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An individualized and adaptive game-based therapy for cerebral visual

impairment: Design, development, and evaluation

Article  in  International Journal of Child-Computer Interaction · December 2021

DOI: 10.1016/j.ijcci.2021.100437

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 An individualized and adaptive game-based therapy for cerebral visual impairment:
Design, development, and evaluation

N. Ben Itzhaka, I. Frankia, B. Jansenb,c, K. Kostkovab,c, Wagemansd,e, E. Ortibusa,f

a
Department of Development and Regeneration, University of Leuven (KU Leuven)
Postal address: O&N IV Herestraat 49, Box 805, 3000 Leuven, Belgium
Email address: nofar.benitzhak@kuleuven.be
b
Department of Electronics and Informatics (ETRO), Vrije Universiteit Brussel (VUB),
Brussels, Belgium
c
imec, Leuven, Belgium
d
Department of Brain & Cognition, University of Leuven (KU Leuven), Leuven, Belgium
e
Leuven Brain Institute (LBI), Leuven, Belgium
f
Child Youth Institute (L-C&Y), Leuven, Belgium

The views expressed in the submitted article are our own and not an official position of the
institution or funder.
This work was supported by the Fund Scientific Research Flanders (FWO-project) (grant
number T003817N). Author JW was supported by the Flemish Government (grant number
METH/14/02).
The authors report no conflict of interest.

The manuscript contains 47 pages, and 1 table, 8 figures, and 9 appendices.

Word count: 8000.

Acknowledgments

This complex research project would not have been possible without the commitment from the
caregivers and therapists living with and working with children with cerebral visual
impairment. The authors would like to thank Ann Van Hoegaerden and Centrum Ganspoel for
their willingness to provide us the opportunity to collaborate with them, parents of the children,
and the children themselves. Moreover, the commitment of the vision scientists and clinicians
from the CVI clinic in Leuven who contributed to every phase in this project is appreciated. We
would like to thank the summer playgrounds Don Bosco and Kettelo in Leuven for contacting
parents and organizing for us to work with the children, as well as our friends who were willing

1
to allow their children to test the games. We extend our gratitude to Kathleen Vancleef who
provided us with guidance throughout the development process of the games. The authors
would also like to thank Wouter Durnez and Jan Van Looy who ran the focus groups and user
requirements analyses and Anissa All who shared her expertise on game development. We
would like to thank Sophie Decavele who worked as a research assistant in the different phases
of the project. Finally, the authors would like to thank the speech and language pathologist
Katrijn Miermans who verified that the language content was correct and age-appropriate.

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 An individualized and adaptive game-based therapy for cerebral visual impairment:
Design, development, and evaluation

Abstract

Children with cerebral visual impairment (CVI) exhibit a very heterogeneous clinical
visuoperceptual picture, which implies that a targeted individualized and adaptive therapy is
necessary. Serious games for CVI are limited, especially those that train multiple
visuoperceptual skills in an individualized and adaptive manner without the frequent manual
input from clinicians. In this paper, we describe the design, development, and evaluation
process of novel individualized and adaptive serious mini-games for visual perceptual skills.
First, an informant-led design, including focus groups with relevant stakeholders implementing
a participation-via-proxy and brainstorming sessions, was performed. This resulted in rapid
prototypes of four mini-games (MatchMaker, Hurricane Chaos, Maze Explorer 2D, and Maze
Explorer 3D), targeting six visuoperceptual skills commonly impaired in children with CVI: (1)
visual discrimination and matching, (2) object or picture recognition, (3) visual spatial
perception, (4) figure-ground perception, (5) motion perception, and (6) visual short-term
memory. Therapeutic game content (selecting, manipulating, and rating images; defining entry-
level difficulty and in-game adaptivity rules) was evaluated by clinical and research experts.
Finally, formative testing and expert feedback, including usability and user experience by
clinicians, researchers, and typically developing children, led to important modifications in the
mini-games.

Keywords

Cerebral visual impairment; Visuoperceptual profile; Serious game-based therapy; Functional

vision; Individualized; Adaptive.

Introduction
Cerebral visual impairment (CVI) is defined as “a verifiable visual dysfunction which cannot
be attributed to disorders of the anterior visual pathways or any potentially co-occurring ocular
impairment” [1]. As brain damage is usually diffuse, diverse deficits in visual perception are
characteristic for CVI [2–4]. CVI occurs on a gradient of severity and comorbid conditions such
as cerebral palsy and autism spectrum disorder are common, further complicating the clinical
picture [5–7]. CVI profoundly affects everyday activities, lowering the psychosocial and
physical quality of life [5]. Hence, to enhance children’s development and functioning, early
rehabilitation is crucial. CVI deficits include visual recognition and visual memory of objects
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and routes [2,5,8–12], figure-ground perception and visual search [13,14], visual spatial
perception and navigation [5,10,11], motion perception [2,8,9], and visual discrimination
[5,15].

Currently, no standard treatment for visual perception impairments in CVI exists [16].
Therapies targeting more basic, low-level functions do exist, for instance, teaching line and
edge detection, and presenting simple distinct black or white shapes or figures [17]. Visual
stimulation tools (e.g., high-contrast black and white/coloured slides, fluorescent material)
improve visual attention, spontaneous visual interest, gazing and following, comparison, and
visual exploration in CVI [18]. However, data are scarce and controlled studies lack, hence, no
single, specific tool can be uniformly advocated [16]. Furthermore, traditional CVI therapy
mainly focuses on orientation, eye-hand coordination, looking at objects, and learning
compensatory strategies. The improvement on these skills is difficult to quantify, hence,
measuring the effectiveness of such therapies is challenging.

Evaluation of therapy effectiveness is hampered further because their content, the platform on
which the therapy is delivered, and the disorders that they target vary widely. In general
however, studies using computerized methods of training have shown positive training effects
on visual perception and child behaviour compared to a control group [19–21].

Also, visual perceptual training interventions using multimedia tools are superior to those
presented on paper [22]. For example, children with developmental disabilities improved their
visual perception more after following a computer-based cognitive rehabilitation program for
children compared to a paper and pencil control group [23]. Other research has also shown that
a multimedia program training memory, spatial relations, recognition, and discrimination
improved visual perception more than an equivalent paper and pencil program [22]. Traditional
paper activities are not motivating nor encouraging for children as they rely on static picture
and text, while computer multimedia is more diversified with animations and multimodal output
of visual presentation including video, sound, light, and colour. Moreover, computer
multimedia provides immediate and animated feedback with interactivity, which increases
attention, maintains concentration, promotes motivation, and induces learning [22,24].
Additional advantages of game-based therapy include an easy-to-use (touchscreen) interface,
portability, and self-paced and personalized learning [25]. Lastly, by performing therapy at
home, intervention can be more accessible and last longer, with less parental effort [25].

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Existing game-based therapies for CVI are promising, but they also have limitations.
Specifically, current games still need to be manually modified and personalized. Vandewaetere
and Clarebout’s [26] framework discusses the static, dynamic, and combination approaches to
learner modelling. A combination model involves both a static and dynamic modelling, which
first classifies the learner based on prior information (i.e., static), but also keeps track of the
progress (i.e., dynamic), providing individualized practice. It has been argued that it is not the
medium as such that leads to training improvements but rather game characteristics such as
feedback and adaptivity [27]. Therefore, for game-based therapy to be even more effective, we
propose a targeted individualized and adaptive therapy.

An individualized therapy considers each child’s unique pattern of visual, perceptual, and
visuomotor dysfunction together with their intact functions and uses it as the basis for their
individualized rehabilitation programme and entry-level game difficulty [2,28–31]. A
quantified visuoperceptual profile has been previously developed for children with CVI based
on the following six VP dimensions (1) visual discrimination and matching, (2) object or picture
recognition, (3) visual spatial perception, (4) figure-ground perception, (5) motion perception,
and (6) visual short-term memory [31]. Moreover, adaptivity is defined as “the ability of a
learning system to diagnose a range of learner variables, and to accommodate a learner’s
specific needs by making appropriate adjustments to the learner’s experience with the goal of
enhancing learning outcomes” [32]. Adaptive serious games promote motivated usage, user
acceptance, and user identification [33], and in heterogeneous target groups such a personalized
experience facilitates achieving targeted outcomes [33]. Both an appropriate definition of entry-
level as well as in-game adaptivity are necessary to maintain an optimal difficulty to attain a
flow state. Flow can be defined as being “fully in the zone”, focused, engaged, and enjoying,
which triggers an increased motivation to repeatedly perform an activity [34]. To retain a state
of flow, a skill-challenge balance is important [34] (see Figure 1). One method that
automatically adapts difficulty level to the player’s current skill level is dynamic difficulty
adjustment (DDA), in which the game difficulty is decreased when performance is below a
certain threshold and increased when performance is above a certain threshold [33]. Adaptivity
supports the user to stay in the flow channel or optimal gameplay corridor where a good match
between their skill and the game difficulty is experienced.

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Figure 1. The optimal gameplay corridor, based on combination of numerous works [33–36].
Adaptivity is shown by the dotted arrow-lines and the player’s interaction through the game is
shown by the arrow-lines. When the player leaves the flow channel, the adaptivity mechanism
pushes the player back into the optimal gameplay zone.

This paper focuses on the creation of individualized and adaptive mini-games for children with
CVI (performance age between 3 and 12 years). We present the development and evaluation
process using participation-via-proxy, involving a multidisciplinary team as well as usability
and user experience testing in clinicians, researchers, and typically developing children.

Previous research: A short overview of games for CVI

Previous research has developed an iPad curriculum with individualized goals and modified
settings [37], and has shown to be superior to a traditional tool in improving communication,
visual attention, reaching, and activating items on the screen [38]. Another company, Little
Bear Sees, developed iPad applications for CVI [39], but these applications and the iPad
curriculum target basic functions. Moreover, other games have been developed (training
visuomotor coordination, simultaneously seeing and touching an object, and cognitive decision
making), and although they are adaptive and individualized, the therapist still needs to make
adjustments manually according to the child’s performance [40–42]. Finally, another game
training functional vision has the possibility to adapt to the visual, cognitive, and physical
abilities of a player, but has to be defined by a user, carer, or therapist [43,44].

Linehan et al. [45] summarized design principles for game rehabilitation for children with
cerebral visual impairment. Examples of important features to consider include: (1) therapy-
appropriate behaviour with the goal of fulfilling therapeutic goals as the basis of the core game

6
mechanics, (2) adapting the game based on the patient’s ability (i.e., both visual and cognitive
challenges), (3) performance over time should be trackable to determine whether sufficient
progress is being made or not, and (4) simple visual aspects (i.e., not starting with complex
images) and the use of other forms of representation (e.g., audio).

The current research

This paper outlines four phases of design and development to formative evaluation (outlined in
Figure 2) of four serious mini-games, for use by children with a performance age between 3
and 12 years with CVI. The collaboration of different experts is a key necessity when
developing serious games, hence the multidisciplinary consortium that set out to develop these
games had different backgrounds (vision science, experimental psychology, clinical
psychology, physiotherapy, child neurology, occupational therapy, computer science,
engineering, and therapeutic game development). Rapid game prototyping was performed by a
game development company, PreviewLabs, and further game development by the research
group. In phase 1, we focussed on the informant-led design, phase 2 included the initial
development of the mini-games resulting in first versions of the game, in phase 3, we evaluated
the therapeutic content, and in phase 4, formative testing and expert feedback was obtained. All
phases are detailed later in this paper.

