Charline Grossard
email: charline.grossard@aphp.fr

Carlotta Bettencourt

Ryan Kellems

Mohamed Chetouani

David Cohen

Building the design ICT inventory (DICTI): A Delphi study

Keywords: Neurodevelopmental disorders Information and communication technologies Delphi study Inventory Design Assistive technology metareview, ICT, neurodevelopmental disorders, design, methodology autism, social assistive robot, Wizard of Oz robotic interface, social skills, engagement

The increasing research focus of Information Communication Technologies (ICT) in therapeutic and educational approaches for children with Neurodevelopmental Disorders (NDD), raises crucial questions about the design conception of these tools and its effectiveness. ICT are suggested to provide new opportunities to enhance social and communication skills, cognitive functioning, and overall quality of life for children with special needs.

I would like to begin by expressing my deepest gratitude and appreciation to my director Professor David Cohen. Five years ago, following a clinical internship in his child psychiatry department, he took a leap of faith on me and offered me the opportunity to embark in this Ph.D. journey. He has accompanied me through a professional transformative journey over the last few years, with his consistent availability, productive feedback and support. Under his supervision, I experienced the importance of teamwork in research and how diverse profiles can complement each other resulting in inspiring work. While working with him, I was in admiration of his excellence, leadership, authenticity and creativity. I am also grateful to him for providing me with the opportunity to continue working as a clinician in his child psychiatry department in parallel of my research work. I'm thankful to my co-director, Professor Mohamed Chetouani, for his academic guidance and trust, and for introducing me to the health engineering perspective through the ISIR lab. A heartfelt thank you to Charline Grossard for being my professional role model and tutor throughout my Ph.D. Thanks to our extensive collaborations, notably in the assessment of new technologies applied to NDD, my thesis was able to recover from the administrative difficulties it faced due to the e-GOLIAH study. Her research skills, patience and positivity were instrumental in my work. Thanks to her supervision and trust, I was able to experience first hand the process of creating from scratch and implementing an applied research project. Notably, the robotic social skills intervention became the highlight of my Ph.D., in which I was fortunate to work with two of her students, Marie Segretain and Morgane Bree. My warmest thanks go to them for their professionalism, contributions and kindness during our study. I would also like to thank the team from the Hôpital de Jour, specially Sévrine and Céline for the interest they took in our research, their productive feedback and help in recruiting participants from their unit. I extend my thanks and appreciation to my research and clinical colleagues and friends from the hospital, Salvatore Anzalone, Soizic Guathier, Alex Castilla, Cyril Hanin, Soraya El Farhane, Marie Gallien, Sam Charpentier, and Jian Ling Zou, Alice Oppetit and Marie-Pierre Schoving. Their constant motivation, stimulating conversations, and support have kept me going. Our close-knit lab became a safe and fun space to work in, becoming a true privilege to be surrounded by such inspiring colleagues. I also extend my deepest gratitude to Hugues Pellerin, without whom tackling the statistics aspect of my research would have been even more difficult. I'm appreciative of his patience, pedagogy and kindness. A special thanks to Giulio Bertamini, who has been one of my unwavering pillars both personally and professionally during this journey. His significant contributions to the Epigram study, especially in machine learning clinical interpretations, were incredibly valuable. My warmest thanks also go to my colleagues from the psychodrama therapy group, Lionel Rottenberg, Antoine Langlois, Elisabeth Desrousseaux, Cora Bouchet and Benoit De Galembert, for welcoming me into their team three years ago. Their dedication, passion and expertise have been an endless source of inspiration.

! I would also like to express my profound appreciation and gratitude to my long time mentor Dr. Susan Sherkow, who took me under her wing when I was just starting university. It is thanks to her that I was able to discover and experience first hand the beauty behind autism therapy, and appreciate the unique lenses from which autistic children see and perceive the world. For several years, I led and coordinated with her The Spark social skills group at her center. Little did I know, my past clinical experience would become of outmost relevancy and comfort in the development and implementation of the social skills group study of my Ph.D. A decade later, I continue to cherish our professional and personal relationship.

A heartfelt thank you to my best friends from NY and Paris, Rebecca Amar, Marine Muller, Myriam Dahan and Jean Sfez for their love and support. Last but not least, I owe an immeasurable debt of gratitude to my parents, Margarita and Jean-Baptiste, for being my best role models and for always pushing me to become the best version of myself. Despite of being overseas for the majority of my doctorate, they were most present, supportive and empowering. Thank you to my dear brothers Hector, Juan, and Pierre, and my sisters in-law, Laure and Ale, who have also been steadfast pillars of support and affection throughout this journey. My family's influence and encouragements have played a critical role in my well-being and accomplishments.

Table of Contents

The work of this thesis is structured around two part incorporating engineering and clinical perspectives. The assessment part investigated how ICT for NDD care are conceived in terms of design. To answer this objective, we created the first transtechnology inventory with the support of a Delphi validation, aiming to assess the design of therapeutic and education ICT for NDD care. We also conducted a systematic meta review allowing us to contextualize the evolution of ICT research concerning implications for design and research methodology choices.

The clinical perspective explored two therapeutic ICT interventions for social skills training for Autism Spectrum Disorder (ASD). To answer this objective, we conducted a feasibility and usability study of a robotic intervention in a social skills group. At last, we finalized the protocol of a randomized control trial of a home-based delivered serious game intervention investigating its efficacy and medico-economic implications.

