface (Blikstein & Krannich, 2013; Hancock et al., 2013; Honey & Kanter, 2013; Resnick & Rosenbaum, 2013). It could thus overcome barriers created by physical disabilities, extending different effects through different games and rehabilitation treatments. The device is lower-cost than other custom expert assistive technologies, and it is simple for the user to change the input material and apply it to web games, Flash games, or Scratch games to create different designs in different fields to suit individual needs. Therapists, teachers, or parents can use the same concept to redesign the device, encourage the limb to move and touch the conductive material instead of pressing a single switch, creating an effective loop that provides an opportunity for interaction for people with physical disabilities. Acknowledgement This work was financially supported by the National Science Council, Taiwan, under the grant no. 100-2410-H-024-028MY2. References Aron, J. (2012). Makey Makey DIY circuit board makes bananas musical. New Scientist, 214, 22. Blikstein, P., & Krannich, D. (2013). 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Contents lists available at ScienceDirect
Research in Developmental Disabilities
Increase in physical activities in kindergarten children with cerebral palsy by employing MaKey–MaKey-based task systems Chien-Yu Lin a,*, Yu-Ming Chang b a
Department of Special Education, National University of Tainan, 33, Section 2, Shu-Lin Street, Tainan 700, Taiwan, ROC College of Digital Design, Southern Taiwan University of Science and Technology, No.1, Nantai Street, Yongkang District, Tainan City 710, Taiwan, ROC
b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 2 April 2014 Received in revised form 21 April 2014 Accepted 22 April 2014 Available online
In this study, we employed Flash- and Scratch-based multimedia by using a MaKey– MaKey-based task system to increase the motivation level of children with cerebral palsy to perform physical activities. MaKey MaKey is a circuit board that converts physical touch to a digital signal, which is interpreted by a computer as a keyboard message. In this study, we used conductive materials to control this interaction. This study followed single-case design using ABAB models in which A indicated the baseline and B indicated the intervention. The experiment period comprised 1 month and a half. The experimental results demonstrated that in the case of two kindergarten children with cerebral palsy, their scores were considerably increased during the intervention phrases. The developmental applications of the results are also discussed. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Interaction Cerebral palsy MaKey MaKey Conductive materials Single-case design
1. Introduction Cerebral palsy is a permanent neurodevelopmental disorders. Beyond motor function impairment, it also compromises cognitive, visual, hearing, and verbal functions (Huang, Pan, Ou, Yu, & Tsai, 2014), because of these limitations, physical activities are quite important. Recently, with technological advances, technology has become applied for special needs individuals (Kagohara, Sigafoos, Achmadi, O’Reilly, & Lancioni, 2012), but one challenge in human–computer interaction is to design systems that users find appealing as well as usable (Bonnardel, Piolat, & Bigot, 2011). As such custom designed assistive technology for people with disabilities is always too costly to promote, Friederich, Bernd, and De Witte (2010) stated that professionals often use selfmade tools to fill this gap. To operate human–machine interface systems effectively, efficiently, and safely, much research has addressed human performance, technological possibilities (Carvalho, dos Santos, Gomes, Borges, & Guerlain, 2008), significant technical improvements including more user-friendly input mechanisms, and a more general procedure (Seeber et al., 2011). Therefore, this study focuses on easy learn features on the interface and interaction. Despite their facilitative features, the overall effectiveness of these keyboards may be negligible and/or their use may be very tiring for participants who exhibit particularly serious motor disabilities (Lancioni et al., 2011), although many
* Corresponding author. Tel.: +886 62133111#744. E-mail address: [email protected] (C.-Y. Lin). http://dx.doi.org/10.1016/j.ridd.2014.04.028 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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multi-screen designs have changed the method of operating the screen, using only the finger to touch the screen and control it, specific participation in more vigorous leisure activities has proven to improve participants’ physical fitness and adjustment to a life with disabilities. As the majority of leisure pastimes available for people with severe physical limitations is often extremely limited (Lotan, Yalon-Chamovitz, & Weiss, 2009), such leisure activities are not useful for people with severe physical disabilities. People with physical disabilities experience limitations in fine motor control, strength, and range of motion. These deficits can dramatically limit their ability to perform daily tasks independently, such as dressing, hair