This study was approved by the ethical committee of UZ/KU Leuven (no. S61226). Parents
provided written informed consents and in case of young children, verbal assent was given
where possible but researchers monitored participants closely for reluctance to participate.

7
Figure 2. Overview of the iVision game development process.

Phase 1: Informant-led design

4.1. Focus groups to define user requirements
Focus groups were conducted to elicit user requirements and teach the team about gameplay of
children with CVI, therapy goals, context of use, and barriers and facilitators with which the
iVision games needed to comply.

To assist with analysing the requirements, we considered the GuideaTemplate developed by De

Troyer and Janssens [46], developed to support the requirement analysis phase for the
development of serious games for children, although this tool does not provide support for
adaptive games, we found this tool the most informative for our needs. In this project, we only
focused on user aspects, context of use, pedagogical aspects, game aspects, and implementation
aspects, as the others were not relevant for our research purpose. First, for the user aspects, we
characterized the target users’ age and competences (skills and knowledge). Second, the context
of use specifies the platform which will be used to play the games and the place where the
games will be played. Third, for the pedagogical requirements, a didactical goal and didactical
approach should be elicited. The fourth element concerns game aspects namely genre, format
(e.g., mini-games or one main game), single/multiple player game, concept, length, and
elements. Game elements include motivating elements (reward and feedback system), and the
dialogs between game and player (using speech or text). Finally, the fifth element concerns the

8
implementation aspects which target the implementation technology, in our case the technical
requirements for the child and feedback tools for the clinician.

In order to gather a representative set of user requirements, we conducted two focus groups.
Research has shown that intermediaries such as teachers play a major role in the adoption of a
new therapy, therefore we (potential) adopters of the games who have an interest in the degree
of effectiveness of a new therapy participated [47,48]. Research has shown that. Each focus
group lasted three hours, targeting parents of children with CVI and specialists treating children
with CVI, one focusing on 3-7 year olds and the other on 8-12 year olds. In the first focus group,
five parents of children with CVI, two occupational therapists, and one home counselor were
present. The second focus group involved three parents of children with CVI, two occupational
therapists, one home counselor/occupational support in schools, one physiotherapist, and one
teacher for the visually impaired. As both parents and specialists have invaluable information
on their children, we targeted both of these groups’ perspectives. Specifically, we worked with
the parents of the children as they may have a different perspective on their child’s needs and
how they behave at home. In addition, we targeted different specialists such as occupational
therapists, physiotherapists, home counsellors etc., as we wanted to have a wide variety of
opinions to define the user requirements. We had two different focus groups targeting different
ages as (1) we believed that the requirements may have been different between the groups and
(2) we targeted different performance ages of the children hence targeting a wider range of
severity of CVI. Therefore, children represented by these focus groups spanned the entire
spectrum of CVI. Each focus group was led by a trained facilitator and conducted in the
presence of a note-taker from the iVision team, as well as two distant observers (one researcher
and one game developer). Notes, observations, and audio recordings were transcribed,
synthesized, and the requirements were analyzed, using the GuideaTemplate as framework to
organize the results.

4.2. Brainstorm sessions and game idea generation

As a next step in the development process, information, which was based on literature search,
the team’s knowledge and prior experience, difficulties that children with CVI experience based
on the Flemish cerebral visual impairment questionnaire factors [30] and visuoperceptual
dimensions [31], and user requirements extracted from the focus groups, was shared with the
non-clinicians of the team. Using this information, a brainstorming session was held in which
a visuoperceptual skill was linked to a game type. To assist this process, a random generator
was used which generated game genres (e.g., card game, action-adventure, etc.,) and matched

9
it with the listed visuoperceptual skill. In the initial brainstorm session, 54 ideas for game
concepts were produced. From this list, the iVision team voted on their top six game concepts
that were most appropriate for the target group, and the game developers provided more detailed
explanations of what these six games could entail. Through discussions, the team decided to
focus on the development of three games.

Phase 2: Initial development of the iVision mini-games

The first basic prototypes of the games and their re-iteration stages are shown in Appendix A,
Figure A.1. Soon after the initial “mockups” were developed, it became clear that the Maze
Explorer game would be too difficult for younger children, so the game was split into two
versions, a 2D and a 3D one (see Appendix A, Figure A.2). The 3D version was also simplified
and adapted (see Appendix A, Figure A.3). Finally, four mini-games namely MatchMaker,
Hurricane Chaos, Maze Explorer 2D, and Maze Explorer 3D, targeting six visuoperceptual
dimensions were developed in collaboration with our partners and their goals are explained in
Table 1. To add more variation, MatchMaker and Hurricane Chaos consisted of two themes, a
farm theme and a pirate theme. Unity 2019.3.15f1, .Net Framework, and C# were used for game
development. To serve the needs of our diverse target group, the iVision games can be played
on different operation systems – Windows, Mac OS, Android, and iOS, and can be controlled
using a mouse or touchscreen, depending on the device. Moreover, the games can be played
with a small or large display, close to the child or on a screen placed at a distance.

10
Table 1
Description of the four iVision mini-games.
MatchMaker (MM)
The goal is to match the most similarly looking pair of cards.
Images on the cards have undergone different manipulations
to challenge visual perception. Each image had an unaltered
version (prototypical), possible manipulations are (1) details
differ, (2) different poses, (3) missing parts, (4) partial, (5)
atypical, (6) silhouettes, (7) contour, (8) closure, (9) noise
(see Figure 3). Viewpoints of images were also included (see
Figure 4).
Maze Explorer 2D (ME2D)
The goal is to navigate through and exit a 2D maze with the
assistance of a smaller mini-map. In this example, the bunny
resembles the player’s location, the flag with a carrot in the
mini-map is the exit, and other carrots serve as distractors
along the route. The child is required to click on the red
arrows in the direction they want to walk. The green dot
resembles the starting point. Points of interest (POIs) e.g., the
dog and sheep, serve as guiding cues/landmarks along the
route.
Phase 3: Therapeutic content evaluation
To finalize the different aspects of the mini-games, individual workshops took place.
11
Hurricane Chaos (HC)
The goal is to find different objects in a scene after
hearing a voice-over instruction. Distractor images were
added to challenge visual search. Each loudspeaker icon
is a voice-over of a different image, once the image is
found and clicked on, it appears in place of the
loudspeaker icon, and a new image replaces the found one
in the scene.
Maze Explorer 3D (ME3D)
The goal is to navigate through and exit a 3D maze, with
the assistance of a smaller mini-map. The child is
required to click on the red arrows in the direction they
want to walk. The green dot in the mini-map resembles
the starting point, the yellow dot the current location of
the player, and the flag indicates the exit. Points of
interest (POIs) e.g., the crocodile, serve as a guiding
cue/landmark along the route. The red eyes icons at the
top serve as a means to turn around in the maze.
6.1. Selecting and manipulating images
Images downloaded from https://www.freepik.com/ and http://www.tarrlab.org/ and their
manipulations, were rated on their visuoperceptual difficulty. All presented manipulations with
the matching required by the child are explained in detail in Appendix B, Figure B.1. Each
image had an unaltered version (prototypical) and had undergone nine different manipulations
namely (1) details differ, (2) different poses, (3) missing parts, (4) partial, (5) atypical, (6)
silhouettes, (7) contour, (8) closure, and (9) noise. Original images were in vector graphic
format and all manipulations (except noise) were created using Inkscape (version 1.0) and
GIMP (version 2.10.20) programs. The noise images were programmatically generated using
.NET Framework 4.5 including a C# 5.0 programming language. “Prototypical” images were
well-recognizable exemplars of a specific object category. In “details differ”, minute details
were changed (e.g., a pink pig nose was changed to black). In “different poses” different
positions were created (e.g., for an animal: sitting, running; for an apple: bitten off, sliced etc.).
“Missing parts” removed some (important) feature in a step-wise manner to make the object
less recognizable (e.g., a pig without a nose). “Partial” always had five different manipulations
per item (only the diagonal, top, bottom, right, or left parts being visible). In “atypical”, a
manipulation was made that would not be expected for that object (e.g., changing a pink pig
into green). “Silhouettes” involved blackening the complete object, while “contour” only
showed the closed contour of the object (black solid line), and “closure” showed a fragmented
outline of the object. These three versions were based on a tradition in the object recognition
literature, in which specific processes underlying object recognition are hampered to various
degrees [49,50]. “Noise” images had five increasing noise levels, with two versions, one where
noise occluded a coloured object and one where noise occluded a greyscale object.
Additionally, the 11th manipulation called “viewpoints” included viewpoints of everyday
objects retrieved from the Object Databank
(https://sites.google.com/andrew.cmu.edu/tarrlab/resources/tarrlab-stimuli). Objects had 14
viewpoints ranging from 0 to 330 degrees rotation in steps of 30 degrees, as well as a top and
bottom view. For MatchMaker, all manipulations and images were used, while for Hurricane
Chaos, only “prototypical”, “different poses”, and “viewpoints” were integrated into the game.
Finally, MatchMaker and Hurricane Chaos had backgrounds (downloaded from
https://www.freepik.com/) in which saturation was decreased using GIMP and any additional
clutter was removed using Inkscape.

12
Figure 3. An example of different manipulations for one image. From left to right: prototypical,
details differ, different poses, missing parts, partial, atypical, silhouettes, contour, closure, noise
(coloured and greyscale). Original images were downloaded from https://www.freepik.com/,
and manipulations of images were done by the iVision team.

Figure 4. An example of an object with different viewpoints. A top and bottom viewpoint is
presented and the numbers under the images reflect the degrees of rotation. Stimulus images
courtesy of Michael J. Tarr, Center for the Neural Basis of Cognition and Department of
Psychology, Carnegie Mellon University, http://www.tarrlab.org/.

6.2. Rating manipulated images

During four mini-workshops, clinicians and researchers rated all images (printed on cards;
presenting one manipulation at a time) on the difficulty for a child to recognize and match.
Specifically, participants rated the cards using a 5-point Likert-scale (see Figure 5). They could
reorganize the cards until they were satisfied. The 11 sets of image manipulations were placed
in an individual envelope with items from a similar category. Participants rated the images
category by category, presented in a random order. At the end of each workshop, participants
were shown photos of the scoring of the manipulations, and were asked to compare between
manipulations and rank them from easy to hard by giving them an overall difficulty rating
between 1-5. We then calculated an average (median) perceptual rating across all the
participants per image (ratings of 0.5 and above were rounded up as it was better to place a
potentially difficult image in a higher level rather than an easier level), and placed them in their
corresponding difficulty level in MatchMaker. For details on the workshops, see Appendix C,
Table C.1.

13
Figure 5. An example of a participant rating’s of silhouette images.
Some participants remarked that a number of typical items belonging to the farm theme were
missing (e.g., tools, etc.,). We therefore added a new set of recommended images for the farm
theme and performed a second workshop, applying a similar methodology as the first one.
Participants also indicated that to increase the variation of images, another theme would be
interesting, hence we included the pirate theme, where the images were split into two separate
rating workshops.