In conclusion, this thesis demonstrates that ICTs can be valuable tools in providing innovative approaches to treating individuals with NDD. However, it emphasized the significant importance of design choices when developing digital therapeutic tools. It does so by providing the first ICT Inventory, which encompasses a coordinated vision between engineering and clinical perspectives. DICTI aims to provide an easy tool to guide ICT developers into considering clinical objectives related to design features. Moreover, it aims to make a valuable contribution to the ICT field by proposing ! two therapeutic technological tools implemented in ASD care. The development of the DICTI is of significant relevancy in the assessment of the R2C3 robotic interface, as it proposes a more suitable version for a future repeatability study. Mots-clés: troubles neurodéveloppementaux, trouble du spectre de l'autisme, technologies de l'information et de la communication, conception, efficacité, robots sociaux, jeux sérieux.

Keywords

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Foreword

My doctoral research was structured to embrace Information and Communication Technologies (ICT) within the field of Neurodevelopmental Disorders (NDD), focusing specifically on Autism Spectrum Disorder (ASD). While collaborating with my tutors, Professors David Cohen and Mohamed Chetouani, our goal was to explore a wide range of scientific and clinical contexts, where ICTs could be applied. This implied adopting a multidisciplinary approach that integrated clinical, psychopathological, developmental, engineering and ICT design perspectives.

In terms of research objectives, we had the opportunity to be implicated in two extensive treatment studies, allowing us to employ computational approaches in two distinct ways. Firstly, we utilized computational analyses to assess prognostic factors related to ASD, including the impact of treatments given to autistic children. This data was made available to us by Dr. Nicole Garret-Gloanec, principal investigator of the EPIGRAM prospective study. Secondly, as a tool to provide therapeutic training through a serious game e-GOLIAH, a technological parent-delivered intervention at home. This innovative therapeutic training tool was intended to be evaluated through a randomized controlled trial, which unfortunately faced delays due to COVID pandemics and lockdowns. As a result, the timeline and scope of my thesis was adjusted accordingly.

The objective of the Epigram study was to explore prognostic factors of ASD after one year of treatment given in French day care hospitals and following Integrative Care Practices recommendations (ICPs, Squillante et al., 2022). During the first two years of my PhD, we collaborated with Dr. Nicole Garret-Gloanec and her team on the analysis of the EPIGRAM study, a naturalistic treatment study of children with severe ASD. This study included 89 autistic children aged less than 6 years and receiving ICPs. Unlike most previous studies, we included participants with low economic status, migrant status, and low ASD functioning. We used two complementary modeling approaches, including multivariable regression models and machine learning (Classification and Regression Tree, CART). Notably, our results revealed that migration negatively impacted the oneyear outcome [START_REF] Bettencourt | Migration is associated with baseline severity and progress over time in autism spectrum disorder: Evidence from a French prospective longitudinal study[END_REF], while emotion/behavior interventions led to significantly better one-year outcomes (Bettencourt et al., in submitted).

Additionally, I collaborated with my co-tutor, Charline Grossard, on developing the first ICT Inventory through a Delphi study [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. We also conducted a meta-analysis investigating the evolution of ICTs over the last few decades, examining the ICT design and research methodology implications (Grossard et al., submitted).

Although my planned experimental PhD work with e-GOLIAH, a serious game inspired by the Early Start Denver Model (ESDM), was delayed, we adapted and carried out a retrospective study exploring the hypothesis that screen overexposure could lead to symptoms similar to ASD, which might regress after removing access to electronic screens. The initial sample included 15 patients described as secondary ASD due to screen overexposure. The study revealed that ASD stereotypical behaviors diminished following screen removal, parental involvement, and improved play quality. However, due to the study design, small sample size and lack of heterogeneity in clinical variables across participants, we could not make generalizable or trustworthy conclusions.

Nevertheless, this experience taught me the importance of rigorous, well-designed methodology in evidenced-based research.

Furthermore, while at the research lab at the child psychiatry department of the Pitié Salpêtrière Hospital and the Institut des Systèmes Intelligents et de Robotique (ISIR), I witnessed my colleagues naturalistic observational research with robots and children with NDD. The Co-Writer project, a remarkable robotic and serious game intervention aiming to help children with dysgraphia, truly caught my attention. The Co-Writer project implemented a learning-by-teaching paradigm, where children taught the robot to improve its handwriting skills through a tablet, leading to improved writing skills, self-esteem and confidence (Gargot et al., 2020).

My interest for ASD care was awakened during my time in NYC when I volunteered at a center for child development, in a social skills group pairing neurotypical children and teens with autistic children. This experience, led me to become the mentor coordinator and eventually the program co-director-using my interpersonal skills, creativity, and understanding of ASD to develop social skills programs for the center involving physical expression, arts and craft, sports, and social games.

During my third PhD year, due to the continuous uncertainty of the e-GOLIAH trial, we continued exploring alternative options. The possibility of implementing the Rehabilitation Robotic Companion for Children and Caregivers (R2C3) robotic interface from the Co-Writer project in a social skills group for autistic children came up [START_REF] Zou | A wizard of oz interface with qtrobot for facilitating the handwriting learning in children with dysgraphia and its usability evaluation[END_REF]. Combining my clinical experience with my interest in social robotics, this multidisciplinary collaborative research experience became one of the highlights of my PhD. We conducted one of the first exploratory clinical trials investigating the feasibility and usability of a social robot, the Wizard of Oz Rehabilitation Robotic Companion for Children and Caregivers (R2C3) interface, in a social skills group for autistic children.