combing, and bathing. These deficits can also reduce participation in community and leisure activities (Chang, Chen, & Huang, 2011). Participation in leisure activities is a fundamental human right and an important factor in quality of life. Many people with intellectual disabilities also have physical difficulties that prevent them from using standard computer control devices. Custom-made alternative devices for those with special needs are expensive, and the low unit turnover makes the prospect unattractive to potential manufacturers (Standen, Camm, Battersby, Brown, & Harrison, 2011). Just as the art games on console systems such as Microsoft Xbox, Nintendo Wii, or Sony PlayStation offer fun but also function as rehabilitation treatment, therapeutic systems could be used the business device (Ding et al., 2013). Recently, efforts have been made to assess new method, MaKey MaKey is an invention kit containing a printed circuit board running Arduino Leonardo firmware (Aron, 2012). It uses the human interface device (HID) protocol to communicate with the computer, and it can transmit key presses. The use of the MaKey MaKey board to create a novel game controller to control different types of Flash or other games could become a new platform for improvising tangible user interfaces. It enables people to make nature-based interfaces, it is compatible with all software, and it does not require the user to program or assemble electronics (Collective & Shaw, 2012); furthermore, educators are finding ways to increase students’ motivation, one of which is making a task more enjoyable (Sun & Han, 2013). With the progress of technology, the input interface from the traditional mouse and keyboard has evolved to the touch screen. Although the special nature of touch screens focuses on easier user operation and learning (Wu, Lin, & You, 2011), it might not be well suited for people with physical disabilities. The MaKey MaKey, however, uses high resistance switching to detect when a user makes a connection, even though the materials are not very conductive. This study used aids for children with disabilities; compared with the expert device, the advantage of the MaKey MaKey is its low cost and the fact that this kit could be redesigned with relatively more conductive materials for children with physical disabilities to expand their activities. Physical activity is an effective intervention for improving physical complaints (Mirandola et al., 2013), enhancing cognition (Erickson et al., 2011), and improving body alignment and function (Howden et al., 2013). Physical activity may have a prognostic benefit (Hogg, Grant, Garrod, & Fiddler, 2012) and improves both balance and performance (Chou, Hwang, & Wu, 2012). For people with cerebral palsy, physical activity is a good strategy for maintaining the muscle flexibility. Motivation is a strong intervention, enabling participants to benefit from more frequent bodily activity. 2. Method 2.1. Participants This study recruited two participants, both of whom are children studied at self-contained class room in kindergarten. We obtained formal consent from their parents for this study designed to enhance the frequency of the participants’ physical activities. Helen studies in kindergarten, and is a 5-year and 9-month-old female. Her condition is severe physical disabilities, with cerebral palsy convulsions. Her hands and both legs cannot operate a mouse button because of lack the motivation of physical activities; all of her limbs involuntarily twitch, and so she must sit on a customized Kinder chair and be strapped into her H-harness to remain stable. Her upper arms and forearms could move, but her legs move weakly, and so she always sits on the customized Kinder chair and lacks the initiative to exercise. Jay also studies in kindergarten, and is a 3-year and 8-month-old male. His condition is moderate multiple disabilities, with both legs weak and low vision. He always sits on chair. If he stands, he always uses a walker for support. He could lift his legs, but also lacks the initiative to strengthen his legs. 2.2. Apparatus, material and setting The study tested the experiment at a self-contained class room in kindergarten. The input device used in this study is the MaKey MaKey and wood pulp fiber. The MaKey MaKey is a device that promises to turn anything even slightly conductive into a key or mouse button. The principle is clipping two objects to the MaKey MaKey board, which then makes a circuit, and MaKey MaKey sends the computer a keyboard message. Wood pulp fiber is a type of cloth that offers flexibility and high conductivity (Chu, Zhang, Liu, & Leng, 2014) and feels softer than aluminum foil; it was originally used in clean kitchenware, so it is easy to obtain at a supermarket and priced less than $1 USD. This study focused on how to use conductive materials as an intuitive input interface. Makey Makey was connected to a notebook computer on which the interactive Flash- and Scratch-base multimedia were installed with Microsoft Window 7. The configuration of the study is shown in Fig. 1. The Makey Makey connected with one
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Fig. 1. The configuration of this study.