6.3. Linking visuoperceptual dimensions to the mini-games and entry-level difficulty

Finally, in phase 3, we aimed to capture which visuoperceptual dimensions are trained in each
mini-game, and to what extent. Therefore For this aim, seventeen clinicians and researchers
played the mini-games. Clinicians and researchers consisted of a representative sample
including 10 clinicians (i.e., (educational, clinical) (neuro)psychologist, occupational therapist,
ophthalmologist, speech and language pathologist, physiotherapist, child neurologist,
pediatrician, and a person offering remedial education), four researchers, and 3 participants who
were both clinicians and researchers. After playing the games, they linked the visuoperceptual
dimensions to the mini-games by indicating how much each specific dimension is trained in
each of the four mini-games on a scale of 0 to 100. We then calculated an average of the
participants’ responses and used it as a weight in the formula to define the child’s entry-level
difficulty per mini-game (static adaptivity). By linking the visuoperceptual dimensions to the
mini-games, children who play the games will not start at a “random” difficulty level, but rather
their entry-level difficulty will be calculated based on their visuoperceptual test results.

14
6.4. Defining expert-based in-game adaptivity rules and evaluation criteria
In phase 3, the in-game adaptivity rules and evaluation criteria to implement into the mini-
games were defined. Five therapists from Centrum Ganspoel, specialized in treating children
with visual impairment, played the mini-games and filled out a self-developed 26-item
questionnaire targeting gameplay progression e.g., “How many times can the player click on a
wrong pair of cards before he/she gets a new exercise in an easier level?” (MatchMaker) or
“How many times can the player click on the wrong object before getting a new scene
(Hurricane Chaos)?”. The average of the therapists’ responses was used as an initial expert-
driven basis for the in-game adaptivity rules and evaluation criteria (dynamic adaptivity).

Phase 4: Formative testing and expert feedback

7.1. Usability and user experience testing in clinicians and researchers
In phase 4, we first tested the usability and user experience in clinicians and researchers, in
order to remove obstacles that impede learning and to acquire suggestions of features that could
enhance learning [51]. Usability is defined according to ISO-9241-11 as “the extent to which a
system, product or service can be used by specified users to achieve specified goals with
effectiveness, efficiency and satisfaction in a specified context of use” [52]. The usability
characteristics from ISO 9241-11 and ISO/IEC 9126-1 are related to goals based on different
researchers [52–54] (see Figure 6). During design and development both ISO 9241-11 and
ISO/IEC 9126-1 usability approaches need to be combined [52], as done by Tahir and Arif [55]
who developed usability guidelines for interface design of educational applications for children.
User experience is defined as “a person’s perceptions and responses that result from the use
and/or anticipated use of a product, system or service” [56]. Studies have shown that a high
usability and aesthetic appeal is related to satisfaction and game appreciation [57,58].
Moreover, studies have also shown that a positive gameplay experience is crucial for learning
[59].

Figure 6. Usability characteristics and their goals. According to the standards from the

15
international organization for standardization ISO-9241-11:1998 and ISO/IEC 9126-1. Based
on Tahir and Arif [55] and Bevan [52].

Generally, there is no consensus on the sample size suggested for usability testing [60].
However, research has shown that to find more catastrophic, major, minor, cosmetic design,
navigation, and key function problems, 16 +-4 is recommended, discovering approximately
90% of usability problems [60]. In the present study, twenty clinicians and researchers played
two simulated versions of each mini-game, one with low visuoperceptual profile scores (lower
game difficulties) and one with high visuoperceptual profile scores (higher game difficulties).
To assess the iVision application and the specific mini-games, a 93-item questionnaire was
developed by adapting the usability goals, guidelines, and user satisfaction questionnaire
developed by Tahir and Arif [55]. Averages on each of the 93-items were calculated and results
of the (1) iVision application and (2) a reduced set of items from the questionnaire common to
all the mini-games are presented.

7.2. Usability and user experience testing in typically developing children

Secondly, in the same phase, we tested the usability and user experience in typically developing
children. The iteration was tested on summer playgrounds with 11 younger children (aged 38
months – 78 months (M = 60; SD = 12)) and 12 older children (aged 80 months – 141 months
(M = 107; SD = 21)), hence a total of 23 children participated. Younger children played a
simulated easy version of the mini-games, while older children played a simulated harder
version, in an uninterrupted manner for approximately 5 minutes per mini-game, while being
audio and video recorded. Usability was evaluated via observations, and user experience was
evaluated using the “This-or-That” method followed by a semi-structured interview to elicit
feedback on what children liked and suggestions for what they would change [61]. The five
This-or-That questions used were:

1. Which game did you find most fun?

2. Which game would you want to receive as a present?
3. Which game would you like to take home with you?
4. Which game would you like to play again?
5. Which game did you find the most stupid?

Following these five questions, children had to identify once more their favourite game, through
a “reminder” question (“Can you remind me again which game did you find most fun?”). After
children finished gameplay and responded to our questions, they were given the option to “free

16
play” any mini-game again while they waited for their instructor to pick them up, which served
as an additional measure.

By using audio, video recordings, and the observations of the gameplay sessions, the usability
of the games was investigated by observing items from the task list published by Tahir and Arif
[55]. We aimed to define which elements should be adjusted to increase the children’s
independent gameplay. During observations, the interaction with the game and the children’s
verbal and non-verbal expressions were noted, to investigate whether the games were
understandable, child-friendly, and compatible with their cognitive and visuoperceptual skills.

Results
8.1. Phase 1: Informant-led design
8.1.1 Focus groups to define user requirements
In terms of user aspects (point 1), children aged 3-12 years performance age were defined as
the end-users. Both CVI-related (e.g., structured learning, repetition, predictability) and game-
related (e.g., adaptable parameters e.g., colours, contrast, button size) requirements were
identified. Moreover, the difficulties children with CVI exhibit (e.g., contour images, searching
exercises, different perspectives, finding the way) were discussed. Finally, what children like
(e.g., colours, sounds) and what frustrates them (e.g., loosing lives, fast games) was expressed.
In terms of context of use (point 2), the games should be developed on PC, Mac, tablet, and
smartphone (platform), and should be playable from home, school, or any other organization
(place). In terms of the pedagogical requirements (point 3), the didactical goal should focus on
practicing skills in a constructive, workable, and fun way, and the didactical approach should
reflect practice and feedback. For the game aspect requirements, (point 4) short repeated mini-
games using a single player game format were recommended, due to children’s limited attention
span. Preferred game elements included a reward system, feedback system, and dialogs.
Implementation technology (point 5) (technical requirements for the child (i.e., using mouse
and touchscreen), and feedback tools for the clinicians (e.g., overview of completed levels, and
saved configurations for each child) were discussed. For a full description of the requirements,
see Appendix D, Figure D.1.

8.2. Phase 2: Initial development of the iVision mini-games

8.2.1 Difficulty levels of the mini-games
Based on literature review, therapeutic and research experience, different parameters were used
to define the difficulty in the four mini-games. For MatchMaker, game difficulty was increased
by increasing the number of cards (see Appendix E, Equation 1), decreasing the time between
17
the presentation of the cards (see Appendix E, Equation 2), more perceptually difficult
manipulations, and a gradually complex background image.
In Hurricane Chaos, game difficulty was increased by increasing the number of targets to find
and number of distractors (Appendix E, Equation 3 and Equation 4), decreasing the size of the
objects and distractors (Appendix E, Equation 5 and Equation 6), decreasing the minimum
distance of placement of objects to the border (Appendix E, Equation 7), and switching the
perspective mode off (from a threshold of level 60 and above). In the perspective mode, the
objects in the front are bigger and those in the back are smaller. A theme-congruent background
image was present for all levels.
For Maze Explorer 2D, the number of branches per route increased from 4 to 12 (Appendix E,
Equation 8), the number of dead-ends increased from 1 to 10 (Appendix E, Equation 9), and
the number of points of interest (POIs) decreased (up until 0) (Appendix E, Equation 10) with
increasing difficulty. POIs were animals placed on the cross points to help children orient.
Finally, for Maze Explorer 3D, the number of branches per route was fixed to 10, and the
number of dead-ends was randomly set between 3-6. Moreover, the POIs decreased with
increasing difficulty (Appendix E, Equation 10), the mini-map was static and the position of
objects was related to the position of other objects (allocentric representation, object-to-object
relation), while in the easier levels the mini-map turned so that the child had a view in
accordance with that of the direction of the map (egocentric representation, object-to-self
relation). In the highest levels, the mini-map was removed and the child had to recall the route
from memory. All implementations of different parameters in the mini-games were performed
by engineer/computer science specialists in VUB-ETRO.
8.2.2 The therapist dashboard
The iVision therapist dashboard was developed using Java Spring framework and PostgreSQL
database. The exchange of data between the therapist dashboard (server side) and games occurs
via JSON files. The dashboard is accessible to registered users/therapists/researchers and serves
as an interface for the underlying database where all iVision-related patient and game data are
stored. The dashboard enables therapists to (1) add new patients, (2) group the patients, (3) store
their visuoperceptual profile – including both subtests scores and z-score/percentile scores on
the visuoperceptual dimensions, (4) store their patient details (e.g., gender, chronological and
performance age, diagnoses), (5) see details of each play session (e.g., games played, frequency
of gameplay, date played, length of gameplay), and (6) details of the child’s gameplay
performance, progress, and evaluation (e.g., score, use of hints, time taken per game, errors).
Moreover, extra information about each game (e.g., repetition of instructions, a replication of

18
the scene the child saw, evaluation details etc.,) is available. Each patient in the system gets a
random player ID assigned, via pseudonymization, to avoid misuse of personal information.
8.2.3 Reward system
Children could earn stars, and their number depended on the mini-game and their performance.
In MatchMaker and Hurricane Chaos, the number of stars awarded was calculated based on a
multiplier system which ranges between one and three. In MatchMaker, for the first correct pair
children earned one star, as the multiplier was one. For the second correct pair in a row, the
multiplier increased to two (child earned two stars) and for the third correct pair in a row, to
three (child earned three stars). For correct pairs in a row after this point, the multiplier remained
at three. After a wrong pair, the multiplier reset to one (child earned one star). Hence, the range
of stars that could be earned in MatchMaker per game of 10 rounds was between 10 and 27.

The same multiplier system was integrated in Hurricane Chaos for correctly found objects,
where depending on the possible number of objects to find in the scene, the number of earned
stars varied. Three objects had to be found in the lowest level, so between three and six stars
could be earned, while in the highest level, 10 objects had to be found, so between 10 and 27
stars could be earned.

For Maze Explorer 2D and 3D, between three and 10 stars could be earned for each solved
maze and the number of stars depended on the number of arrows clicked. Children earned the
maximum amount of stars when they took the shortest route possible, and with every mistake
along the way and lengthening of the path, the number of earned stars decreased (Appendix E,
Equation 11). The number of stars earned was cumulative and saved between sessions.

8.3. Phase 3: Therapeutic content evaluation

8.3.1 Rating difficulty of manipulated images
The clinicians and the researchers rated the images in terms of their perceptual difficulty as
follows from easy to difficult: (1) prototypical, (2) details differ, (3) missing parts, (4)
silhouettes, (5) atypical, (6) different pose, (7) contour, (8) partial, (9) closure, (10) viewpoints,
and (11) noise. Additionally, from discussions with clinicians and vision scientists, the highest
level included a mixture of closure, contour, and silhouette images.