Although both active and inactive robotic interfaces showed no significant differences, the use of the robot resulted in increased engagement and interaction initiations, likely due to the novelty effect. Furthermore, including a robot in the social skills group did not hinder the intervention's effectiveness (Bettencourt et al., submitted). Our future work involves adapting the R2C3 interface to the group's needs and developing an efficacy design protocol.

Introduction

In recent years, the field of Information Communication Technologies (ICTs) has significantly increased in the care of individuals with Neurodevelopmental Disorders (NDD), notably Autism Spectrum Disorder (ASD). These tools, including serious games and apps, socially assistive robots, video modeling, and augmentative and alternative communication devices, have created new approaches to therapeutic and educational interventions. These digital technologies have been suggested in studies as effective tools to teach autistic individuals social and communication skills. ASD is characterized by difficulties in social interaction and communication, presenting unique challenges in their care. Interestingly, many studies have highlighted that autistic children often exhibit a natural affinity for technology and a good disposition for using and learning through the use of digital tools. This inclination may stem from the predictability and structure that ICTs provide. That is because the environment and context that these experiences provide are predictable and structured, which helps autistic children to maintain their routines and repetitive behaviors without affecting their comfort. Notably, socially assistive robots and games leveraging technology, including serious games, gamification, and e-learning, are particularly effective for teaching conceptual knowledge and communication and social skills to autistic children.

The increasing number of studies examining the effectiveness of these digital tools in therapy and education setting has arisen the critical need to assess their design features and research methodologies to accurately determine their efficacy and ways to improve their design adapted to the heterogeneous profiles of autistic children.

Chapter 1: Clinical Perspective Neurodevelopmental Disorders (NDD)

Neurodevelopmental Disorders (NDD) are characterized by early-onset deficits of variable severity in personal, social, academic, or occupational functioning (APA, 2013).

The term "neurodevelopmental" is used for a wide range of neurological and psychiatric disabilities that involve disruption in brain development [START_REF] Thapar | Using natural experiments and animal models to study causal hypotheses in relation to child mental health problems[END_REF]. NDD include Autism Spectrum Disorder (ASD), Intellectual Disability, Communication Disorders, Attention Deficit Hyperactivity Disorder (ADHD), Specific Learning Disorders, and Motor Disorders (APA, 2013). These disorders share common features of developmental delays and deficits that impact various aspects of cognitive, social, emotional, language, motor functioning, executive functioning, and autonomy (APA, 2013). One of the main features of these NDD is that they usually begin during childhood, before puberty, and they are more prevalent in males [START_REF] Thapar | Using natural experiments and animal models to study causal hypotheses in relation to child mental health problems[END_REF].

The severity of NDD can vary significantly, ranging from mild to severe delays or impairments. Some occur early before three years of three (e.g. Autism Spectrum Disorder (ASD); Intellectual Disability (ID)), whereas others only appear later (e.g., Tourette syndrome) or when exposed to learning at school (e.g., Specific Learning Disorder (SLD)). It is not uncommon for individuals with NDD to have multiple cooccurring disorders, resulting in complex and multidimensional impairments (Xavier & Cohen, 2020). To facilitate accurate diagnosis and understanding of these disorders, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides a standardized framework. This diagnostic tool enables clinicians to identify and assess the symptoms of NDD, leading to more informed treatment decisions. By recognizing the distinct features and diagnostic criteria outlined in the DSM-5, clinicians can have a comprehensive understanding of NDD [START_REF] Thapar | Using natural experiments and animal models to study causal hypotheses in relation to child mental health problems[END_REF]. This understanding is crucial for designing personalized interventions and support strategies tailored to the unique needs of individuals with NDD.

Table 1. Current state of knowledge on the prevalence of neurodevelopmental disorders in childhood according to the DSM-5 [START_REF] Francés | Current state of knowledge on the prevalence of neurodevelopmental disorders in childhood according to the DSM-5: a systematic review in accordance with the PRISMA criteria[END_REF]

Neurodevelopmental Disorders Worldwide Prevalence

Autism Spectrum Disorder (ASD) 0.70-3%

Intellectual Disability (ID) 0.63% Attention-Deficit/Hyperactivity Disorder (ADHD) 5-11%

