Proceedings

EL-DORADO: SERIOUS GAME DEVELOPED FOR SENSORY

STIMULATION IN CHILDREN WITH AUTISM SPECTRUM
DISORDER
Richard Ribeiro Brancato de Souza1[0000-0001-5240-7855], Marcelo de Souza Bravin1[0000-0001-7582-8679], Henrique da
Costa Rodrigues1[0000-0002-8912-6026], Thais Fernandes da Silva1[0000-0003-1375-041X], Jany Mazini Fontes1[0000-0002-6267-
2254]
Silvia Cristina Martini Rodrigues1[0000-0002-0858-4050] and Márcia Aparecida Silva Bissaco1[0000-0002-3219-2567]

1
Mogi das Cruzes University (UMC), Mogi das Cruzes – SP, Brazil

marciaaab@umc.br

ABSTRACT- Many children with Autism Spectrum Disorder (ASD) have sensory alterations as a frequent
characteristic, which may be disturbing, generating anxiety and aggressive or self-mutilating behaviors. Like
any other child, regardless of the disorder or comorbidity, children with ASD can benefit from training based
on interaction with sensory stimuli. However, they need special attention on how these stimuli are presented.
In this research, a digital technology focused on the health area, El-Dorado, was developed that can be
performed through mobile devices (Smartphone/Tablet), in order to make habituation to sensory stimuli (visual,
auditory and vibrational) commonly presented in digital media. Becoming innovative and extremely useful, as
it can prevent or decrease the occurrence of hypersensitivity while running experiments, digital games, serious
games, videos, animations etc.

KEYWORDS: Autism, Digital Game, Senses, ASD, Sensory Game, Sensory Stimuli.

1. Introduction

The currently accepted and globally widespread definition of autism is the presented in the DSM-V,
which describes Autism Spectrum Disorder (ASD) as a group of disorders of complex and genetically
heterogeneous neurodevelopment, characterized by difficulties in social interaction, communication skills and
a pattern of repetitive and stereotyped behaviors, and may present distinct levels of severity with distinct
presentations and manifestations, which leads to the designation as spectral[1].

Many children with ASD have sensory changes as a frequent characteristic, which may be disturbing,
generating anxiety and aggressive or self-mutilating behaviors. Like any other child, regardless of the disorder
or comorbidity, children with ASD can benefit from training based on interaction with sensory stimuli.
However, they need special attention on how these stimuli are presented[1–4].

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Many researchers in the field of health, psychology and pedagogy believe that the use of teaching
methods, in which human-machine interaction occurs instead of face-to-face social interaction or group work,
helps in the development of these individuals with the advantage of generating less anxiety and frustration [5–
8]. For this reason, there are qualities in the use of digital games for the therapy and education of individuals
with ASD, presenting as advantages: ease of access, mobility, possibility of making instant feedback to the
player, adjustment to individual needs, diversity of sensory stimuli, possibility of grouping individuals to
perform the same task, adjusting the levels of difficulty and possibility of repeatability of the same action several
times [9, 10].

However, many of the software currently developed for the treatment or training of various behavioral
aspects presented by individuals with ASD do not deepen or ignore the need to adapt to habituation to the
sensory stimuli of these individuals[11–14]. Because when applied without due care or a pre-stimulation in
which children with ASD habit sensory stimuli presented through digital media, it is possible to generate anxiety
and frustration by activating the hypersensitivity systems of these children [15, 16].

In addition, existing digital tools that include the work of sensory integration of children with ASD,
use high-cost equipment, mostly do not have mobility and require constant attention from a professional
qualified to perform the training [4, 17, 18]

Because of the great search for the development of new technologies for training and treatment in the
health area, especially aimed at individuals with ASD, the need to reduce costs, amplification of access together
the presentation of hypersensitivity to digital stimuli presented by individuals with ASD. It was concluded that
it would be of great value to develop a serious game that can be performed through mobile devices (Smartphone
/Tablet), in order to make habituation to the sensory stimuli (visual, auditory and vibrational) commonly
presented in digital media. Becoming innovative and extremely useful, as it can prevent or decrease the
occurrence of hypersensitivity while running experiments, digital games, serious games, videos, animations etc.

2. Aterian M and Methods

The game described below was called El-Dorado, in reference to the indigenous legend about a lost
city entirely made of gold. The game was designed to accustom sensory stimuli (visual, auditory and
vibrational) commonly presented in digital media, and can help literate or unliterate children with ASD, aged
between 4 and 12 years.