8.3.2 Linking visuoperceptual dimensions to the mini-games and entry-level difficulty

Figure 7 shows the linking of the mini-games to the visuoperceptual dimensions. Handcrafted
rules provided by the clinicians and researchers were used to map the visuoperceptual profile
onto the game difficulty. The four mini-games target more or less a combination of all
visuoperceptual dimensions with variable emphasis on specific dimensions. Specifically,

19
MatchMaker targets mostly visual discrimination and matching, and object/picture recognition,
Hurricane Chaos targets object/picture recognition and figure-ground perception, Maze
Explorer 2D targets mostly visual spatial perception and motion perception, and Maze Explorer
3D targets mostly visual spatial perception and visual short-term memory.

Figure 7. Average of participants' linkage of the visuoperceptual dimensions to the mini-games.

Each mini-game sums up to 100.

Based on these results, formulas for entry-level difficulty calculation were specified (Equation
1). Game difficulty level is a score on 100, where “W” represents the weight of the dimension
per mini-game (four game difficulties). The scores on each visuoperceptual dimension (VDaM:
Visual discrimination and matching; OR: Object/picture recognition; VSP: Visual spatial
perception; FGP: Figure-ground perception; MP: Motion perception; VSTM: Visual short-term
memory) are average percentile scores (translated from z-scores) based on each child’s
visuoperceptual profile calculated from their visuoperceptual test scores.

Equation 1. Game difficulty calculation.

Game Difficulty
= 𝑊𝑉𝐷𝑎𝑀 × VDaM + 𝑊𝑂𝑅 × OR + 𝑊𝑉𝑆𝑃 × VSP + 𝑊𝐹𝐺𝑃 × FGP
+ 𝑊𝑀𝑃 × MP + 𝑊𝑉𝑆𝑇𝑀 × VSTM

8.3.3 Defining expert-based in-game adaptivity rules and evaluation criteria

In-game adaptivity was based on handcrafted rules provided by the therapists and based on the
combination of three parameters (1) time taken, (2) number of errors, and (3) whether a hint
was used or not, this can lead to three states in which the game can be finished (success, neutral,
or failure) (see Figure 8). The values of these three parameters differed per mini-game. For
more details on the adaptivity rules and evaluation criteria see Appendix F.

20
Figure 8. Entry-level difficulty and in-game adaptivity processes. The values of the number of
errors, time limit, and hint use differed per mini-game. W: stands for weight. VDaM: Visual
discrimination and matching. OR: Object/picture recognition. VSP: Visual spatial perception.
FGP: Figure-ground perception. MP: Motion perception. VSTM: Visual short-term memory.

8.4. Phase 4: Formative testing and expert feedback

8.4.1 Usability and user experience testing in clinicians and researchers
Low-scoring statements from the questionnaire (and the qualitative interviews) led to mini-
game changes (see Discussion). Results in Appendix G, Figure G.1. show that in terms of
effectiveness, efficiency, operability, and attractiveness, the iVision application was
satisfactory. Lower results were obtained in terms of learnability (e.g., language) and
satisfaction. Results in Appendix H, Figure H.1, show that effectiveness and learnability was
satisfactory for MatchMaker and Hurricane Chaos. It was easy to interact with the mini-games
(e.g., clicking on the cards or objects), to navigate across the platform, and appropriate feedback
for actions was provided. On the other hand, effectiveness and learnability was lower for Maze
Explorer 2D and Maze Explorer 3D (e.g., the voice-over instructions were unclear, the
background interfered with the game elements, and the objects were not clearly visible).
Efficiency was satisfactory for all the mini-games.

8.4.2 Usability and user experience testing in typically developing children

Usability results were used to suggest new recommendations (see Discussion) for the mini-
games which were implemented in the next versions. In terms of effectiveness (interactivity),
children could interact with the mini-games and play independently, except for Hurricane
Chaos, where, for some items, children had to click numerous times as the “clickable” area

21
around the item was not large enough. The mini-games did not implement help icons, and some
children asked for additional assistance. In terms of learnability (e.g., cognitive load), children
had difficulties understanding the audio instructions on how to play the game. The learning
potential of the application seemed adequate as children easily learnt how to use the application
and the mini-games provided different difficulty levels targeting both the younger and older
children. Finally, operability was good.

In terms of user experience, Appendix I, Figure I.1 and Appendix I, Figure I.2 show the younger
children’s and older children’s responses to the This-or-That method, respectively, showing
that both groups liked all the mini-games. Moreover, the younger children especially liked
Maze Explorer 3D, and the older children also liked Hurricane Chaos. Nineteen out of 23
children continued to play one of the mini-games during the “free play” option, implying that
they enjoyed the games. From the semi-structured interviews it was clear that for MatchMaker
and Hurricane Chaos children liked the different images and the task of searching. Moreover,
in Hurricane Chaos, children enjoyed the interactivity with the loudspeaker icons. In the maze
games, children liked the different game elements, following the route/path, walking through
the maze, and searching for the way out. Moreover, in terms of rewards, children liked the
positive and negative sound feedback, the stars, and the animation of them flying into and filling
up the jar. Children remarked that the mini-games were too quiet, with little music and sounds.

Discussion
In this project, we discuss the development and evaluation process of an individualized and
adaptive series of mini-games for CVI targeting visuoperceptual skills. The development
process involved rigorous testing with clinicians, researchers, and typically developing
children. To define an appropriate entry-level for individualized play, six visuoperceptual
dimensions, namely (1) visual discrimination and matching, (2) object or picture recognition,
(3) visual spatial perception, (4) figure-ground perception, (5) motion perception, and (6) visual
short-term memory, were targeted [31]. Moreover, a dynamic difficulty adjustment method was
implemented to maintain an optimal level of difficulty matching the child’s skill and thus
allowing a state of “flow” to be experienced [33–35].

The focus groups using a participation-via-proxy approach, revealed that children with CVI
require structured learning, repetition, predictability, simple visuals, and verbal information, to
help them work gradually towards a clear end-goal. The most prominent difficulties
experienced in their daily life, match the ones reflected in the existing literature. Specifically,

22
children have difficulties with recognizing objects (e.g., from other perspectives, in contour, in
black and white, abstract figures), search exercises, visual attention, navigating in a new
environment and searching for anchor points. Therefore, a requirements analysis using a
participation-via-proxy proves crucial for game development [62–64].

The workshops with the clinicians and researchers confirmed that all the visuoperceptual
dimensions that are part of the visuoperceptual profile are covered by all of the mini-games to
some extent, in different proportions. However, we did not ask the clinicians and researchers
whether additional visuoperceptual tests are trained in the games, and hence, there could be
other skills that the mini-games target that are not measured. Future research could integrate
additional tests e.g., visual attention and visual search to enrich a child’s clinical picture.

In MatchMaker, images are manipulated (degraded) in different ways to evoke a challenge on

the visual system to discriminate and recognize objects, which are skills commonly impaired in
CVI [5,12,15,65] and are an early sign of CVI [10]. Different manipulations were used. For
instance, in the “atypical” and “details differ” manipulations, it is much more perceptually
demanding to recognize on object (e.g., an incongruently coloured object compared to a
congruently coloured object) [66]. We hypothesize that by training with more variation in the
set of images by including different exemplars will transfer to completely new objects, in line
with Baeck et al. [67].

According to the clinicians and researchers, we aim to target object/picture recognition and
figure-ground perception in the Hurricane Chaos mini-game. We hypothesize that
implementing an object-scene congruency will facilitate recognition of objects. This is in line
with studies which have found that the scene context affects object identification, and that a
rapidly extracted gist activates associative memories of scene-congruent schemas, which
facilitates object recognition of congruent compared to incongruent objects [68–71]. Coping
with complex situations (e.g., locating a person in a crowded room or a character/object in a
book) is indeed another early sign of CVI [10,14]. For that purpose, in Hurricane Chaos, we
increased clutter and placed more demand on visual search, similarly to Bennett, Bailin et al.
[13] and Bennett, Bex et al. [14]. Bennett, Bex et al. [14] developed two virtual reality-based
assessment tools integrating eye-tracking, one evaluating static search and the other dynamic
search, termed the Virtual Toy Box and the Virtual Hallway, respectively. These paradigms
could also be related to figure-ground perception expressed as an increase in clutter in the scene,
and research has shown that figure-ground is impaired in CVI [72]. We believe that due to the
similarity of especially the Virtual Toy Box with Hurricane Chaos, a similar mechanism may
23
be at play. Another recently developed assessment tool, called the Austin Playing Card
Assessment, measures visual perceptual difficulties relating to clutter by using playing cards.
Children with CVI focused on one card and then sought out its match, with a random search
strategy and darting eye movements, leading them to being slower at finding the pairs [73],
similarly to Bennett et al. [74], who found increased variability in search patterns and reaction
times. Moreover, another study found that training with a non-action hidden-object video game
where the goal was to find hidden objects in a complex scene, enhanced cognitive performance
in visual search and spatial working memory [75].

In Maze Explorer 2D and Maze Explorer 3D, we aim to train visual spatial perception, motion
perception, and visual short-term memory and place more demand on navigational efficiency
and capacity. Children with CVI often display difficulties in navigating surroundings [76],
which could be due to visual field deficits or impaired space perception [10]. Other researchers
have also developed immersive virtual reality (IVR) mazes where a child has to navigate in the
environment by moving their body in space, to study visual spatial navigation in children (aged
6-14) with cerebral palsy [77]. The IVR mazes were used to train and test egocentric (subject-
centered) and allocentric (object-centered) representations. They found that children with
cerebral palsy adopted a more egocentric navigation and found it difficult to shift to an
allocentric perspective, in comparison with typically developing children [77]. Egocentric
representations develop earlier, are innate, and preferred by children, while allocentric
representations are acquired based on visual experience [78,79]. Research has shown that 5, 7,
and 10 year-olds can learn egocentric and allocentric strategies, but adult-like performance was
attained by the 10 year olds, indicating that allocentric representation arises between the age of
7 and 10 [80]. Another study showed that children aged 3 already use a combination of
egocentric and allocentric representations, and pure allocentric representations already emerge
at the age of 5 [81]. In Maze Explorer 3D, children are trained both in egocentric and allocentric
representation. Moreover, impaired motion perception [2,82–84] and visual memory are
reported in CVI [5,85], which we hypothesize are also skills trained by our mini-games.

Numerous design principles reported by Linehan et al. [45] were followed when developing
these mini-games. (1) The targeted visuoperceptual skills formed the core game mechanics,
hence we hypothesize that children will engage in therapy-appropriate behaviour. (2) We
integrated an individualized profile as well as an adaptive system to maintain the child’s flow
state as gameplay was in line with the child’s needs. (3) We developed a therapist dashboard
where the child’s performance over time can be tracked and detailed information on the child’s

24
gameplay can be used to inform healthcare professionals on the training effectiveness, also
implemented in the game by Waddington et al. [44]. Finally, (4) throughout the mini-games,
we used audio representation and visual simplicity which ensures accessibility to a spectrum of
severity of visual impairment [44].