Communication Disorders (CDs) 1-3.42% Specific Learning Disorder (SLD) 3-10%

Motor Disorders (MDs) 0.76-17%

There is growing evidence that NDD stem from a complex interplay of genetic and epigenetic factors [START_REF] Bale | Early Life Programming and Neurodevelopmental Disorders[END_REF][START_REF] Rangasamy | Epigenetics, Autism Spectrum, and Neurodevelopmental Disorders[END_REF]. Genetic predisposition plays a significant role, and certain inherited gene mutations or variations can increase susceptibility to develop a NDD. The high recurrence of autistic siblings supports the presence of heritable variants among multiplex families [START_REF] Sandin | The familial risk of autism[END_REF]. The largest population-based twin study of child neuropsychiatric disorders (N= 17000 children) confirmed the high heritability for ASD estimated at 80%, 79% for ADHD and 70% for motor coordination disorders [START_REF] Lichtenstein | The genetics of autism spectrum disorders and related neuropsychiatric disorders in childhood[END_REF]. However, it appears that genetic vulnerability combines a mixed of rare major genes with strong causal value and common variants with low causal value even within multiplex families (Cirnigliaroa et al., 2023). Additionally, most cases of ASD caused by major genetic variants occur after de novo mutation, meaning without heritability. The role of gender in the disorders' vulnerability has not been well examined, despite of the higher prevalence of NDD in males (Sandin et al., 2013). Furthermore, perinatal influences, like maternal stress, exposure to toxins, and nutrition have been likely linked to the offspring of the disorders [START_REF] Kolevzon | Prenatal and perinatal risk factors for autism: a review and integration of findings[END_REF]. Epigenetic factors, which involve modifications to gene expression without altering the DNA sequence, attributing an important role to the environment, have also been linked to the disorder (LaSalle, Vallero & Mithcell, 2013). Research on motor coordination disorder has connected epigenetics to the heritability of the disorder. Notably, studies have shown the involvement of both genetic and shared environmental factors in the familial clustering of tic disorder in childhood [START_REF] Ooki | Genetic and environmental influences on finger-sucking and nail-biting in Japanese twin children[END_REF]Bolton et al, 2007). In contrast, in their epidemiological study [START_REF] Lichtenstein | The genetics of autism spectrum disorders and related neuropsychiatric disorders in childhood[END_REF] did not find shared environmental effects for tic disorder. Environmental influences during critical developmental periods can lead to epigenetic changes that impact brain development, potentially increasing the likelihood of NDD (Sandin et al., 2013). Finally, environmental factors can also cause NDD. They include a large list of environmental injuries that will affect fetuses' or infants' brain development such as toxins (e.g. valproate during pregnancy), viral infections measles during pregnancy;

infant's herpes virus encephalopathy), premature birth, neonatal anoxia [START_REF] Guinchat | Pre-, peri-and neonatal risk factors for autism[END_REF]. Understanding and identifying these complex causes is crucial for early intervention and effective management of these disorders.

Autism Spectrum Disorder: Overview Epidemiology

Autism Spectrum Disorder (ASD) is a complex heterogeneous NDD that manifests in early childhood. ASD is characterized by persistent deficits in social interactions and communication across multiple contexts associated with restricted, repetitive patterns of behaviors and interests or hypo/hyper-reactivity to sensory stimuli (APA, 2015). ASD is a highly heritable and a heterogeneous disorder that has underlying cognitive features and commonly co-occurs with other conditions [START_REF] Lord | Autism spectrum disorder[END_REF].

ASD comorbidity is significant and can impact occupational, academic, autonomy, and other important areas of functioning. According to the World Health Organization (2023), it is estimated that 1 in 100 children meet the diagnostic criteria for ASD.

However, the largest WHO study reported prevalence rates of 0.33% worldwide, with significant differences according to countries and socioeconomic indexes (Figure 1, [START_REF] Solmi | Age at onset of mental disorders worldwide: large-scale meta-analysis of 192 epidemiological studies[END_REF]. In France, the prevalence of ASD (all spectrum) is estimated between 0.9 and 1.2%, but the largest epidemiological study to date found a prevalence at 8 years of age of ASD with a significant handicap at 0.35% in Isère and Haute Garonne districts [START_REF] Delobel-Ayoub | Socioeconomic disparities and prevalence of autism spectrum disorders and intellectual disability[END_REF]. Over time, the reported incidence of ASD in children has risen, prompting questions from primary care providers about the underlying causes. [START_REF] Hyman | Identification, evaluation, and management of children with autism spectrum disorder[END_REF] attributed the increase in prevalence to several factors, including the broadening of diagnostic criteria through successive revisions of the DSM, heightened public awareness of the disorder along with screening recommendations, and improved access to early intervention and school-based services. The emergence of ASD symptoms begins around 12 months of age and becomes more pronounced by 18 months of age, although a definitive diagnosis is often made at 3 years of age [START_REF] Georgiades | Investigating phenotypic heterogeneity in children with autism spectrum disorder: a factor mixture modeling approach[END_REF].

From 12 months, observable markers of ASD start to appear, such as reduced eye contact, decreased vocalization towards others, decreased smiling, and a lack of response to their name [START_REF] Werner | Variation in Early Developmental Course in Autism and its Relation with Behavioral Outcome at 3-4 Years of Age[END_REF]. Affect expression also becomes poorer during this period [START_REF] Zwaigenbaum | Behavioral manifestations of autism in the first year of life[END_REF][START_REF] Mitchell | Differentiating autism spectrum disorder from other developmental delays in the first two years of life[END_REF]. Attention flexibility and stereotyped behaviors of exploration and object use show differences from 12 months as well [START_REF] Zwaigenbaum | Behavioral manifestations of autism in the first year of life[END_REF].