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Fig. 2. The experimental setup.
participant and conductive materials. At the beginning, there is a prepared multimedia show on the screen for 5 s, then on the pause situation. When the participant touches the conductive material again, the multimedia plays for 5 s, after which the multimedia pauses. When the participant touches the conductive material, it creates a conductive loop, which then starts the play function. Because the participants are two children with physical disabilities, and they respond more slowly than normal children, the operating process time was set to 1 min. The intervention materials design by Flash and Scratch technology (Brennan & Resnick, 2013; Brennan, Resnick, & Monroy-Hernandez, 2010; Monroy-Herna´ndez & Resnick, 2008) to set up the multimedia pauses automatically every 5 s, and so the multimedia could not play anything unless the participant touches the conductive material. The goal was to identify how many times the participant applied his/her physical strength to touch any part of the conductive material as a physical activity. Helen could sit on her Kinder chair; her upper arms are weak, so this study put wood pulp fiber on the edge of her table, focused on giving her motivational training to stretch her arms to touch the wood pulp fiber. Jay sat on a chair, and this study set wood pulp fiber on the floor, requiring that he lift his legs to touch the conductive material, and so focused on giving him motivational training to move his legs. 2.3. General procedure This study examines the effect of interactive multimedia training on operating a computer to help people with physical disabilities engage in physical activity. The input interface is low-cost conductive materials with a computer and MaKey MaKey. Fig. 2 depicts the experimental setup.
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The experimental design adopted the ABAB reversal design for the single-case model (Chang, Han, & Tsai, 2013; Neely, Rispoli, Camargo, Davis, & Boles, 2013; Shih, 2013; Shih, Shih, & Luo, 2013). These case designs are a set of research methods for evaluating treatment effects by assigning different treatments to the same individual and measuring outcomes over time, and they are used across fields such as behavior analysis, clinical psychology, and special education (Hedges, Pustejovsky, & Shadish, 2012). The A (baseline phase) was followed by B (intervention phase), a return to the baseline phase, and then a final intervention phase. In this study, the A represented baseline phases and the B represented intervention phases with the MaKey MaKey system. The experiment was divided into four phases: Baseline 1, Intervention 1, Baseline 2, and Intervention 2. Single-case design is a research method involving deliberate assignment of different conditions to the same individual and measurement of one or more outcomes over time (Hedges, Pustejovsky, & Shadish, 2013). Cohen (1988) offered a large (>0.35), medium (0.15–0.35), or small effect size (0.02–0.15), an effect size for predictive regression equations that could indicate the actual effect. The experiment period comprised one months and a half, 2–3 sessions per day, 4–5 days a week, and each session lasted 1 min during which we collected data points. In the first phrase, Baseline 1 (A1), we collected nine data points. In the second phrase, Intervention 1 (B1), the intervention input device was adjusted to the conductive material and used MaKey MaKey as a connecting mechanism to the computer, in the second phase, we collected 21 data points. In the third phrase, Baseline 2 (A2), withdrawal of the device and multimedia, we collected nine data points. In the fourth phrase, Intervention 2 (B2), the intervention setup just like B1, we collected 24 data points, the trend remained stable, and thus the experiment ended.