In terms of usability, clinicians and researchers indicated appropriate levels of effectiveness,

efficiency, operability, and attractiveness. However, in a subsequent version, based on the
present feedback obtained through the questionnaires and interviews with both the clinicians
and researchers as well as the children, modifications were made to the games. First, learnability
difficulties, specifically in understanding the goals of the games, were reported, which could be
due to a combination of the novelty of the games and the unclear instructions. As clear
unambiguous goals is one of the elements of flow, this prompted us to include introductory
videos in a next version of the mini-games [34,86]. Moreover, to improve the effectiveness of
the mini-games, we collaborated we implemented recommendations to improve the mini-game
effectiveness was improved by collaborating with a speech therapist to improve (1) to improve
the voice-over instructions in Maze Explorer 2D and Maze Explorer 3D, and (2) to improve the
language-related content in Hurricane Chaos to avoid the influence of comprehension
difficulties. In terms of learnability (from interviews), a higher number of distractors, more
overlapping of images, and more cluttered backgrounds were added to Hurricane Chaos to
further challenge figure-ground perception. Moreover, the games were adapted by adding more
salient (larger and more visible bunny, carrots, POIs, mini-map, start and blue looming current
location dots) and appropriate game elements into the mazes, and the end location was changed
from a red flag to a black and white checkered flag. Furthermore, in Maze Explorer 3D, the
walking speed and turning was slowed down to avoid nausea, turning at a junction was made
more smooth (without bumping into the walls), and the start location and end flag were
integrated into the main map. Moreover, in Maze Explorer 2D, the background clutter (e.g.,
grass patches) was removed. Lastly, in terms of attractiveness (from interviews), MatchMaker
was made more visually appropriate for CVI (e.g., by lightening the shadows around the cards,
changing the colour of the card from yellow to blue when it was clicked, and organizing the
cards symmetrically). For Hurricane Chaos, we removed less child-friendly images (e.g., gun,
scary skull).

In MatchMaker, in terms of attractiveness, the game was made more visually appropriate for
CVI (e.g., lightening the shadows around the cards, changing the colour of the card from yellow
to blue when it was clicked, and organizing the cards symmetrically).

25
In Hurricane Chaos, typically developing children experienced difficulty, in effectiveness
(interactivity) as clicking on some items required numerous attempts. Hence, the area of
possible clicking was increased so that the system would respond if the child would click in
between the bow and the bowstring, for instance. In terms of learnability, in the higher levels,
a higher number of distractors, more overlapping of images, and more cluttered backgrounds
were added to further challenge figure-ground perception. Moreover, we removed less child-
friendly images (e.g., gun, scary skull).

In the maze games, more salient and appropriate game elements were added (e.g., larger and
more visible bunny, carrots, POIs, mini-map, start and blue looming current location dots,
changing the end location from a red flag to a black and white checkered flag). Moreover, in
Maze Explorer 2D, the background clutter (e.g., grass patches) was removed. Finally, in Maze
Explorer 3D, the walking speed and turning was slowed down to avoid nausea, turning at a
junction was made more smooth (without bumping into the walls), and the start location and
end flag were integrated into the main map.

Finally, as some children asked for the researchers’ assistance, hint options were integrated
(e.g., for Hurricane Chaos, the hint circled an area around the searched/target object).

A general important consideration was the amount of clutter and amount of background
information presented in the games as this can affect children with CVI [72]. Specifically, to
target a wide range of severity of CVI, we included in the lower levels of MatchMaker and
Hurricane Chaos pale plain backgrounds, and in the higher levels more complex backgrounds.
Moreover, in the maze games, a simple non-distracting background was integrated to allow for
visually aesthetic games that still allow children to focus on the main task. Finally, the
presentation of the rewards during gameplay was visually simplified to avoid distracting the
child.

The typically developing children experienced some difficulty in effectiveness (interactivity)

as in Hurricane Chaos, clicking on some items required numerous attempts. Hence, the area of
possible clicking was increased so that the system would respond if the child would click in
between the bow and the bowstring, for instance. Moreover, learnability difficulties,
specifically in understanding the goals of the games, were reported, which could be due to a
combination of the novelty of the games and the unclear instructions. As clear unambiguous
goals is one of the elements of flow, this prompted us to include introductory videos in a next
version of the mini-games [34,86]. Moreover, as some children asked for the researchers’

26
assistance, hint options were integrated (e.g., for Hurricane Chaos, the hint circled an area
around the searched/target object).

In terms of user experience, 19 out of 23 children continued to play voluntarily, and had to be
stopped by the teacher, implying that they enjoyed the games and may have been less conscious
of the passage of time, which is an element of flow [34,86]. From the interviews, children
enjoyed the task of searching (e.g., for the correct matching pairs in MatchMaker or for the
finish flag in the mazes). Additionally, the interactivity with the games (e.g., clicking on the
arrows), and feeling in control, which is another element of flow, was crucial for increasing
attention and enjoyment [34,86]. Children also mentioned the stars and points, demonstrating
the importance of rewards and winning, as was found by Celis et al. [87]. Moreover, another
element of flow includes immediate feedback of actions which was attained in our mini-games
by providing positive or negative sounds after correct or incorrect responses, respectively, and
rewards [34,86]. Finally, children liked elements related to media richness e.g., visuals, even
though they were simple and adapted to children with CVI [88]. Children remarked that
background music, sound, and animated rewards would be more exciting. Hence, in Maze
Explorer 2D, when reaching the flag, a “bunny chewing” sound was played, while in Maze
Explorer 3D, a victory sound was played. Finally, in all four mini-games, background music is
played, and when the child’s star jar is full, exploding fireworks are visible with sound effects.

The next step in the iVision project will involve modifications of the mini-games based on the
attained feedback. Moreover, the usability and user experience of the mini-games will be tested
in children with CVI, which will lead to additional modifications. Initial handcrafted rules were
defined for the mini-games using expert-based input, but future steps in the iVision project
include data collection to improve the entry-level rules for mapping the visuoperceptual
dimensions to the entry-level difficulty, and to use reinforcement learning to better train the
model for in-game adaptivity. Finally, we will evaluate the effectiveness of the mini-games in
a randomized controlled trial in children with CVI.

Conclusion
In this paper, the design and evaluation process of novel individualized and adaptive mini-
games targeting visuoperceptual skills for children with a performance age of 3-12 with cerebral
visual impairment was presented. Throughout development, a multidisciplinary team with
expertise in vision science, experimental psychology, clinical psychology, physiotherapy, child
neurology, occupational therapy, and therapeutic game development was included. Moreover,

27
we used a participation-via-proxy approach involving parents, teachers, and education experts
with intimate knowledge of the children. This resulted in the development of four mini-games
targeting six visuoperceptual skills which are impaired in CVI including (1) visual
discrimination and matching, (2) object or picture recognition, (3) visual spatial perception, (4)
figure-ground perception, (5) motion perception, and (6) visual short-term memory. During
formative and expert feedback, clinicians and researchers rated the games highly, while
typically developing children highlighted several usability difficulties specifically in
understanding the instructions, but user experience was high. The mini-games were modified
for testing in children with CVI.

28
 References

[1] H.E.A. Sakki, N.J. Dale, J. Sargent, T. Perez-Roche, R. Bowman, Is there consensus in
defining childhood cerebral visual impairment? A systematic review of terminology
and definitions, Br. J. Ophthalmol. 102 (2018) 424–432.
https://doi.org/10.1136/bjophthalmol-2017-310694.

[2] S.S. Philip, G.N. Dutton, Identifying and characterising cerebral visual impairment in
children: A review, Clin. Exp. Optom. 97 (2014) 196–208.
https://doi.org/10.1111/cxo.12155.

[3] D.G.M. Bosch, F.N. Boonstra, N. de Leeuw, R. Pfundt, W.M. Nillesen, J. de Ligt, C.
Gilissen, S. Jhangiani, J.R. Lupski, F.P.M. Cremers, B.B.A. de Vries, Novel genetic
causes for cerebral visual impairment, Eur. J. Hum. Genet. 24 (2016) 660–665.
https://doi.org/10.1038/ejhg.2015.186.

[4] L.B. Merabet, L. Mayer, C.M. Bauer, D. Wright, B.S. Kran, Disentangling how the
brain is “wired” in cortical/cerebral visual impairment (CVI), Semin. Pediatr. Neurol.
24 (2017) 83–91. https://doi.org/10.1016/j.physbeh.2017.03.040.

[5] H.E.A. Sakki, R. Bowman, J. Sargent, R. Kukadia, N. Dale, Visual function subtyping
in children with early-onset cerebral visual impairment, Dev. Med. Child Neurol. 63
(2020) 303–312. https://doi.org/10.1111/dmcn.14710.

[6] S.S. Philip, A. Guzzetta, O. Chorna, G. Gole, R.N. Boyd, Relationship between brain
structure and cerebral visual impairment in children with cerebral palsy: A systematic
review, Res. Dev. Disabil. 99 (2020) 103580.
https://doi.org/10.1016/j.ridd.2020.103580.

[7] E. Fazzi, S. Micheletti, J. Galli, A. Rossi, F. Gitti, A. Molinaro, Autism in children

with cerebral and peripheral visual impairment: Fact or artifact?, Semin. Pediatr.
Neurol. 31 (2019) 57–67. https://doi.org/10.1016/j.spen.2019.05.008.

[8] J. Zihl, G.N. Dutton, Development and neurobiological foundations of visual

perception, in: Cereb. Vis. Impair. Child. Visuoperceptive Visuocognitive Disord.,
Springer Science & Business Media, New York, 2015: pp. 11–49.
https://doi.org/10.1053/siny.2001.0078.

[9] G.N. Dutton, “Dorsal stream dysfunction” and “dorsal stream dysfunction plus”: A

29
 potential classification for perceptual visual impairment in the context of cerebral
visual impairment?, Dev. Med. Child Neurol. 51 (2009) 170–172.
https://doi.org/10.1111/j.1469-8749.2008.03257.x.

[10] R. Schraauwers, M. van Genderen, I. Bals, M. Dekker-Pap, F. Pilon-Kamsteeg, K.

Vancleef, A qualitative exploration of the early signs of cerebral visual impairment in
preschool children, (2020) 1–16. https://psyarxiv.com/j5xad/.

[11] E. Fazzi, S. Bova, A. Giovenzana, S. Signorini, C. Uggetti, P. Bianchi, Cognitive

visual dysfunctions in preterm children with periventricular leukomalacia, Dev. Med.
Child Neurol. 51 (2009) 974–981. https://doi.org/10.1111/j.1469-8749.2009.03272.x.

[12] E. Ortibus, J. Verhoeven, S. Sunaert, I. Casteels, P. de Cock, L. Lagae, Integrity of the

inferior longitudinal fasciculus and impaired object recognition in children: A diffusion
tensor imaging study, Dev. Med. Child Neurol. 54 (2012) 38–43.
https://doi.org/10.1111/j.1469-8749.2011.04147.x.

[13] C.R. Bennett, E.S. Bailin, T.K. Gottlieb, C.M. Bauer, P.J. Bex, L.B. Merabet,
Assessing visual search performance in ocular compared to cerebral visual impairment
using a virtual reality simulation of human dynamic movement, ACM Int. Conf.
Proceeding Ser. (2018). https://doi.org/10.1145/3183654.3183674.

[14] C.R. Bennett, P.J. Bex, C.M. Bauer, L.B. Merabet, The assessment of visual function
and functional vision, Semin. Pediatr. Neurol. 31 (2019) 30–40.
https://doi.org/10.1016/j.spen.2019.05.006.