Children at risk for ASD exhibit less functional play and more nonfunctional and repetitive play compared to typically developing children [START_REF] Christensen | Play and developmental outcomes in infant siblings of children with autism[END_REF]. Early signs of atypical restricted and stereotyped behaviors are observed in children with ASD from 12 months [START_REF] Wolff | Longitudinal patterns of repetitive behavior in toddlers with autism[END_REF]. Differences in gaze orientation and visual exploration of objects can also be detected at an early age, with some studies showing differences as early as 9 months [START_REF] Zwaigenbaum | Behavioral manifestations of autism in the first year of life[END_REF]. ASD is prevalent and can be diagnosed as early as 18 months. It is crucial for primary care providers to possess knowledge on the diagnostic criteria for ASD, as well as conduct accurate etiologic evaluations, and address any coexisting medical and behavioral issues (including sleep and feeding disorders, gastrointestinal symptoms, obesity, seizures, attentiondeficit/hyperactivity disorder, anxiety, and wandering) that may interfere with the child's well-being and functional abilities [START_REF] Hyman | Identification, evaluation, and management of children with autism spectrum disorder[END_REF].The emergence of observable behavioral signs of ASD typically occurs after the first six months of a child's life [START_REF] Zwaigenbaum | Behavioral manifestations of autism in the first year of life[END_REF]. This delay in the manifestation of ASD related behaviors could be attributed to several factors. First, the social behaviors affected by ASD may not become evident until around 12 months of age [START_REF] Langlois | Infants' differential social responses to attractive and unattractive faces[END_REF]. At this stage, typically developing children begin to display more pronounced social interactions and communication skills, which are significantly impacted in individuals with ASD. The absence of these behaviors in the early months can make it challenging to identify potential signs of ASD. Additionally, certain behaviors that may later be associated with ASD can initially be perceived as typical or age-appropriate during infancy. These behaviors only become concerning or pathological if they persist beyond the expected developmental timeline. For example, certain repetitive behaviors commonly observed in young children, such as repetitive hand movements or body rocking, may not be initially recognized as stereotypies until later in development [START_REF] Mccarty | Early detection and diagnosis of autism spectrum disorder: why is it so difficult?[END_REF]. Though the clinical signs that allow the diagnosis of ASD, such as communication deficits and restricted interests, are not present before 18 months, there are indications that certain characteristics may already be present in a different form [START_REF] Elsabbagh | Getting answers from babies about autism[END_REF]. The search for signs moves towards identifying risk factors rather than the specific diagnostic criteria [START_REF] Elsabbagh | Getting answers from babies about autism[END_REF][START_REF] Gliga | From early markers to neuro-developmental mechanisms of autism[END_REF]. It is important to note that the absence of early observable signs does not imply the absence of ASD. As ASD manifests itself in early childhood, early diagnosis and intervention may considerably improve the quality of life of children with ASD and their families [START_REF] Narzisi | Non-pharmacological treatments in autism spectrum disorders: an overview on early interventions for pre-schoolers[END_REF].

However, there are a number of challenges in terms of early identification and treatment.

First, it is in part due to the lack of available biomarkers, accurate and timely diagnoses for children with ASD are a challenge for many health care systems [START_REF] Pickles | The adult outcome of children referred for autism: typology and prediction from childhood[END_REF]. Second, due to the heterogeneity of the disorder, children with ASD show differences both in social and cognitive functions, thereby necessitating different and adapted interventions tailored to the profile of the child [START_REF] Warren | A systematic review of early intensive intervention for autism spectrum disorders[END_REF]. Third, it is problematic for parents to choose the most appropriate and effective interventions for their children, in addition to the challenges they face navigating the healthcare system [START_REF] Salomone | Use of early intervention for young children with autism spectrum disorder across Europe[END_REF]. It is through comprehensive developmental monitoring and regular assessments that healthcare professionals can identify the onset of ASD-related behaviors and intervene accordingly [START_REF] Lord | Autism spectrum disorder[END_REF].

In this context, the French government launched the fourth autism plan in 2018 with the aim of improving the overall care of autistic patients. It is based in particular on the good practice recommendations of the HAS (2012). Early intervention is therefore at the heart of this project. Its objective is to promote diagnosis as early as possible and intensive therapeutic support from the first years of the child's life. To this end, it recommends in particular the greater involvement of families.

Therapeutic Approaches

Autistic children show differences both in social and cognitive aspects, thereby necessitating different interventions tailored to individual profiles [START_REF] Vivanti | Predictors of outcomes in autism early intervention: why don't we know more?[END_REF]. [START_REF] Narzisi | Non-pharmacological treatments in autism spectrum disorders: an overview on early interventions for pre-schoolers[END_REF] summarized the common components of intervention models for autistic children that appear to be linked to greater therapeutic outcomes. They find that (i) early intervention, which includes both making an early diagnosis and minimizing the time between that diagnosis and treatment; (ii) intensity; (iii) family oriented; and (iv) regular assessments, updates on treatment goals and therapeutic supervision. They also find that most first intervention methods are aimed at developing communication prerequisites such as joint attention, imitation and symbolic play. Indeed, the development of these prerequisites is an important issue in the care of autistic children. The HAS also provided a set of recommendations with some level of evidence of effectiveness, consistent with the observations of [START_REF] Narzisi | Non-pharmacological treatments in autism spectrum disorders: an overview on early interventions for pre-schoolers[END_REF]. It advocates a global intervention aiming to improve several skills: imitation, language, communication, play, social interactions, motor organization and action planning, daily life adaptive behaviors (HAS, 2012).

The intervention must be regularly evaluated in order to review and adapt to the objectives. In addition, the inclusion of parents in the therapeutic project is essential so they can accompany their child at home and thus allow the transfer of skills to daily life.

A recent meta-review indicated that there was suggestive evidence for the effectiveness [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF]. These interventions have led to their widespread adoption in clinical practice, e.g., Naturalistic Developmental Behavioral Interventions (NDBI) [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF], notably, early intensive behavioral intervention (EIBI) [START_REF] Rattaz | School inclusion in children and adolescents with autism spectrum disorders in France: report from the ELENA French Cohort Study[END_REF], the Early Start Denver Model (ESDM) [START_REF] Dawson | Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model[END_REF], the Exchange and Development Therapy [START_REF] Blanc | La thérapie d'échange et de développement, une rééducation neurofonctionnelle de la communication sociale[END_REF] and Joint Attention Symbolic Play Engagement and Regulation (JASPER) [START_REF] Goods | Preschool based JASPER intervention in minimally verbal children with autism: Pilot RCT[END_REF].