3. Results The data collected from the four phases were graphed, with the x-axis indicating the four phases and points scored in each, and the y-axis represents the number of times the participant touched the correct conductive materials and obtained feedback. 3.1. Helen’s result Helen finds taking and operating items with her arms difficult. When she stretched her arm 30 cm to the table’s edge so that she could touch the conductive materials, the multimedia played, after playing for 5 s, it paused, making Helen stretch her arm again to execute the play function. Fig. 3 reports Helen’s data. In Baseline 1 (A1: 9 sessions), the mean for each session of Helen was low; the mean score at A1 was 1.11, with a range of 0–2 in 1 min. The results of Baseline 1 (A1) indicated that Helen lacked motivation for physical activities as she maintained a static position sitting on her customization Kinder chair. When the experiment proceeded to Intervention 1 (B1: 21 sessions), the mean score was 7.05, with a range for 5–9 in 1 min, indicating different stability in B1. Helen achieved higher scores in B1 than A1. In B1, Helen understood that when she stretched her hand to touch the wood pulp fiber, she could watch the multimedia and listen to the sound; 5 s later, when the multimedia paused, if she stretched her hand again to touch the wood pulp fiber, she could watch the multimedia continue. In Baseline 2 (A2: 9 sessions), this study withdraw the intervention, and the data indicated that the mean in A2 reverted to that of A1, the mean score at A2 was 1.00, with a range of 0–2 in 1 min. The results of A2 indicated that upon withdrawing the intervention, Helen again lacked the motivation for physical activities; absent the attraction motivating her perform physical activities, she sat immobile on her Kinder chair just as before. [(Fig._3)TD$IG]
Fig. 3. Reports of Helen’s data.
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Fig. 4. Reports of Jay’s data.
In intervention 2(B2: 24 sessions), the study indicated a difference from A2, the mean score at B2 was 7.38, with a range of 5–9 in 1 min. Helen found the intervention materials, stretched her arm to touch the wood pulp fiber repeatedly, and understood that when she performed this action repeatedly, she could watch the multimedia continue, thus representing an attractive motivation for Helen. In the effect measurement, for A1 and B1, the xt’s p = 0.60 > 0.05, and the intercept effect size f_square = 2.2618. For A2 and B2, the xt’s p = 0.54 > 0.05, and the intercept effect size f_square = 2.2870. The intervention phase demonstrated significantly higher effectiveness than the baseline; A1 and B1 produced a large effect (2.2618 > 0.35), as did A2 and B2 produced a large effect (2.2870 > 0.35), with the interventions producing an immediate effects on Helen’s physical activities. From visual analysis, the correct score significantly increased at the B1 phase, the B2 score results are higher than A2. The effect sizes both are both large effect. The results demonstrated that the improvement between baseline phases and intervention phases was significant (p = 0.00 < 0.05), from the Kolmogorov–Smirnov statistic test, thus, this intervention had significant effectiveness on Helen’s physical activity. 3.2. Jay’s result Because Jay has cerebral palsy with low vision, this study sought to train him to lift his legs and move by himself. He sat on the chair, and we installed conductive materials on the floor so that he must lift and move his legs to touch it; the contents also used the serial multimedia by Flash and Scratch software. After 5 s, the multimedia would pause, motivating him to make the multimedia continue by lifting his legs to touch the conductive material again. Fig. 4 reports Jay’s data. In Baseline 1 (A1: 9 sessions), the mean for each session of Jay was low; the mean score at A1 was 0.78, with a range of 0–2 in 1 min. The results of A1 indicated that Jay lacked motivation for physical activities. When the experiment proceeded to Intervention 1 (B1: 21 sessions), the mean score was 6.67, with a range for 5–9 in 1 min, indicating different stability in B1. Jay understood that when he lifted and moved his legs so that his foot touched the wood pulp fiber, he could listen to the songs (he has low vision, and so he likes focus on sounds); then, 5 s later, when the sound paused, he had strong motivation to lift his leg to touch the wood pulp fiber to continue listening to the songs. In Baseline 2 (A2: 9 sessions), this study withdraw the intervention, and the data indicated that the mean in A2 reverted to A1, the mean score at A2 was 1.22, with a range of 0–2 in 1 min. The results of A2 indicated that Jay also lacked motivation to exercise his legs. In B2 (B2: 24 sessions), the study indicated a difference from A2, the mean score at B2 was 7.54, with a range of 7–10 in 1 min. Jay found that he could control the feedback again; he appeared excited and lifted his legs to touch the wood pulp fiber repeatedly. He understands that when he repeated this action, he could obtain the real-time feedback, which was an achievement for Jay. In the effect measurement, for A1 and B1, the xt’s p = 0.69 > 0.05, and the intercept effect size f_square = 1.8900. For A2 and B2, the xt’s p = 0.64 > 0.05, and the intercept effect size f_square = 2.7679. The intervention phase demonstrated significantly higher effectiveness than the baseline; A1 and B1 produced a large effect (1.8900 > 0.35), as did A2 and B2 produced a large effect (2.7679 > 0.35), with the interventions producing an immediate effects on Jay’s physical activities. The intervention phase demonstrated significantly higher effectiveness than the baseline; thus, the interventions produced an immediate effect on Jay’s physical activity. B1 and B2, the score results are higher than after A1 and A2. The effect sizes both are both large effect. The results demonstrated that the improvement between baseline phases and intervention phases was significant, from the Kolmogorov–Smirnov statistic test, p = 0.00 < 0.05; Therefore, this study suggested a good intervention to motivate Jay to engage in more training for his physical activity.
