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2013
http://informahealthcare.com/pdr
ISSN: 1751-8423 (print), 1751-8431 (electronic)
Dev Neurorehabil, Early Online: 1–5
!
2013 Informa UK Ltd. DOI: 10.3109/17518423.2013.784817
ORIGINAL ARTICLE
TOBY play-pad application to teach children with ASD – A pilot trial
Dennis W. Moore
1
, Svetha Venkatesh
2
, Angelika Anderson
1
, Stewart Greenhill
3
, Dinh Phung
2
, Thi Duong
2
,
Darin Cairns
4
, Wendy Marshall
5
, & Andrew J. O. Whitehouse
6,7
1
Krongold Centre, Faculty of Education, Monash University, Melbourne, Australia,
2
Center for Pattern Recognition and Data Analytics (PRaDA),
Deakin University, Geelong, Australia,
3
Department of Computer Science, Curtin University of Technology, Perth, Australia,
4
The Charles Street
Clinic, North Perth, Western Australia, Australia,
5
Autism West, Nedlands, Western Australia, Australia,
6
Telethon Institute for Child Health Research,
Centre for Child Health Research, University of Western Australia, Subiaco, Western Australia, Australia, and
7
Neurocognitive Development Unit,
School of Psychology, University of Western Australia, Western Australia, Australia
Abstract
Purpose: To investigate use patterns and learning outcomes associated with the use of Therapy
Outcomes By You (TOBY) Playpad, an early intervention iPad application.
Methods: Participants were 33 families with a child with an autism spectrum disorder (ASD)
aged 16 years or less, and with a diagnosis of autism or pervasive developmental disorder – not
otherwise specified, and no secondary diagnoses. Families were provided with TOBY and asked
to use it for 4–6 weeks, without further prompting or coaching. Dependent variables included
participant use patterns and initial indicators of child progress.
Results: Twenty-three participants engaged extensively with TOBY, being exposed to at least
100 complete learn units and completing between 17% and 100% of the curriculum.
Conclusions: TOBY may make a useful contribution to early intervention programming for
children with ASD delivering high rates of appropriate learning opportunities. Further research
evaluating the efficacy of TOBY in relation to independent indicators of functioning is warranted.
Keywords
Autism, early and intensive behavioural
intervention, i-Pad, learn unit, Therapy
outcomes by you
History
Received 7 March 2013
Accepted 8 March 2013
Published online 18 July 2013
Introduction
There is growing evidence that with early and intensive
behavioural intervention (EIBI) sizeable gains can be made in
cognitive, communication, social, academic and adaptive
skills of children with an autism spectrum disorder (ASD)
[1–3]. Effective interventions are characterised by a number
of key ingredients including early onset of treatment, high
intensity and data-based decision making. The American
Academy of Pediatrics (AAP) recently released a series of
recommended guidelines for nonmedical interventions for
children with ASD [4]; guidelines developed by a Technical
Expert Panel following a systematic review of research
findings. The first conclusion of the AAP Technical Expert
Panel is that: ‘‘Individuals with ASD should receive com-
prehensive intervention within 60 days of identification’’
[4, p.S174]. The guidelines go on to specify that such a
comprehensive programme must be (i) ‘‘...individualized
to the strengths and deficits of the person with ASD, ...
(ii)...must address the concerns of the family and offer
opportunity for their active participation, ...and (iii)...chil-
dren with ASD should be actively engaged in comprehensive
intervention for a minimum of 25 h per week throughout the
year’’ (p.S174).
Despite clear evidence of the benefits of EIBI for the
treatment of children with ASD researchers have reported
problems with the implementation of such interventions,
problems with availability of suitably qualified consultants for
home-based programmes and other staff to supervise and
implement such programmes [5], the quality of the programs
provided [6, 7], and funding more generally. In seeking
feasible ways to provide effective behavioural intervention
in the face of these difficulties researchers have investigated
a number of alternatives including providing fewer therapy
hours, and employing technology.
Eldevik et al. [8], in a two year randomised control trial
(RCT), found significant gains in intellectual functioning, and
both receptive and expressive communication with 12 h per
week of behavioural intervention over an eclectic treatment
control group but no significant differences in adaptive
behaviour, socialisation or daily living skills. Peters-Scheffer
et al. [9] also reported that after 8 months children in a
behavioural treatment group receiving on average 6.5 h
intervention per week in their RCT had significantly higher
developmental ages and made more gains in adaptive skills
than did a regular treatment control but no significant
differences were evident on autistic symptom severity or
emotional or behavioural problems present.