Treatment for autistic children should also include parent-mediated interventions (e.g.,

The Preschool Autism Communication Trial -PACT [START_REF] Pickles | Parent-mediated social communication therapy for young children with autism (PACT): long-term follow-up of a randomised controlled trial[END_REF]. These have been initially included in the Treatment and Education of Autistic and Communication Related

Handicapped Children (TEACCH) program, which has shown minor effects in meta-analyses [START_REF] Virues-Ortega | The TEACCH program for children and adults with autism: A meta-analysis of intervention studies[END_REF]. Furthermore, educational interventions and specific therapies (e.g., speech therapy, occupational therapy, psychotherapy) can also be found in ASD care (Narzisi et al., 2014). (Sandbank et al., 2020). Indeed, one of the first intervention that was proven to be effective in a randomized controlled study [START_REF] Dawson | Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model[END_REF], was ESDM. The authors observed "improvements in intellectual quotient, language, adaptive behavior, and brain function" in autistic children who received this intervention [START_REF] Dawson | Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model[END_REF]. However, [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF] revealed in their random-effects meta-analysis that ESDM efficacy was supported by weak evidence, a statistically significant but small-pooled effect size (SMD = 0.22, p-value = 0.02). We briefly describe here ESDM as it has inspired GOLIAH a serious game that will be detailed in chapter 6. This early intervention program was developed for autistic children from 12 to 48 months and is grounded on a developmental approach with positive reinforcement.

It is based on two theoretical hypotheses [START_REF] Schröder | Le modèle de Denver (Early Start Denver Model). Une approche d'intervention précoce pour les troubles du spectre autistique[END_REF]: on the one hand, the studies of Daniel N. Stern (1991) assumes that autism is linked to "an early imitation disorder", and on the other hand those of G. Dawson and C. Chevallier which hypothesize "a lack of social motivation" [START_REF] Dawson | Neurocognitive and electrophysiological evidence of altered face processing in parents of children with autism: Implications for a model of abnormal development of social brain circuitry in autism[END_REF][START_REF] Chevallier | The social motivation theory of autism[END_REF]. The ESDM is based on an important work of social interactions through ritualized game-based situations that can then be transferred to the ecological environment. The goal is to reduce the severity of autism-related disorders and to accelerate the pace of development in all areas: imitation, joint attention, communication, language, and the desire to join others and play. Among the precursors of communication, social skills such as imitation and joint attention are particularly important to develop. Clinicians regularly assess the child's progress in order to tailor goals to ensure personalized intensive therapy [START_REF] Schröder | Le modèle de Denver (Early Start Denver Model). Une approche d'intervention précoce pour les troubles du spectre autistique[END_REF]. In addition, parental participation especially at home is essential in the context of this method to allow intensive rehabilitation (the HAS recommends between 20 and 25 hours of weekly training). From a broader view, the treatment that can be offered to children with ASD depends on both macro-and micro-variables. Macro-variables include the healthcare system, the financial support available for low-income families, and the school system's openness to accommodating children with special educational needs. Micro-variables include the socioeconomic background, migrant status, time of diagnosis, and severity of any comorbid intellectual disability (ID) (Salomone et al., 2020;[START_REF] Hyman | Identification, evaluation, and management of children with autism spectrum disorder[END_REF]. [START_REF] Salomone | Use of early intervention for young children with autism spectrum disorder across Europe[END_REF] found that a varied implementation of intervention is observed throughout Europe, considering both the type of intervention and the quantity received. Additionally, the study revealed a correlation between the use of intervention and both the educational level of parents and the characteristics of the child. For example, in France, day care hospital from free public services provide care of autistic individuals that come from low-income and/or migrant families more often. Autistic patients from migrant families exhibit more severe autism and more frequent challenging behaviors [START_REF] Bettencourt | Migration is associated with baseline severity and progress over time in autism spectrum disorder: Evidence from a French prospective longitudinal study[END_REF]. Furthermore, due to the disorder's heterogeneity and symptoms variability, there is no single best approach.

What works well for one child in therapy may not be effective for another due to the diversity in their experiences [START_REF] Cabibihan | Why robots? A survey on the roles and benefits of social robots in the therapy of children with autism[END_REF].

Specific interests related to this thesis Social Skills Deficits as the Core of ASD

The origin of social skills deficits in ASD has been the subject of several theories. Baron-Cohen (1995), in particular, uses his modular model of the development of the theory of mind to explain the cause of these difficulties. Indeed, some stages of this model would be deficient in autistic patients. The first two modules, the intentionality detector and the eye direction detector,

would not be impacted in the context of ASD. Thus, autistic individuals would be able to understand that others have purpose-oriented mental states and to detect and interpret the presence and direction of others' gaze. On the other hand, their system of shared attention that allows coordinated joint attention would be in deficit. Thus, their theory of mind would be deficient which would explain the difficulties faced by autistic children in terms of social skills.

A second theory is that these difficulties are caused by a lack of early social motivation. Dawson (2005) explained that autistic individuals would be less influenced by social reward marks and thus less attentive to certain social signals. As a result, autistic individuals would be less likely to initiate and maintain interactions and thus less exposed to social learning situations.

This lack of social attention could increase their difficulties in developing the prerequisites for communication (joint attention, imitation, etc.) [START_REF] Chevallier | The social motivation theory of autism[END_REF]. [START_REF] Chevallier | The social motivation theory of autism[END_REF] presupposes that this lack of motivation would have effects upstream of the acquisition of social cognitive abilities.