[15] A.D. Barsingerhorn, F.N. Boonstra, J. Goossens, Symbol discrimination speed in

children with visual impairments, Investig. Ophthalmol. Vis. Sci. 59 (2018) 3963–
3972. https://doi.org/10.1167/iovs.17-23167.

[16] M.Y. Chang, M.S. Borchert, Advances in the evaluation and management of
cortical/cerebral visual impairment in children, Surv. Ophthalmol. 65 (2020) 708–724.
https://doi.org/10.1016/j.survophthal.2020.03.001.

[17] D. Malkowicz, G. Myers, G. Leisman, Rehabilitation of cortical visual impairment in

children, Int. J. Neurosci. 116 (2006) 1015–1033.
https://doi.org/10.1080/00207450600553505.

[18] J. Lanners, A. Piccioni, F. Fea, E. Goergen, Early intervention for children with

30
 cerebral visual impairment: Preliminary results, J. Intellect. Disabil. Res. 43 (1999) 1–
12. https://doi.org/10.1046/j.1365-2788.1999.43120106.x.

[19] P. Bangirana, B. Giordani, C.C. John, C. Page, R.O. Opoka, M.J. Boivin, Immediate
neuropsychological and behavioral benefits of computerized cognitive rehabilitation in
Ugandan pediatric cerebral malaria survivors, J. Dev. Behav. Pediatr. 30 (2009) 310–
318. https://doi.org/10.1097/DBP.0b013e3181b0f01b.

[20] S.J. Bennett, J. Holmes, S. Buckley, Computerized memory training leads to sustained
improvement in visuospatial short-term memory skills in children with down
syndrome, Am. J. Intellect. Dev. Disabil. 118 (2013) 179–192.
https://doi.org/10.1352/1944-7558-118.3.179.

[21] J.B. Nyquist, J.S. Lappin, R. Zhang, D. Tadin, Perceptual training yields rapid
improvements in visually impaired youth, Sci. Rep. 6 (2016) 1–13.
https://doi.org/10.1038/srep37431.

[22] Y.N. Chen, C.K. Lin, T. Sen Wei, C.H. Liu, Y.P. Wuang, The effectiveness of
multimedia visual perceptual training groups for the preschool children with
developmental delay, Res. Dev. Disabil. 34 (2013) 4447–4454.
https://doi.org/10.1016/j.ridd.2013.09.023.

[23] J.H. Park, J.H. Park, A randomized controlled trial of the computer-based cognitive
rehabilitation program for children (CoTras-C) to examine cognitive function and
visual perception in children with developmental disabilities, J. Phys. Ther. Sci. 27
(2015) 3623–3626. https://doi.org/10.1589/jpts.27.3623.

[24] O. choon Park, S.S. Gittelman, Selective use of animation and feedback in computer-
based instruction, Educ. Technol. Res. Dev. 40 (1992) 27–38.
https://doi.org/10.1007/BF02296897.

[25] S. Lee, Project Injini: Developing cognitive training games for children with special
needs, Games Health J. 1 (2012) 69–73. https://doi.org/10.1089/g4h.2012.1016.

[26] M. Vandewaetere, G. Clarebout, Advanced technologies for personalized learning,

instruction, and performance, Handb. Res. Educ. Commun. Technol. Fourth Ed. (2014)
425–437. https://doi.org/10.1007/978-1-4614-3185-5_34.

[27] D.B. Clark, E.E. Tanner-Smith, S.S. Killingsworth, Digital games, design, and

31
 learning: A systematic review and meta-analysis, Rev. Educ. Res. 86 (2016) 79–122.
https://doi.org/10.3102/0034654315582065.

[28] S. Chokron, G.N. Dutton, Impact of cerebral visual impairments on motor skills:
Implications for developmental coordination disorders, Front. Psychol. 7 (2016) 1471.
https://doi.org/10.3389/fpsyg.2016.01471.

[29] N. McDowell, A review of the literature to inform the development of a practice

framework for supporting children with cerebral visual impairment (CVI), Int. J. Incl.
Educ. 0 (2021) 1–21. https://doi.org/10.1080/13603116.2020.1867381.

[30] Anonymous, Details omitted for double-blind reviewing, (2020).

[31] Anonymous, Details omitted for double-blind reviewing, (2021).

[32] J.L. Plass, S. Pawar, Adaptivity and personalization in games for learning, in: J.L.
Plass, & R. E. Mayer, B.D. Homer (Eds.), Handb. Game-Based Learn., MIT Press,
Cambridge, 2020: pp. 263–282.

[33] A. Streicher, J.D. Smeddinck, Personalized and adaptive serious games, Springer
International Publishing, 2016. https://doi.org/10.1007/978-3-319-46152-6.

[34] M. Csikszentmihalyi, Flow: The psychology of optimal experience, New York, 1990.

[35] J.M. Thomas, R.M. Young, Annie: Automated generation of adaptive learner guidance
for fun serious games, IEEE Trans. Learn. Technol. 3 (2010) 329–343.
https://doi.org/10.1109/TLT.2010.32.

[36] M. Zohaib, Dynamic difficulty adjustment (DDA) in computer games: A review, Adv.
Human-Computer Interact. 2018 (2018). https://doi.org/10.1155/2018/5681652.

[37] L. Campaña, Wayfinder iPad Curriculum, (n.d.).

https://www.wayfinderfamily.org/ipad-curriculum.

[38] L. V. Campaña, D.A. Ouimet, Istimulation: Apple iPad use with children who are
visually impaired, including those with multiple disabilities, J. Vis. Impair. Blind. 109
(2015) 67–72. https://doi.org/10.1177/0145482x1510900110.

[39] Little Bear Sees, (n.d.). https://littlebearsees.org/.

[40] M. Ciman, O. Gaggi, T.M. Sgaramella, L. Nota, M. Bortoluzzi, L. Pinello, Serious

games to support cognitive development in children with cerebral visual impairment,

32
 Mob. Networks Appl. 23 (2018) 1703–1714. https://doi.org/10.1007/s11036-018-1066-
3.

[41] M. Ciman, O. Gaggi, L. Nota, L. Pinello, N. Riparelli, T.M. Sgaramella, HelpMe!: A

serious game for rehabilitation of children affected by CVI, WEBIST 2013 - Proc. 9th
Int. Conf. Web Inf. Syst. Technol. (2013) 257–262.
https://doi.org/10.5220/0004371002570262.

[42] O. Gaggi, T.M. Sgaramella, L. Nota, M. Bortoluzzi, S. Sara, A serious games system
for the analysis and the development of visual skills in children with CVI: A pilot study
with kindergarten children, in: Smart Objects Technol. Soc. Good, 2016: pp. 155–165.
https://doi.org/10.1007/s11036-021-01748-y.

[43] J. Waddington, C. Linehan, K. Gerling, C. Williams, L. Robson, R. Ellis, T. Hodgson,

Evaluation of eyelander, a video game designed to engage children and young people
with homonymous visual field loss in compensatory training, J. Vis. Impair. Blind. 112
(2018) 717–730. https://doi.org/10.1177/0145482X1811200607.

[44] J. Waddington, C. Linehan, K. Gerling, K. Hicks, T.L. Hodgson, Participatory design

of therapeutic video games for young people with neurological vision impairment,
Conf. Hum. Factors Comput. Syst. - Proc. 2015-April (2015) 3533–3542.
https://doi.org/10.1145/2702123.2702261.

[45] C. Linehan, J. Waddington, T.L. Hodgson, K. Hicks, R. Banks, Designing games for
the rehabilitation of functional vision for children with cerebral visual impairment,
Proc. Ext. Abstr. 32nd Annu. ACM Conf. Hum. Factors Comput. Syst. - CHI EA ’14.
(2014) 1207–1212. https://doi.org/10.1145/2559206.2581219.

[46] O. De Troyer, E. Janssens, Supporting the requirement analysis phase for the
development of serious games for children, Int. J. Child-Computer Interact. 2 (2014)
76–84. https://doi.org/10.1016/j.ijcci.2014.05.001.

[47] J. Van Looy, A. All, E. Patricia, Towards a conceptual framework for assessing the
effectiveness of digital game-based learning, Comput. Educ. 88 (2015) 29–37.
https://doi.org/10.1016/j.compedu.2015.04.012.

[48] J. Bourgonjon, F. De Grove, C. De Smet, J. Van Looy, R. Soetaert, M. Valcke,

Acceptance of game-based learning by secondary school teachers, Comput. Educ. 67
(2013) 21–35. https://doi.org/10.1016/j.compedu.2013.02.010.
33
[49] S. Panis, J. De Winter, J. Vandekerckhove, J. Wagemans, Identification of everyday
objects on the basis of fragmented outline versions, Perception. 37 (2008) 271–289.
https://doi.org/10.1068/p5516.

[50] J. Wagemans, J. De Winter, H.O. De Beeck, A. Ploeger, T. Beckers, P. Vanroose,

Identification of everyday objects on the basis of silhouette and outline versions,
Perception. 37 (2008) 207–244. https://doi.org/10.1068/p5825.

[51] E. Mkpojiogu, A. Hussain, F. Hassan, A systematic review of usability quality

attributes for the evaluation of mobile learning applications for children, in: AIP Conf.
Proc., 2018. https://doi.org/10.1063/1.5055494.

[52] N. Bevan, J. Carter, J. Earthy, T. Geis, S. Harker, New ISO Standards for Usability,
Usability Reports and Usability Measures, in: M. Kurosu (Ed.), Human-Computer
Interact. Theory, Des. Dev. Pract., Springer International Publishing, 2016: pp. 268–
278.

[53] A. Seffah, M. Donyaee, R.B. Kline, H.K. Padda, Usability measurement and metrics: A
consolidated model, Softw. Qual. J. 14 (2006) 159–178.
https://doi.org/10.1007/s11219-006-7600-8.

[54] K. Hornbæk, Current practice in measuring usability: Challenges to usability studies

and research, Int. J. Hum. Comput. Stud. 64 (2006) 79–102.
https://doi.org/10.1016/j.ijhcs.2005.06.002.

[55] R. Tahir, F. Arif, A measurement model based on usability metrics for mobile learning
user interface for children, Int. J. E-Learning Educ. Technol. Digit. Media. 1 (2014)
16–31.

[56] ISO 9241-210:2019 Ergonomics of human-system interaction — Part 210: Human-

centred design for interactive systems, (n.d.).
https://www.iso.org/obp/ui/#iso:std:iso:9241:-210:ed-2:v1:en.

[57] C.-L. Hung, J.C.-L. Chou, C.-M. Ding, Enhancing mobile satisfaction through
integration of usability and flow, Eng. Manag. Res. 1 (2012).
https://doi.org/10.5539/emr.v1n1p44.

[58] R. Leroy, Immersion, flow and usability in video games, Conf. Hum. Factors Comput.
Syst. - Proc. (2021). https://doi.org/10.1145/3411763.3451514.

34
[59] S. Airey, L. Plowman, D. Connolly, R. Luckin, Rating children’s enjoyment of toys,
games and media, World Congr. Int. Toy Res. Assoc. Toys, Games Media. (2002) 1–7.
http://www.stir.ac.uk/media/schools/education/documents/projectdocuments/cachet/rati
ng-children-enjoyment.pdf.

[60] R. Alroobaea, P.J. Mayhew, How many participants are really enough for usability
studies?, Proc. 2014 Sci. Inf. Conf. SAI 2014. (2014) 48–56.
https://doi.org/10.1109/SAI.2014.6918171.