Though clear gains were achieved in both these lower
intensity clinical trials, the gains appear not to match reported
gains of more intensive (420 h) intervention programmes
[3, 10, 11]. Sufficient intensity or dosage appears to be an
Correspondence: Angelika Anderson, Krongold Centre, Faculty of
Education, Monash University, Clayton, VIC 3800, Australia. Tel: +61
3 990 52856. E-mail: angelika.anderson@monash.edu.
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important element in optimal interventions for children with
ASD. Intensity of teaching, however, is not entirely captured by
time engaged in instruction. Reed et al. [12], for example while
finding greater gains with what they termed ‘‘high intensity’’
programmes (mean 30 h/week) relative to low intensity (mean
12 h/week) also found that within their high intensity group
increased temporal input was not associated with increased
gains in the children. Greer and colleagues have argued that
intensity of instruction is best captured by the concept of the
learn unit, which consists of an opportunity to respond, a
response and feedback for each partner in a learning interaction
[13]. Greer and McDonough suggest that the learn unit is the
strongest predictor of effective teaching. However, elsewhere
they have demonstrated that delivering correct learn units
accurately and at a high rate requires considerable expertise
[14]. It is not something that we can assume that parents or
teachers will do readily.
A challenge for policy makers, clinicians, researchers and
parents alike is to find ways to increase the intensity of the
intervention programmes provided to children with ASD and
their families. The use of technology in the delivery of services
holds promise. Developments such as web-based behaviour
capture and store technologies [15] and the emerging focus
on video-based intervention procedures which capitalize on
the often observed preference children with ASD show for
flat screen information media/visuals [16–19] are examples
of novel use of technology. Another such innovation is
TOBY (Therapy Outcomes By You) Playpad, a unique early
intervention iPad application for children with autism.
TOBY was designed by a team of computer scientists
specialized in machine learning, working with behaviour
analysts, clinical psychologists and speech therapists specia-
lising in autism. For technical details regarding TOBY, see
Venkatesh et al. [20] and Venkatesh et al. [21]. The program
targets important areas of early language learning as well as
skills in sensory awareness, imitation, and social interaction.
In developing the program, the following system outcomes
were achieved:
A platform for flexible delivery of stimuli. The delivery
of stimuli, responses, prompts and reinforcement are
encapsulated in a rigorous learning framework.
A syllabus with four main skill areas: visual and auditory
understanding, receptive and expressive language, social
skills including joint attention, and imitation. A flexible
syllabus, responsive to the child’s progress, is delivered.
Learning trials are arranged in mixed environments, on
and off the iPad, within the same learning framework.
Prompting is increased or decreased in response to
performance. Reinforcement is provided both at a trial
and task level. There are strict and measureable criteria
for mastery, and for progression through the syllabus,
As well as using data to inform the immediate prompt
levels provided and next steps in the curriculum, TOBY
presents performance data graphically thereby facilitating
data-based decision making and the tracking of progress.
TOBY adjusts stimuli, reinforcement, and prompting as a
result of responses in three fundamental task types:
(1) Solo: Tasks in which the computer can measure the
response directly, and can deliver reinforcement and
prompting to the child. For example, the child is required
to find a given stimulus picture from a set of pictures.
The child can perform these tasks without assistance
from the parent. These tasks cover a small subset of
skills.
(2) Partner: Other tasks involve the parent. The system
presents the stimuli, the parent recognises the child’s
response and prompts as guided by the system. The parent
and child work together, the parent prompting as required
and delivering reinforcement. Examples of partner tasks
include expressive speech, and imitation tasks.
(3) Natural environment task (NET): Computer-based activ-
ities can teach basic skills, but it is crucial that these
skills can be used in other settings. To enhance gener-
alisation NET tasks are completed off the iPad. Tasks and
instructions are provided by TOBY. The instructions
detail (a) how to perform the task, (b) how to prompt for
and (c) reinforce correct responding. The parent performs
the task with the child in play or in daily routines. Parents
then provide TOBY with feedback about their child’s
performance which guides the system to decide progres-
sion to subsequent tasks. Each partner or solo activity has
corresponding NET activities teaching the same skills
away from the computer.