In contact with the entire developer team, it was stipulated that the serious game El-Dorado would
present a visual memory game inspired by the game Simon, which was created in 1978 by the current Milton
Brandley company Hasbro, in which the player constantly repeats the sequence of colors and sounds presented
gradually and randomly. In this game, each color demonstration was emitted a polyphonic sound equivalent to
the color, from a color until an error occurred by the player, when the sequences were [20] However, considering

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the fact that many individuals with ASD have sensory integration dysfunctions, as well as atypical reactions to
sensory stimuli (hyper/hyporeactivity) [1, 21]. In the El-Dorado game, modifications were made to add the
psychological technique of Exposure and Prevention of Responses (PRS) and the basic principles of behavior
analysis (CA) for gradual exposure to sensory stimuli in a preventive manner[22, 23].

AC is a psychological approach that focuses on the understanding of the human being from the
interaction of the human being with [23]. Moreira and Medeiros (2007) systematically presented the concepts
and principles of it, such as: inborn reflex, learned reflex, reinforcement, punishment, among others.

In this project, two concepts of (CA) were used. Positive Reinforcement that is a type of behavior
consequence with the addition of a positive stimulus and that increases the probability of occurrence,
maintenance and/or repetition of a given behavior. And the Laws of intensity/magnitude that establish that the
stimulus intensity is a measure directly proportional to the magnitude of the response. That is, the higher the
intensity of the stimulus, the greater the magnitude of [23].

The concept of Punishment was totally avoided, this is a consequence of the behavior in which
something aversive is issued to the individual or taken away something reinforcing from the individual, thus
tending to control the behavior. This principle can trigger adverse behaviors, such as anguish, frustration, and
others, which are hardly controlled in any study [23]

The EPR technique was developed by physician and behaviorist Joseph Wolpe[22] It consists of
gradually presenting stimuli that may or may not be aversive, anxious or phobic from less intense levels to more
intense levels to individuals, controlling the environment and contingencies so that it does not cause any danger.
This helps in overcoming anxiety, fear or fear, thus effecting a process of habituation so that individuals
naturally accustom to these stimuli [24, 25].

This technique fits into the specific needs of the mobile game proposal, such as gradual exposure,
adaptation to individual characteristics, possibility of insertion in digital medium since it does not require
peripherals for the desired nest functionality and design.

During the development of the game, the concepts of international software quality were considered,
following the ISO/IEC 9126 and ISO/IEC 14598 standards, taking into account the quality of internal and
external use of the software and the evaluation of the software by the main characteristics of the process
(reproducibility, repeatability, impartiality and objectivity).

2.1 Software development

For the development of El-Dorado, surveys of analysis and design, implementation and final tests were
carried out [17, 26].

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All requirements were organized through two systematic reviews and the help of a multidisciplinary
team (psychologists, computer specialists and biomedical engineers)[16, 17, 26]. After this were listed the
functional and non-functional requirements, the prototypes, diagrams modeled in the Astah Community [27]
Figures 1 and 2 show the use case case diagram (UC) and the El-Dorado game activity diagram. Presenting
statically and dynamically the functions of the game.

Fig. 1. Use Case Diagram (UC) (In Brazilian Portuguese).

The modeling of the characters, scenarios and objects was performed using the Tools Adobe
Illustrator[28]; and Adobe Photoshop [29].

The animations and any interactive elements of the game were developed using Game Sprite, which is
a set of animation frames that correspond to each action of the [28, 29]. Interactivity will occur by finger
pressures on the Touch Screen touchscreen of the device used.

For the creation of the mobile application in Android version 4.0.3 or higher, we used the integrated
development environment, Integrated Development Evironment (IDE) Android Studio and the Android
software (SDK) Fluteer software belonging to Google, together with the Java programming language, Kotllin
and the Language JSON (JavaScript Object Notation). The frameworks of the Maven software development kit
have been installed.

The audio playback feature of phrases for NPC communication with the player was implemented
through MP3 voice recordings. The polyphonic sounds used as distracting in the playable phases were acquired
in MP3 format made available free of charge by Google [30].

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Fig. 2. Activity Diagram (In Brazilian Portuguese).