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4. Discussion This study investigated the use of technology from MaKey MaKey to create a custom-designed, low-cost interactive basic program for an individual diagnosed with physical disabilities, and the study demonstrated that this type of mechanism is useful for motivating and increasing such individuals’ physical activity. This approach could be used as an independent interactive feedback for children with physical disabilities. Helen, at the baseline, always remained in a static situation, but the results of the intervention phases prove the mechanism’s effectiveness. The study interviewed her mother after the experiment, and she also reported that the adjusted interface would be suitable for her child; moreover, she set up the same device and materials at home to train Helen’s other body parts to strengthen muscles. Jay, at the baseline, exhibited no autonomous activities, but the results of the intervention phases proved that creating an intuitive feedback is suitable for him. He found that he could control the multimedia when he lifted his legs and touch the wood pulp fiber, and so the system encouraged him to repeat that physical activity. This study added only wood pulp fiber and MaKey MaKey kit to the original environment, rather than creating a totally new experimental environment for the children. This study was conducted at a self-contained class room in kindergarten, in an environment more familiar than a lab for the children, and their parents and teachers who participated in the study. The participants in this novel program were not only restricted for this two participant; one girl thought to have developmental disabilities also studied in the same class room, and she also enjoyed this study, and participated in the activities on her own initiative. The study involved interaction among teachers, parents, and researchers. This study used conductive materials, a computer, and Flash- and Scratch-based multimedia to create an interactive environment for participants with cerebral palsy who lack motivation to perform physical activities, and we found that this type of intervention could be effective. As related research (Shih, Wang, Chang, & Shih, 2012) used films as a solution to improve motivation and enhance their physical activities, this study also focused on audio feedback because Jay has low vision; we invited him to record his voice, and when he lift and move his leg touch the conductive material, he heard his voice as the feedback, which motivated him to perform the activity repeatedly. The MaKey MaKey interactive technology supports a variety of input materials, such as fruit, water, or anything that could provide a conductive materials as the interface (Blikstein & Krannich, 2013; Hancock et al., 2013; Honey & Kanter, 2013; Resnick & Rosenbaum, 2013). It could thus overcome barriers created by physical disabilities, extending different effects through different games and rehabilitation treatments. The device is lower-cost than other custom expert assistive technologies, and it is simple for the user to change the input material and apply it to web games, Flash games, or Scratch games to create different designs in different fields to suit individual needs. Therapists, teachers, or parents can use the same concept to redesign the device, encourage the limb to move and touch the conductive material instead of pressing a single switch, creating an effective loop that provides an opportunity for interaction for people with physical disabilities. Acknowledgement This work was financially supported by the National Science Council, Taiwan, under the grant no. 100-2410-H-024-028MY2. References Aron, J. (2012). Makey Makey DIY circuit board makes bananas musical. New Scientist, 214, 22. Blikstein, P., & Krannich, D. (2013). 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