Solo iPad tasks consist of a series of discrete trials – a
stimulus is presented by the system and a response is elicited
from the child. Prompts and reinforcement follow incorrect
and correct responses, respectively. Each such stimulus
presentation, response and feedback (prompt or reinforce-
ment) is effectively what Greer and others termed a ‘‘learn
unit’’ [13]. This is also true for Partner iPad tasks, the
difference being that here parents feed their child’s response
into the system, and provide prompting if required. The
system gives reinforcement. TOBY comes with a built-in
reward system to reinforce learning. As learners progress
through tasks they collect tokens that can be spent on play
activities such as painting, balloon and bubble popping, visual
displays of fireworks, and access to parent-selected videos.
In all cases, the system progresses to subsequent tasks based
on the performance of the child thereby guiding the child
systematically through the curriculum. There are between
10 and 15 specific skills in each of the four syllabus
areas, with 51 skills and 326 tasks in all; 34 iPad tasks
and 292 NET tasks, reflecting the focus on generalisation
enhancement.
A typical day with TOBY might include 20 min of iPad
time and a similar amount of time off the iPad doing TOBY-
directed tasks that weave into daily routines and the child’s
play interests. How much time is spent in TOBY-guided
activities depends on the parent and the child. Each session
TOBY presents a choice of tasks drawn from the curriculum
based on how the child has progressed with pre-requisite
tasks. TOBY can adapt to the child’s learning and develop-
mental needs by choosing goals and adjusting the difficulty
level of tasks presented. Based on TOBY’s recommendations
the parent can choose which tasks to complete each day and,
based on the child’s results, the program will generate
suggestions for the following day’s activities. TOBY tracks
the child’s progress by generating clear and easy to read
reports – the parent or therapist can monitor a child’s progress
through the curriculum, and how much support, or prompting
2 D. W. Moore et al. Dev Neurorehabil, Early Online: 1–5
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is required. This helps parents, therapists and educators track
the child’s learning, pinpoint where and why problems
might be occurring, and design strategies to address such
problems.
In summary, TOBY is a program based on current best
practice guidelines, which provides a comprehensive system
for facilitating the delivery of intensive early intervention
by parents in the home and as part of daily routines. This,
together with the in-built parent training videos, might enable
it to be used to bridge the oft-noted gap in service provision
by enabling increased training hours for young children with
ASD at home, with their parents or care givers.
In this paper, we report on a preliminary evaluation of
TOBY designed to provide initial data on patterns of use and
outcomes of the program under naturalistic conditions in
which parents have access to the program and to the
instructions provided therein regarding how to use it. The
following questions are answered in this report:
Do people use TOBY?
If so, how much?
Do they use the NET tasks as well as the iPad based tasks?
Do children benefit from the use of TOBY?
Do they learn?
What evidence is there regarding the efficiency of the
program in terms of the rate of instruction delivered and
learning achieved?
Method
Ethics approval was granted by an Institutional Ethical
Review Board prior to commencement of the study.
Participants
Participants were parents of children with autism and their
children from a large urban centre in Australia. Parents were
recruited through internet advertising with the understanding
that they could withdraw at any time without notice. Due to
the anonymous data capture processes data could not be
withdrawn once the participants had uploaded it.
Recruitment specifications were that the participating
child be aged 16 years or less, have a diagnosis of Autism
or Pervasive Developmental Disorder – Not Otherwise
Specified, and not have an intellectual disability or other
developmental delay. Participants were required to have an
effective non-vocal communication capacity – generally
through gestures, and other physical actions (such as hand
leading, bringing items), and sounds, but with some vocal
capacity, typically single words or two-word phrases. The
children also were required to be able to sit at a table for up
to 10 min at a time and have some familiarity with a
computer. Families were required to have an iPad updated
to the current version of the Operating System and wireless
internet connection. The explanatory statement indicated that
it was anticipated that they would be able to complete
activities across the week (preferably daily) over a period of
4–6 weeks. Parents were not given any further instruction
or support, nor were they encouraged or directed to use
TOBY throughout the trial period.
All 33 children participated in the pilot and data were
collected for each participant over between 4 and 6 weeks.
Materials
An iPad for each participating child loaded with the TOBY
app and connected to the internet. In addition various
common household items (e.g. socks, small toys) was used
by the parents in NET activities.
Data collection
All participant responses were uploaded, automatically in the
case of Solo and Partner activities and manually, by the
parents, for NET activities, as an integrated part of TOBY use.