[61] B. Zaman, V. Vanden Abeele, Laddering with young children in user eXperience
evaluations: Theoretical groundings and a practical case, Proc. IDC2010 9th Int. Conf.
Interact. Des. Child. (2010) 156–165. https://doi.org/10.1145/1810543.1810561.

[62] C. Frauenberger, J. Good, A. Alcorn, Challenges, opportunities and future perspectives

in including children with disabilities in the design of interactive technology, ACM Int.
Conf. Proceeding Ser. (2012) 367–370. https://doi.org/10.1145/2307096.2307171.

[63] S.R. Arnstein, A ladder of citizen participation, J. Am. Plan. Assoc. 85 (1969) 216–
224. https://doi.org/10.1080/01944363.2018.1559388.

[64] A. Druin, Cooperative inquiry: Developing new technologies for children with
children, in: SIGCHI Conf. Hum. Factors Comput. Syst. CHI Is Limit, ACM Press,
New York, NY, 1999: pp. 592–599. https://doi.org/10.2307/1179902.

[65] F.H. Boot, J.J.M. Pel, J. van der Steen, H.M. Evenhuis, Cerebral visual impairment:
Which perceptive visual dysfunctions can be expected in children with brain damage?
A systematic review, Res. Dev. Disabil. 31 (2010) 1149–1159.
https://doi.org/10.1016/j.ridd.2010.08.001.

[66] L. Teichmann, G.L. Quek, A.K. Robinson, T. Grootswagers, T.A. Carlson, A.N. Rich,
The influence of object-color knowledge on emerging object representations in the
brain, J. Neurosci. 40 (2020) 6779–6789. https://doi.org/10.1523/JNEUROSCI.0158-
20.2020.

[67] A. Baeck, K. Maes, C. Van Meel, H.P. Op de Beeck, The transfer of object learning
after training with multiple exemplars, Front. Psychol. 7 (2016) 1–8.
https://doi.org/10.3389/fpsyg.2016.01386.

[68] A. Truman, L. Mudrik, Are incongruent objects harder to identify? The functional

35
 significance of the N300 component, Neuropsychologia. 117 (2018) 222–232.
https://doi.org/10.1016/j.neuropsychologia.2018.06.004.

[69] C.M. Smith, K.D. Federmeier, Neural signatures of learning novel object–scene
associations, J. Cogn. Neurosci. 32 (2019) 783–803.
https://doi.org/10.1162/jocn_a_01530.

[70] T. Brandman, M. V. Peelen, Interaction between scene and object processing revealed
by human fMRI and MEG decoding, J. Neurosci. 37 (2017) 7700–7710.
https://doi.org/10.1523/JNEUROSCI.0582-17.2017.

[71] M. Bar, Visual objects in context, Nat. Rev. Neurosci. 5 (2004) 617–629.
https://doi.org/10.1038/nrn1476.

[72] T. Perez-Roche, I. Altemir, G. Giménez, E. Prieto, I. González, J.L. Peña-Segura, O.

Castillo, V. Pueyo, Effect of prematurity and low birth weight in visual abilities and
school performance, Res. Dev. Disabil. 59 (2016) 451–457.
https://doi.org/10.1016/j.ridd.2016.10.002.

[73] N. McDowell, A pilot study of the Austin Playing Card Assessment: A tool to detect
and find the degree of visual perceptual difficulties related to clutter, Br. J. Vis. Impair.
38 (2020) 118–136. https://doi.org/10.1177/0264619619896008.

[74] L.B. Bennett, C. R., Bailin, E. S., Gottlieb, T. K., Bauer, C. M., Bex, P. J., & Merabet,
Virtual reality based assessment of static object visual search in ocular compared to
cerebral visual impairment, in: Int. Conf. Univers. Access Human-Computer Interact.,
2018: pp. 28–38.

[75] A.C. Oei, M.D. Patterson, Enhancing cognition with video games: A multiple game
training study, PLoS One. 8 (2013). https://doi.org/10.1371/journal.pone.0058546.

[76] M. Pavlova, A. Sokolov, I. Krägeloh-Mann, Visual navigation in adolescents with early

periventricular lesions: Knowing where, but not getting there, Cereb. Cortex. 17 (2007)
363–369. https://doi.org/10.1093/cercor/bhj153.

[77] E. Biffi, C. Gagliardi, C. Maghini, C. Genova, D. Panzeri, D.F. Redaelli, A.C. Turconi,
Learning my way: A pilot study of navigation skills in cerebral palsy in immersive
virtual reality, Front. Psychol. 11 (2020) 1–13.
https://doi.org/10.3389/fpsyg.2020.591296.

36
[78] A. Pasqualotto, M.J. Spiller, A.S. Jansari, M.J. Proulx, Visual experience facilitates
allocentric spatial representation, Behav. Brain Res. 236 (2013) 175–179.
https://doi.org/10.1016/j.bbr.2012.08.042.

[79] Q. Hu, Y. Yang, Z. Huang, Y. Shao, Children and adults prefer the egocentric
representation to the allocentric representation, Front. Psychol. 9 (2018) 1–7.
https://doi.org/10.3389/fpsyg.2018.01522.

[80] J. Bullens, K. Iglói, A. Berthoz, A. Postma, L. Rondi-Reig, Developmental time course

of the acquisition of sequential egocentric and allocentric navigation strategies, J. Exp.
Child Psychol. 107 (2010) 337–350. https://doi.org/10.1016/j.jecp.2010.05.010.

[81] M. Nardini, N. Burgess, K. Breckenridge, J. Atkinson, Differential developmental

trajectories for egocentric, environmental and intrinsic frames of reference in spatial
memory, Cognition. 101 (2006) 153–172.
https://doi.org/10.1016/j.cognition.2005.09.005.

[82] K. Hellgren, L. Jacobson, P. Frumento, J. Bolk, U. Ådén, M.E. Libertus, M. Benassi,

Cerebral visual impairment captured with a structured history inventory in extremely
preterm born children aged 6.5 years, J. Am. Assoc. Pediatr. Ophthalmol. Strabismus.
(2020) 1–8. https://doi.org/10.1016/j.jaapos.2019.11.011.

[83] M. Pavlova, C. Bidet-Ildei, A.N. Sokolov, C. Braun, I. Krägeloh-Mann, Neuromagnetic

response to body motion and brain connectivity, J. Cogn. Neurosci. 21 (2009) 837–
846. https://doi.org/10.1162/jocn.2009.21050.

[84] Y.J. van der Zee, P.L.J. Stiers, L. Lagae, J.J.M. Pel, H.M. Evenhuis, Chronological age
versus developmental age in evaluating patients’ performances on motion perception
tests, Neuropsychol. Trends. 2019 (2019) 73–94. https://doi.org/10.7358/neur-2019-
025-vand.

[85] E. Fazzi, S. Bova, A. Giovenzana, S. Signorini, C. Uggetti, P. Bianchi, Cognitive

visual dysfunctions in preterm children with periventricular leukomalacia, Dev. Med.
Child Neurol. 51 (2009) 974–981. https://doi.org/10.1111/j.1469-8749.2009.03272.x.

[86] C. Arzate Cruz, J.A. Ramirez Uresti, Player-centered game AI from a flow perspective:
Towards a better understanding of past trends and future directions, Entertain. Comput.
20 (2017) 11–24. https://doi.org/10.1016/j.entcom.2017.02.003.

37
[87] V. Celis, J. Husson, V. Vanden Abeele, L. Loyez, L. Van Den Audenaeren, P.
Ghesquière, A. Goeleven, J. Wouters, L. Geurts, Translating preschoolers’ game
experiences into design guidelines via a laddering study, ACM Int. Conf. Proceeding
Ser. (2013) 147–156. https://doi.org/10.1145/2485760.2485772.

[88] W.L. Wong, C. Shen, L. Nocera, E. Carriazo, F. Tang, S. Bugga, H. Narayanan, H.

Wang, U. Ritterfeld, Serious video game effectiveness, ACM Int. Conf. Proceeding
Ser. 203 (2007) 49–55. https://doi.org/10.1145/1255047.1255057.

[89] K. Vancleef, E. Janssens, Y. Petré, J. Wagemans, E. Ortibus, Assessment tool for

visual perception deficits in cerebral visual impairment: Development and normative
data of typically developing children, Dev. Med. Child Neurol. 62 (2019) 111–117.
https://doi.org/10.1111/dmcn.14303.

38
 Appendix A

Figure A.1. First basic prototypes of the games

Note. Left: MatchMaker; Middle: Hurricane Chaos; Right: Maze Explorer

Figure A.2. First basic prototypes of Maze Explorer 2D

Note. On the left the first version of Maze Explorer 2D is represented, and on the right the second version.

39
 Figure A.3. First basic prototypes of Maze Explorer 3D

Note. On the left the first version of Maze Explorer 3D is represented, and on the right the
second version.

40
 Appendix B

Figure B.1. Descriptions of manipulations and matches possible in MatchMaker

Note. Images were downloaded from https://www.freepik.com/ and http://www.tarrlab.org/.

Box a shows the prototypical task which involves matching two identical prototypes, and
matching a prototypical image with its manipulated image, specifically for details differ,
different poses, missing parts, partial, and atypical. For silhouettes, contour, and closure,
children have two tasks, either to match a prototypical image to the manipulated image, or two
identical manipulated images (see box b). For the manipulation noise (see box c), children have
three tasks, one which involves matching a prototypical image with a coloured object + noise,
the second involves matching two identical manipulated noise images, and the third requires
matching of a greyscale prototypical image with a greyscale image + noise.

The noise level was generated in a similar manner to Vancleef et al. [89], where the images
were 250 × 250 pixels and each noise square was 14 × 14 pixels. Based on desired image
coverage, 76, 133, 190, 238, and 287 noise squares were generated. The placement of the noise
squares was random, but kept constant throughout all images, and it builds upon itself –
meaning, the images with 133 noise squares contains 76 squares from the “first level of noise”
plus an additional 57 squares. Exact size of the squares depends on the image size to keep the
same proportions throughout all our images as we saw in the original source.

41
 Appendix C

Table C.1. Details of clinician and researcher workshops rating visual perceptual
difficulty of images

Workshop 1: Farm Workshop 2a: Farm Workshop 3a: Pirate Workshop 4a: Pirate
theme (Set 1) theme (Set 2) theme (Set 1) theme (Set 2)
Total number 10b 3c 2c 2d
of
participants
Specialization 6 clinicians; 4 2 clinicians; 1 1 clinician; 1 vision 1 clinician; 1 vision
of vision science vision science science researcher science researcher
participants researchers researcher
Workshop Printed cards, face to face, individual PDF images with an excel to fill out their
type ratings, online, individual
Average 2 3 3 3
duration (in
hours)
Average 432 554 582 585
number of
images
Notes. aWorkshops 2, 3, and 4 were done in an online manner due to the COVID-19 restrictions.
b
All 10 participants rated the full set of images for prototypical, details differ, atypical, different
poses, contour, closure, and silhouettes. For missing parts, two participants rated the complete
set while five participants rated part of the image set. For partial, two participants rated the
complete set while seven participants rated part of the set. For noise, nine participants rated a
part of the set, and finally, for viewpoints, 10 participants rated a part of the set.
c
In workshops 2 and 3, each participant rated a complete image set except that noise images
were no longer a part of the rating exercise as noise images were computer-generated, we used
the premise that an increase in noise increases the difficulty rating, as was demonstrated in
workshop 1. Additionally, only a subset of viewpoints were rated in the consecutive workshops
as after the first workshop we realized that it was difficult to differentiate between the different
viewpoints so we only chose viewpoints that were significantly visually different from each
other. dIn the third workshop, two participants rated all of the pirate theme images from set 1,
and in the fourth workshop, two different participants rated the other set of pirate theme images.
42
 Appendix D

Figure D.1. User requirements mentioned in the focus groups

43
 Appendix E

Equation 1: Equation to compute number of cards, where cards0 is number of cards at level 0,
cards100 is number of cards at level 100 and GD is game difficulty.