2.2 Game Review

The consistency of the game was verified through software tests performed by the authors, observing
usability, functionality, navigation and gameplay, and specialized evaluation was also performed.

All procedures involving the specialists were approved by the Research Ethics Committee of Mogi das
Cruzes University (CAAE- 34348620.0.0000.5497 / Opinion Number: 4,144,313). All experts invited to
evaluate the serious game signed the Free and Informed Consent Form.

The Black Box and White Box tests were applied to check for errors in the coding and operation of the
software. The black box test is used to check system functionality and data output, while the white box test
allows you to check the source code, to analyze the structure of the code and whether any errors [31].

A testing roadmap has also been created that covers the functionalities of the entire serious game in
order to verify that the sequences of actions and feedbacks are occurring as expected, taking into note the quality

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of use of the implemented[17]. The tests were performed in accordance with ISO/IEC 9126, ISO/IEC 14598
and as requested by capability maturity model integration (CMMI) [32]. In addition, the experts also answered
the System Usability Scale (SUS) questionnaire [33].

The System Usability Scale (SUS) is a rapid applicability test and can be used to evaluate products,
services, hardware, software, websites, applications or any type of interface, using three evaluation criteria,
effectiveness, efficiency and satisfaction [33].

2.3 Expert Assessment

To determine the number of experts who were invited to this study, Nielsen's heuristic was taken into
account, which determines that five participants are sufficient to detect errors in a first [34]. Therefore, the
opinions of five specialists in each area of knowledge that cover the study were considered, i.e., five
psychologists, five psychopedagogues, five occupational therapists and five game specialists, totaling twenty
specialists. They were invited via social networks such as Facebook on pages created for communication
between experts in each area or groups of WhatsApp experts. Their participation was restricted to the execution
of the serious El-Dorado game, on their date and place of preference, taking into account technical
considerations relevant to each specialty and answering two questionnaires forwarded via Google Forms [17].
A questionnaire elaborated observing the expertise of each specialist, based on the questionnaire developed and
validated by de Castro (2011) and the System Usability Scale (SUS) [33, 35].

2.4 Data analysis

The qualitative results, obtained from the evaluation performed by specialists, were measured by
descriptive statistical analysis. Calculating the average of the answers of the specialists analyzing the quality
components. The Likert scale was applied to the questionnaires in order to minimize the subjectivity of
qualitative data.

The data from the SUS questionnaire were evaluated by adding the contributions of the results of each
item. The SUS scale has ten statements based on the five-point scale, to evaluate the level of agreement of the
volunteers with the game. The statements of the questionnaire are divided equally, being half written positively
and the other half negatively. Each answer corresponds to a score, being them, 1 - Totally disagree, 2- Disagree,
3- I do not agree or disagree, 4- I agree and 5- I totally agree. The total points of this questionnaire (SUS score)
are obtained by adding the contributions of each item with values from 0 to 4. The contribution of odd questions
is calculated taking into account the position of the scale minus 1, while for even questions, 5 is calculated
minus the value of the scale position. The sum of the values is multiplied by 2.5, resulting in the SUS score, the
total amplitude ranges from 0 to 100[33].

It is also possible to relate the questions to Nielsen's heuristics, for a more structured evaluation, below
I will describe which questions are related to the desired characteristic: Ease of learning, questions 3, 4, 7 and

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10; Efficiency, questions 5, 6 and 8; Ease of memorization, question 2; Minimization of errors, question 6 and
Satisfaction, questions 1, 4 and 9.

3. Findings

The results acquired in the game development process, its expert evaluation and the usability test are
presented in the following items.

3.1 Game El-Dorado

The serious game El-Dorado was developed with the aim of assisting children with ASD, accustoming
them to sensory stimuli (visual, auditory and vibrational) commonly presented in digital media, in order to act
as a complementary tool to traditional treatments of sensory integration. Its main characteristics are its mobility,
no need for full professional follow-up during its reproduction and non-use of equipment that is difficult to
access for the Brazilian population, such as Kinect, because it only uses a Smartphone or Tablet for its
execution.

Introducing a visual memory game, in which the player must constantly repeat the color sequences
presented gradually and randomly. As distracting, the gradual additions of sensory stimuli
(visual/auditory/vibrational) were used and the process of habituation to sensory stimuli was used, according to
their basis in the technique of Exposure and Prevention of Responses [22]. It also presents natural and arbitrary
refills based on Behavior [23].