Dependent variables generated by TOBY algorithms were
(i) participant use patterns including total time engaged
in Solo, Partner and NET activities, number of sessions
and of completed learn units (stimulus, response, feedback –
sequences) and (ii) indicators of child progress: correct/
incorrect response patterns differentiated across the four
curriculum areas.
Results
Use pattern across the cohort
Data on TOBY use and response patterns by this cohort of 33
children and their parents/caregivers are presented in Table I.
The data presented in the table which reflect use patterns
include total time TOBY was open (hours), number of
sessions, number of minutes engaged in TOBY tasks, and
proportion of time in Solo, Partner and NET activities (%).
The total time the program was open during the trial period
includes the time parents spent viewing tutorials and instruc-
tions. All except four participants (#12, 20, 21 and 23) spend
some time engaging with TOBY at some level in on average
44 sessions (number of distinct occasions that TOBY was
opened during the trial period; range 2–151). Of those
participants who engaged with TOBY as evidenced by
completing part of the curriculum, some did not engage in
iPad tasks (participants # 5, 8, 22, 26 and 33). The remaining
participants engaged in iPad tasks on average 178.5 min
(range 16.85–671.11 min). In this time, these 24 participants
completed on average 1129.9 learn units (range 15–4182).
Overall, the data presented suggest that use patterns varied
widely; only 23 of the 33 participants completed more than
a hundred learn units (range 112–4182 complete learn units
[CLUs] across the trial period).
Table I also presents the proportion of the TOBY
curriculum (iPad and NET) each participant completed.
Those 23 children who were exposed to at least 100 CLUs
completed between 100% (five children) and 17% of the iPad
curriculum. Fewer children engaged in the NET activities;
while one completed 100% of these tasks, 19 completed less
than 10% of the NET curriculum and of these 14 did not do
any NET tasks.
In addition Table I presents the proportion of items
participants responded to correctly while engaging with
TOBY iPad tasks – a measure of the difficulty of the tasks
for each participant. Scores ranged from 96% (participants
27 and 24) to 41% (participant 4).
One limitation of this study is that we do not have
information regarding the entry skills of the participants.
Scores of 80% correct and above are commonly considered
DOI: 10.3109/17518423.2013.784817 TOBY play-pad application 3
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to be indicative of mastery of a skill. It can perhaps therefore
be assumed that those participants with an average rate of
correct responses of 80% and over already had many of the
skills in their repertoire. Future studies should assess relevant
entry skills before exposure to TOBY. For the purpose of
further analyses those participants with a rate of correct
responses of 80% and over, and those with fewer than 100
CLUs were removed from the sample. The remaining 11
participants: # 4, 6, 7, 9, 10, 15, 16, 17, 18, 19, 31 are
highlighted in Table I. The learning outcomes for these
participants are summarized in the next section.
Learning outcomes for 11 participants
Data collected by TOBY which is indicative of learning
outcomes is also represented in Table I. These include the
number of completed learn units, completed learn units per
minute, % iPad curriculum completed, % NET curriculum
completed, and learn unites required to complete 1% of the
curriculum.
These 11 participants experienced an average of 6.18 CLUs/
min (range 2.79–10.54), at an average level of 61.5% correct
(range 41.63–79.18%), completing on average 48.62% of the
i-pad curriculum (range 17.4–91.3%), and 17.3% of the
Net curriculum (range 0–96.1%), which on average required
28.24 CLUs to complete 1% of the curriculum (range 10.66–
51.23).
The groups of learners that completed a large proportion
of the i-pad curriculum (470%) and a small proportion of the
curriculum (17.4%) included both slow and fast learners
as measured by number of CLUs required to complete 1% of
the curriculum (ranges 10.66–48.09 and 15.58–51.23, respect-
ively). This suggests that TOBY caters equally well to slow and
fast learners.
Discussion
The results reported show that TOBY was used to some extent
by the majority of families in this trial. This suggests that even
without therapist support and in the absence of any kind of
encouragement, parents were able to utilize this tool. Though
use patterns in this study varied widely, some families
engaged with TOBY extensively and to good effect.
Clearly, in order to be of benefit tools such as TOBY need
to be attractive and easy to use. Reasons for non-use of this
resource could include accessibility issues (instructions for
parents are too complex or require too much time) or
contextual issues, such as high levels of parenting stress.