𝐺𝐷
𝑛𝑢𝑚𝑏𝑒𝑟_𝑜𝑓_𝑐𝑎𝑟𝑑𝑠 = 𝑐𝑎𝑟𝑑𝑠0 + ( × (𝑐𝑎𝑟𝑑𝑠100 − 𝑐𝑎𝑟𝑑𝑠0 ))
100
Equation 2: Equation to compute the time between presentation of the cards, where time0 is
time at level 0, time100 is time at level 100, GD is game difficulty.

𝐺𝐷
𝑡𝑖𝑚𝑒_𝑏𝑡𝑤_𝑐𝑎𝑟𝑑𝑠_𝑝𝑟𝑒𝑠𝑒𝑛𝑡𝑎𝑡𝑖𝑜𝑛 = 𝑡𝑖𝑚𝑒0 + ( × (𝑡𝑖𝑚𝑒100 − 𝑡𝑖𝑚𝑒0 ))
100

Equation 3: Equation to compute number of objects to find, where objects0 is number of objects
to find at level 0, objects100 is number of objects to find at level 100, GD is game difficulty.

𝐺𝐷
𝑜𝑏𝑗𝑒𝑐𝑡𝑠_𝑡𝑜_𝑓𝑖𝑛𝑑 = 𝑜𝑏𝑗𝑒𝑐𝑡0 + ( × (𝑜𝑏𝑗𝑒𝑐𝑡𝑠100 − 𝑜𝑏𝑗𝑒𝑐𝑡𝑠0 ))
100
Equation 4: Equation to compute number of distractors placed in the scene, where distractors0
is number of distractors at level 0, distractors100 is number of objects to find at level 100, GD is
game difficulty.

𝐺𝐷
𝑑𝑖𝑠𝑡𝑟𝑎𝑐𝑡𝑜𝑟𝑠 = 𝑑𝑖𝑠𝑡𝑟𝑎𝑐𝑡𝑜𝑟𝑠0 + ( × (𝑑𝑖𝑠𝑡𝑟𝑎𝑐𝑡𝑜𝑟𝑠100 − 𝑑𝑖𝑠𝑡𝑟𝑎𝑐𝑡𝑜𝑟𝑠0 ))
100
Equation 5: Equation to compute minimal size of the objects, where minSize0 is minimal size
at level 0, mimSize100 is minimal size at level 100, GD is game difficulty.

𝐺𝐷
𝑚𝑖𝑛𝑆𝑖𝑧𝑒 = 𝑚𝑖𝑛𝑆𝑖𝑧𝑒0 + ( × (𝑚𝑖𝑛𝑆𝑖𝑧𝑒100 − 𝑚𝑖𝑛𝑆𝑖𝑧𝑒0 ))
100
Equation 6: Equation to compute maximal size of the objects, where maxSize0 is maximal size
at level 0, maxSize100 is maximal size at level 100, GD is game difficulty.

𝐺𝐷
𝑚𝑎𝑥𝑆𝑖𝑧𝑒 = 𝑚𝑎𝑥𝑆𝑖𝑧𝑒0 + ( × (𝑚𝑎𝑥𝑆𝑖𝑧𝑒100 − 𝑚𝑎𝑥𝑆𝑖𝑧𝑒0 ))
100

44
Equation 7: Equation to compute minimal distance of objects from the border, where
minDistance0 is minimal distance at level 0, minDistance100 is minimal distance at level 100,
GD is game difficulty.

𝐺𝐷
𝑚𝑖𝑛𝐷𝑖𝑠𝑡𝑎𝑛𝑐𝑒 = 𝑚𝑖𝑛𝐷𝑖𝑠𝑡𝑎𝑛𝑐𝑒0 + ( × (𝑚𝑖𝑛𝐷𝑖𝑠𝑡𝑛𝑎𝑐𝑒100 − 𝑚𝑖𝑛𝐷𝑖𝑠𝑡𝑎𝑛𝑐𝑒0 ))
100
Equation 8: Equation to compute number of branches, where branches0 is number of branches
at level 0, branches100 is number of branches at level 100, GD is game difficutly.

𝐺𝐷
𝑏𝑟𝑎𝑛𝑐ℎ𝑒𝑠 = 𝑏𝑟𝑎𝑛𝑐ℎ𝑒𝑠0 + ( × (𝑏𝑟𝑎𝑛𝑐ℎ𝑒𝑠100 − 𝑏𝑟𝑎𝑛𝑐ℎ𝑒𝑠0 ))
100
Equation 9: Equation to compute number of dead ends, where deadends0 is number of dead
ends at level 0, deadends100 is number of dead ends at level 100, GD is game difficulty.

𝐺𝐷
𝑑𝑒𝑎𝑑𝑒𝑛𝑑𝑠 = 𝑑𝑒𝑎𝑑𝑒𝑛𝑑𝑠0 + ( × (𝑑𝑒𝑎𝑑𝑒𝑛𝑑𝑠100 − 𝑑𝑒𝑎𝑑𝑒𝑛𝑑𝑠0 ))
100
Equation 10: Equation to compute max number of POIs, where maxPoisLvl is highest level
where POIs are shown, maxPois0 is maximum number of POIs used at level 0, GD is game
difficulty.

𝐺𝐷
𝑚𝑎𝑥𝑃𝑂𝐼𝑠 = ((1 − ) × 𝑚𝑎𝑥𝑃𝑜𝑖𝑠0 )
𝑚𝑎𝑥𝑃𝑜𝑖𝑠𝐿𝑣𝑙
Equation 11: Equation to compute stars, where minStars is minimum stars to be earned,
maxStars is maximum stars to be earned, movesdone is number of moves taken in the maze,
movesoptimal is minimum moves to pass the maze.

(𝑚𝑜𝑣𝑒𝑠𝑑𝑜𝑛𝑒 − 𝑚𝑜𝑣𝑒𝑠𝑜𝑝𝑡𝑖𝑚𝑎𝑙 )
𝑒𝑎𝑟𝑛𝑒𝑑𝑆𝑡𝑎𝑟𝑠 = 𝑚𝑖𝑛𝑆𝑡𝑎𝑟𝑠 + ((1 − ) × (𝑚𝑎𝑥𝑆𝑡𝑎𝑟𝑠 − 𝑚𝑖𝑛𝑆𝑡𝑎𝑟𝑠))
((3 × 𝑚𝑜𝑣𝑒𝑠𝑜𝑝𝑡𝑖𝑚𝑎𝑙 ) − 𝑚𝑜𝑣𝑒𝑠𝑜𝑝𝑡𝑖𝑚𝑎𝑙 )

45
 Appendix F

Figure F.1. Adaptivity rules and evaluation criteria

Note. In MatchMaker, after seven successful rounds the game difficulty increased and if the
child had three failed rounds the difficulty decreased. In Maze Explorer 2D and Hurricane
Chaos, children could go up or down after three successful or three failed rounds, respectively.
In Maze Explorer 3D, children could go up or down after two successful rounds or three failed
rounds, respectively. The game difficulty increase and decrease changed the game difficulty by
eight points in Match Maker, and by 10 points in all other games, with minimal game difficulty
0 and maximal game difficulty 100. This effectively split the Match Maker to 13 ‘levels’ based
on 11 manipulations and two manipulation combinations, and 10 levels for all other games.

46
 Appendix G

Figure G.1. Usability characteristics of the iVision application.

Satisfaction Attractiveness

The sound effect when the child won a star is not disturbing

The sound effect when the answer is incorrect is not disturbing

The sound effect when the answer is incorrect is not disturbing

The multiplier system would increase the child's motivation

The child has enough control in the games

Operability

*Did you run into error messages during gameplay

Usability characteristics

*Did you run into error messages while downloading the iVision app

The harder levels are appropriate for children with better visuoperceptual skills

The easy levels are appropriate for children with low visuoperceptual skills

The child will visually notice the yellow line/stars filling up in the jar
Learnability

The reward system: The multiplication system would not confuse the child

The multiplier reward system will be understandable for the child

The language used in the games is not difficult for children 6-12 years

The language used in the games is not difficult for children 3-6 years
Efficiency

The iVision application did not take a lot of time for loading
Effectiveness

The child would be comfortable with the horizontal screen orientation

The main menu of the iVision application is not confusing

The game provides easy to use touch screen input

1 1,5 2 2,5 3 3,5 4 4,5 5

Likert-scale: 1 = completely disagree; 5 = completely agree

Note. Likert-scale ratings: 1 = completely disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = completely agree. * reflects negative items, these
were rated as 1.
47
 Appendix H

Figure H.1. Usability characteristics of the four iVision mini-games.

The objects/elements in the games are clearly visible

Learnability

The background does not interfere with the game elements:

Images on the cards (MM), objects in the scene (HC), mazes
(ME2D/ME3D)
Efficiency
Usability characteristics

The game is not too slow and I did not have to wait for a response
to continue

The game provides appropriate feedback for my actions e.g.,

when an answer is (in)correct
Effectiveness

It is easy to know where to click to repeat the general instruction

Useful voice-over instructions explaining how to perform a task

are provided

It is easy to click on the cards (MM), objects (HC), arrows

(ME2D/ME3D)

1 1,5 2 2,5 3 3,5 4 4,5 5

Likert-scale: 1 = completely disagree; 5 = completely agree

Maze Explorer 3D Maze Explorer 2D Hurricane Chaos MatchMaker

Note. Likert-scale ratings: 1 = completely disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = completely agree. MM: MatchMaker. HC: Hurricane
Chaos. ME2D: Maze Explorer 2D. ME3D: Maze Explorer 3D.

48
 Appendix I.

Figure I.1. This-or-That method responses from the younger children (n=11).

11
10
9
8
Number of children

7
6
5
4
3
2
1
0
Most fun Wanted gift Take home Play again Most stupid Reminder Additional
measure

MatchMaker Hurricane Chaos Maze Explorer 2D Maze Explorer 3D No response

Note. Reminder question: “Can you remind me again which game did you find most fun?”. Additional measure: After children finished game-play
they were given the option to ‘free play’ any game again while they waited for their instructor to pick them up.

49
 Figure I.2. This-or-That method responses from the older children (n=12).

12
11
10
9
Number of children

8
7
6
5
4
3
2
1
0
Most fun Wanted gift Take home Play again Most stupid Reminder Additional
measure

MatchMaker Hurricane Chaos Maze Explorer 2D Maze Explorer 3D No response

Note. Reminder question: “Can you remind me again which game did you find most fun?”. Additional measure: After children finished game-play
they were given the option to ‘free play’ any game again while they waited for their instructor to pick them up.

50

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