El-Dorado begins with an introductory story, to instigate the player and motivate during gameplay.

Fig. 3. Introduction (In Brazilian Portuguese).

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A non-playable character (NPC) was developed in order to facilitate the process of habituation, to
make positive refinements in a playful way, as well as generate a closer approximation of the player.

At the beginning of each difficulty level, the NPC performs the process of instructing how to play,
presents the sensory stimuli contained in the level, thus effecting the beginning of the habituation process. All
communication is presented both in audio and in text, thus facilitating the understanding of unliterate children.

Each level ends when the player makes the first mistake after a sequence equal to or greater than five
hits, whenever he misses before completion, a motivational message is presented, thus enhancing the continuity
in the gameplay.

Fig. 4. Gameplay (In Brazilian Portuguese).

All levels present a game of visual memory with gradual intensity and presentation of distracting
stimuli, distinguishing them from the stimulus, level 1- visual stimulus; level 2- visual and auditory distracting
stimulus; level 3- visual and tactile distracting stimulus (vibration); level 4- visual and auditory and tactile
distracting stimuli.

The hits and records are also recorded in order to strengthen the gameplay and maintain the player's
interest.

The fourth and last level has no completion, the purpose of this level is to reinforce the habituation to
the stimuli presented, instructing the player to beat his own records and maintain the repeatability.

3.2 Expert evaluation and usability testing

The following are the results of all evaluations made by the experts.

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3.2.1 Results of evaluations of psychology experts

Through the evaluations of the psychology specialists, it was possible to observe that (n=4) 80% of
them confirmed that the game El-Dorado does not present situations that can expose children with ASD to
aversive, frustrating or anxious uncontrolled experiences. These specialists reinforced the quality of the tool in
presenting sensory stimuli in a controlled and gradual way in intensity. In addition, (n=3) 60% of these experts
identified that the game is about progress and does not insert players in situations of win or lose, it is
emphasized the playful and controlled form and mainly, the non-use of any form of punishment. Unanimously,
the experts agreed that contingencies reinforcing playing behavior are applied correctly. All psychologist
specialists have identified that the tool can be used to accustom sensory stimuli and complement the training of
sensory integration of children with ASD. In all categories analyzed by psychology experts, the serious digital
game El-Dorado has been approved.

3.2.2 Result of evaluations of psych pedagogy specialists

With the qualitative evaluation performed by psychopedagogy specialists, it was possible to verify that
(n=4) 80% of the specialists denied the existence of uncontrolled characteristics that could expose the child
with ASD to situations that hinder the process of sensory integration. They emphasized that the game has the
potential to contribute to the development of cognitive, cultural-motor, emotional and social abilities of children
with ASD. It was also indicated by (n=4) 80% of the psychopedagogic evaluators that the learning facilitators
present in the El-Dorado game are consistent with the needs of the ASD population. These experts reinforced
the characteristics of the game as well-explained content, the use of repetition, motivating phrases,
memorization exercises, exercise that improve attention and concentration and the non-use of any form of
punishment. On the use of the El-Dorado game as a complementary tool in the process of training the sensory
integration of children with ASD, all specialists (N=5) agreed that this game has the potential for this use. They
highlighted the quality of use of digital media with the ASD public. They also confirmed that the use of gradual
progression both in difficulty and in the presentation of stimuli, as a means of promoting the evolution of
reflexive conducts. In all game-oriented reviews, the majority (more than 80%) of the appraisers approved the
requirements in the developed game.

3.2.3 Results of evaluations of occupational therapy specialists

From the evaluations performed by occupational therapy specialists, it was observed that (n=4) 80%
of the specialists identified the presence of sensory stimuli proposed in the El-Dorado game. They also
commented that the game features information related to attention and concentration. About the use of the game
as a complementary tool in the gradual training of sensory integration (n=3), 60% of the expert’s report that the
El-Dorado game can be used for this purpose. It is specific that the game can be used for the habituation of
specific information, which is necessary for the child with ASD to reduce the aversion to visual, auditory and
tactile sensory stimuli. They also commented that the presentation of sensory stimuli is given in a protected and

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careful manner, and can be used for focus training, attention and other skills that are altered in ASD. In their
final comments, the experts the quality of various uses of the tool developed in this research and the acceptance
of it as a proposal for the addition of visual, auditory and tactile sensory stimuli.