Social skills acquisitions are necessary for the development of more complex social skills [START_REF] Tomasello | Understanding and sharing intentions: The origins of cultural cognition[END_REF]. ASD can have a significant impact on the educational and socio-professional integration of patients. Enabling autistic children to develop their social skills from an early age is therefore a major challenge for their empowerment. [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF] recommend specific work to improve autistic children's social interactions. The goal of social skills training is to improve communication, expression of feelings and interactions, by transmitting interpersonal skills to patients and promoting their generalization and maintenance [START_REF] Baghdadli | Entrainement Aux Habiletés Sociales Appliqué a L'autisme[END_REF]. Several studies have shown the effectiveness of social skill groups in autistic children for this type of rehabilitation (Bohlander et al., 2012). These include a reduction in inappropriate behavior and the emergence of socially desirable behaviors [START_REF] Andanson | Les groups d'entraînement aux habiletés sociales pour enfants et adolescents avec syndrome d'Asperger : Revue de la littérature[END_REF]. In addition, through these groups, autistic children develop conversational (initiation, maintenance and closure of the exchange) and emotional skills such as perceiving and understanding an emotion [START_REF] Kruck | Étude sur l'efficacité des groupes d'habiletés sociales proposés aux enfants avec un trouble du spectre autistique[END_REF].

Social Skills Group Interventions

Group-based psychosocial skills interventions are widely employed to enhance social skills in autistic youth [START_REF] Gates | Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis[END_REF][START_REF] Reichow | Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)[END_REF]. However, despite their widespread use, the effectiveness of these interventions remains uncertain due to an absence of rigorous and well-designed research [START_REF] Reichow | Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)[END_REF][START_REF] Mcmahon | Measuring changes in social behavior during a social skills intervention for higher-functioning children and adolescents with autism spectrum disorder[END_REF], and a lack of complete and sensible psychometric tests to effectively measure social skills in their entirety [START_REF] Wigelsworth | A review of key issues in the measurement of children's social and emotional skills[END_REF]. The inconclusive findings can be attributed to several factors, including the absence of a universally accepted definition of social skills, variations in adapted scales, and differences in the implementation of therapeutic approaches, particularly in terms of treatment intensity and duration [START_REF] Rao | Social skills interventions for children with Asperger's syndrome or high-functioning autism: A review and recommendations[END_REF]. Group interventions provide a social context that reflects real-world situations, allowing autistic children to practice and generalize their social skills in a supportive and inclusive environment. By engaging with peers who may share similar experiences and challenges, children with ASD have the opportunity to learn and observe appropriate social behaviors, communication techniques, and social cues [START_REF] Bellini | Building social relationships: A systematic approach to teaching social interaction skills to children and adolescents with autism spectrum disorders and other social difficulties[END_REF].

This social exposure and interaction help them develop a better understanding of social norms, fostering improved social competence and reducing social isolation [START_REF] Gates | Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis[END_REF].

Furthermore, group interventions offer a unique platform for social learning and peer modeling. Autistic children often struggle with social reciprocity and understanding social cues, making it challenging for them to acquire social skills through typical observation and imitation processes [START_REF] Bauminger | Enhancing social communication in high-functioning children with autism through a co-located interface[END_REF]. In a group setting, these children can observe and learn from their peers who demonstrate appropriate social behaviors. This peer modeling allows for the acquisition of new social skills, as well as the opportunity to practice and receive feedback in a supportive and non-judgmental environment [START_REF] Reichow | Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)[END_REF].

Additionally, group interventions facilitate the development of crucial social interaction skills, such as turn taking, active listening, and perspective taking. Through structured activities and group discussions, autistic children learn how to engage in reciprocal conversations, share experiences, and empathize with others [START_REF] Reichow | Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)[END_REF]. These interventions often incorporate evidence-based strategies, such as social stories, visual supports, and video modeling, to enhance learning and comprehension of social concepts [START_REF] Bellini | Building social relationships: A systematic approach to teaching social interaction skills to children and adolescents with autism spectrum disorders and other social difficulties[END_REF].

The success of group-based interventions for autistic children is also attributed to the supportive and inclusive environment they create. Within these groups, children can form connections with their peers, fostering a sense of belonging and acceptance. This positive social environment promotes self-esteem, confidence, and motivation to engage in social interactions [START_REF] Reichow | Social skills groups for people aged 6 to 21 with autism spectrum disorders (ASD)[END_REF].

Nevertheless, a recent meta-review provides suggestive evidence supporting the efficacy of social skills groups (SSGs) in improving social communication deficits and overall symptoms associated with Autism Spectrum Disorder (ASD) in school-aged children and adolescents (Table 2, [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF]. This indicates that despite the challenges and inconsistencies in research methodology and implementation, SSGs have demonstrated promising outcomes for addressing social difficulties in individuals with ASD. Interactive play is a major key in interventions of young autistic children as it addresses the core deficits of relating and communicating with others (Greenspan & Wider, 2006).

The role of Play in ASD care

Play is crucial in the development of children, including those with atypical development.

Autistic children often exhibit unique characteristics in their approach to play, with a preference for sensorimotor activities over symbolic play compared to neurotypical children (Blanc et al., 2005). These differences in play behavior can have a significant impact on the child's development and their relationships with their families [START_REF] Perrin | Le jeu chez les enfants avec autisme. Autisme et Jeu: apprendre à jouer avec la personne autiste[END_REF]. By recognizing the importance of play, it becomes essential to incorporate play-based interventions in ASD care. [START_REF] Perrin | Le jeu chez les enfants avec autisme. Autisme et Jeu: apprendre à jouer avec la personne autiste[END_REF] suggests that play can serve as a valuable medium for developing communication and social skills in autistic children. The social interactions that arise during play naturally foster essential communication precursors such as joint attention, imitation, and symbolic play [START_REF] Perrin | Le jeu chez les enfants avec autisme. Autisme et Jeu: apprendre à jouer avec la personne autiste[END_REF]. Through play, children can learn to understand concepts like yes/no answers, waiting times, transition times, requesting help, and following instructions [START_REF] Donard | La médiation vidéo-ludique en psychothérapie[END_REF].