Parents confronting a diagnosis of autism with one of their
children are often initially quite overwhelmed [22]. The
cohort in this study is likely to include families in this
situation. It is also possible that some of the participating
families were unaware of the importance and potential
benefits of EIBI. Future studies should aim to increase rates
Table I. Participant outcome measures.
User
ID
Time
(h) Sessions
Time (min)
doing
iPad tasks
Completed
Learn Units CLU/min
%
Correct
% iPad
curriculum
completed
% NET
curriculum
completed
LU/1%
complete
1 10.7 48 298.54 1463 4.9 85.16 100 88.2 14.63
2 12.6 74 172.87 1063 6.14 83.44 69.6 21.6 15.28
3 3.5 20 41.28 232 5.61 83.62 69.6 0 3.33
4 5.2 36 177.19 891 5.02 41.63 17.4 0 51.23
5 1.3 6 60 13 0
6 23.1 151 490.08 2402 4.9 67.65 65.2 39.2 36.83
7 22.3 98 298.74 1824 6.1 59.92 65.2 96.1 27.96
8 1.6 5 0 4.3 0
9 8.5 40 96.92 271 2.79 43.91 17.4 2 15.58
10 2.5 19 65.87 562 8.53 57.47 17.4 0 32.31
11 2.3 18 42.34 261 6.16 88.88 65.2 11.8 4
12 0
13 13.4 72 518.25 4145 7.99 71.72 91.3 0 45.39
14 8.9 49 208.56 1253 6 93.37 100 52.9 12.53
15 2.8 22 108.82 888 8.16 64.52 26.1 2 34.04
16 20.2 112 671.11 4182 6.23 74.67 87 35.3 48.09
17 7.5 87 74.37 784 10.54 52.93 43.5 0 18.03
18 5 24 127.72 509 3.98 69.35 30.4 2 16.72
19 10.9 50 153.06 788 5.14 79.18 73.9 3.9 10.66
20 0
21 0
22 1 2 0 4.3 0
23 0
24 11.3 74 123.37 955 7.74 96.12 100 98 9.55
25 7.2 76 146.16 1054 7.21 88.99 100 100 10.54
26 1.8 5 51 4.3 19.6
27 1.6 24 22.91 112 4.88 96.42 52.2 13.7 2.14
28 1.9 22 31.36 200 6.37 81.5 30.4 49 6.57
29 1.9 21 16.85 85 5.04 62.35 26.1 0 3.25
30 4.3 28 107.18 820 7.65 92.19 87 0 9.43
31 6.5 30 264.66 1751 6.61 65.27 91.3 9.8 19.17
32 8.9 43 119.11 1495 12.55 88.69 100 84.3 14.95
33 5.2 21 1 8.7 35.3
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of active engagement with the program by offering some
parent education and support.
A significant limitation of this study was that no
independent pre- or post-intervention measures of functioning
were obtained, nor was there a control group for comparison.
We are therefore, limited in the extent to which we can ascribe
positive outcomes to the TOBY intervention. However, the
data obtained on the completion of learn units are of interest.
Research has shown that high rates of opportunities to
respond are associated with better learning outcomes espe-
cially if they are accompanied by correct teacher responses
or feedback. Hence, both quantity and quality of CLUs
need to be considered [14]. TOBY is likely to deliver more
opportunities to respond than a person in a discrete trial
training program as it requires no pauses for data collection.
Toby is also likely to be more reliable than even a very
experienced teacher at delivering correct feedback. Finally, as
TOBY makes curriculum decisions based on feedback gained
in interaction with the child, a match between a child’s current
knowledge and the difficulty level of tasks offered by the
program is assured, thereby optimizing the benefits associated
with active engagement with TOBY. Future research is
warranted exploring the relationship between CLUs and rate
of learning for individual children. The current data suggests
that those children who engaged with TOBY regularly made
gains in terms of progressing through the curriculum. Most
of these children engaged not only in iPAD tasks but also in
NET tasks, which should facilitate maintenance and gener-
alisation. However, without independent data on indicators
of functioning we can only speculate as to the actual impact of
TOBY on children’s development and performance. Future
studies should address these shortcomings by including pre
and post intervention data on a number of indicators of
functioning as well as assessing the degree of generalisation
and maintenance of treatment effects. However, the prelim-
inary indicators of learning presented here suggest that TOBY
is potentially useful in contributing to the efficacious delivery
of early intervention.
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of the article.
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