3.2.4 Results of reviews of gaming experts

In the evaluations performed by the game specialists, it was possible to observe that all these specialists
(n=5) positively evaluated the colors used in the serious game El-Dorado. On the degree of usability of this
game, most experts (n=4) rated it "Excellent" and only one of them (n=1) rated it "Good", indicating that the
game is intuitive. Considering the standard of 2D graphics, (n=1) 20% of the experts indicated that the game
has "Excellent" quality, (n=2) 40% rated it as "Optimal", (n=1) 20% rated it as "Good" and (n=1) 20% rated
the quality as "Regular". This information is in accordance with the non-functional requirements (scenarios,
images and objects) and the satisfaction of users, as presented in the evaluation of the SUS scale.

The quality of the graphical interface makes the game intuitive and self-explanatory, (n=3) 60% of the
experts reported that the quality of information needed to use the game is present in the game itself, (n=1) 20%
identified this quality as optimal and (n=2) 20% identified it as good. Still analyzing the iteof interaction with
the game, the experts evaluated how (n=2) 40% "Great" and (n=3) 60% "Good", indicating good quality, but
with potential for improvement.

Regarding the sound elements, (n=1) 20% of the specialists rated it as "Excellent", (n=1) 20% rated it
as "Optimal", (n=2) 40% rated it as "Good" and (n=1) 20% rated it as "Regular". Regarding the strategies used
during the game, (n=1) 20% of the experts rated it as "Excellent", (n=3) 60% rated it as "Great" and (n=1) 20%
rated it as "Good". In his comments highlight the quality of attention training, concentration and memorization
techniques during gameplay.

Observing the amplitude of the evaluation performed by game experts, it can be considered that the
game was approved in all categories analyzed, demonstrating quality of use.

3.2.5 Results of usability test (SUS) evaluations

According to Tenório et all (2011) one can recognize the software quality components presented by
Nielsen (2012) through the result of the average score of the SUS questionnaire as shown in Table 1, namely:
Ease of learning (questions 3, 4, 7, 10); Efficiency (questions 5, 6 and 8); Ease of memorization (question 2);
Minimization of errors (question 6) and Satisfaction (questions 1, 4, 9) [33, 36].

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Tab. 1. SUS scale score averages for El-Dorado software quality components (In Brazilian
Portuguese).

By calculating the overall average of the scores obtained from each software quality component, the score
was 84.35 (on a scale from 0 to 100). According to Bangor (2008) this result is above the average score and
indicates a positive assessment regarding the quality and ease of use of the digital game El-Dorado [37].

4 Conclusion

In the present work, the development of a serious game called El-Dorado for sensory stimulation of
individuals with ASD was described. This game aimed at the health area can be used as a pre-stimulation in
therapies, experiments, games, educational activities, among others, in order to generate fewer aversive
sensations during the execution of them, thus improving the results obtained with these tools, as well as a
complementary tool to traditional treatments of deficits in sensory integration. It has compatibility with mobile
devices (Smartphone / Tablet), which makes the game accessible and nomadic, can be used in various
environments and without the full monitoring of a qualified professional.

The quality of its history, character and reinforcers, tends to motivate the player while performing the
process of habituation to sensory stimuli commonly presented by digital media, thus demonstrating the quality
of use of the tool, methods and psychological techniques in the development of software for individuals with
ASD. Experts say that the game has potential qualities to reduce the occurrence of hypersensitivity while
running experiments, digital games, serious games, videos, animations, etc.

The results obtained in the White Box and Black Box evaluations show that the game has no errors in
its codes and allows the expansion of the same. All qualitative and quantitative evaluations carried out by the
20 specialists demonstrate the quality of the tool in its use and objective, as well as the results of the evaluations
of the SUS scale, approve in all requirements analyzed.

Due to the COVID-19 pandemic, the application of the tool with the TEA target audience was made
impossible, for this reason we will wait for the return to normality to carry out this process without putting the
research participants at risk.

Thanks

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This work was funded by the Coordination for the Improvement of Higher Education Personnel
(CAPES),The Research Support Foundation of the State of São Paulo (FAPESP) (Grant no. 2015/12248-2).
We thank Mogi das Cruzes University (UMC) and all employees who participated effectively in this research.

Supplementary Material

The game can be accessed at the link: http://markness.rf.gd/views/genius/

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