Several intervention models for autistic children, such as the Early Start Denver Model (ESDM), rely on play as a fundamental component [START_REF] Dawson | Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model[END_REF].

In addition to traditional forms of play, video games have drawn attention from researchers in the field. [START_REF] Donard | La médiation vidéo-ludique en psychothérapie[END_REF] highlight the potential of video games as a promising tool for supporting the care of autistic children. Video games provide a visually engaging and playful platform that can be used to intensively train deficit skills. Moreover, video games designed to promote shared experiences and social interaction, can act as mediators for developing joint attention and imitation skills. However, adapting commercial video games for therapy sessions can be challenging, leading researchers to advocate for the use of serious games specifically designed for therapeutic purposes. The use of virtual worlds in therapy has also been explored, particularly with autistic adolescents [START_REF] Strickland | Virtual reality for the treatment of autism[END_REF]. Virtual worlds offer a unique opportunity to represent and explore complex emotions and fears that may otherwise be difficult to articulate [START_REF] Maskey | A randomised controlled feasibility trial of immersive virtual reality treatment with cognitive behaviour therapy for specific phobias in young people with autism spectrum disorder[END_REF]. Avatars within virtual worlds can serve as extensions of oneself, characters from personal experiences or stories, or even embodiments of familial or ancestral legends. This immersive and symbolic environment allows individuals to engage with their inner world in a safe and controlled manner [START_REF] Strickland | Virtual reality for the treatment of autism[END_REF]. Play-based interventions can facilitate the development of communication and social skills in autistic children (Greenspan & Wider, 2006).

Additionally, the use of video games, particularly serious games, shows promise in supporting therapeutic interventions for autistic children [START_REF] Grossard | ICT and autism care: state of the art[END_REF]. By leveraging these play-based approaches, therapists and caregivers can enhance the well-being and development of individuals with ASD.

Chapter 2: Engineering Perspective: ! Information and Communication Technologies (ICTs) in

Introduction

The use of Information and Communication Technologies (ICTs) has gained significant attention in the field of NDD, particularly in ASD research and care (Grynszpan et al., 2014;Hollis et al., 2017;Miguel Cruz et al., 2017;Khan et al., 2019;[START_REF] Grossard | ICT and autism care: state of the art[END_REF]. Over the past two decades, the integration of ICTs, including social robots, serious games, video modeling, and augmentative alternative communication devices, has transformed the approach to therapeutic and educational interventions for individuals with NDD [START_REF] Grossard | ICT and autism care: state of the art[END_REF]. These technological advancements have provided clinicians and individuals with NDD with new opportunities to enhance social and communication skills [START_REF] Light | New and emerging AAC technology supports for children with complex communication needs and their communication partners: State of the science and future research directions[END_REF], cognitive functioning [START_REF] Tseng | Social Cognitive Interventions for Adolescents with Autism Spectrum Disorders: A Systematic Review[END_REF], and overall quality of life [START_REF] Grossard | ICT and autism care: state of the art[END_REF].

These digital therapeutic tools can be implemented on many types of supports, including computers, tablets, smartphones, screen projectors, wearable technologies such as virtual reality headsets or smart watches and robots. They can take multiple forms as apps, serious games, assistive technologies, and immersive reality [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. These tools can target a wide range of skills or behaviors as social and communication skills, academic knowledge, sensory and motor skills, autonomy and inclusion, emotion regulation (Grynszpan et al., 2014;Boucenna et al., 2014;Valentine et al., 2020). They can be used in diverse settings including care centers or hospitals, schools or homes (Miguel Cruz et al., 2017, Khan et al., 2019). ICTs are generally well accepted by parents and professionals but also by children or adolescents with NDD (Valentine et al., 2020;Richardson et al., 2018). However, a few numbers of studies have targeted adult users (Valentine et al., 2020).

The growing increase of numerical tools application in NDD care created a crucial need to assess the design of ICTs and the research methodology quality used to evaluate them [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. Moreover, the absence of standard framework to assess ICTs design influenced the creation of the first Design ICT Inventory (DICTI, [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF], a tool aiming to support ICT developers when creating therapeutic digital tools for NDD people. While the application of ICTs in NDD care is promising, there are some challenges that need to be addressed, particularly in regards to the poor methodological quality of studies and optimizing the design of these technologies [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. The need for high-quality studies and user-friendly and affordable ICTs is evident, as current research lacks consensus on intervention duration, intensity, and user support requirements (Zervogianni et al., 2020;Miguel Cruz et al., 2017;Hollis et al., 2017;Moon et al., 2020).

Socially Assistive Robots in ASD Care

In recent decades, robotics have become firmly embedded in the field of healthcare in various disciplines, elevating medicine and providing relief to people with countless conditions [START_REF] Grossard | ICT and autism care: state of the art[END_REF]. These robotic interfaces have essential features like communicating with people, understanding social, organizational, and physical situations through sensed data, supporting individuals with special needs, improving elderly healthcare, and aiding in learning and rehabilitation during daily tasks [START_REF] Esposito | Modeling emotion, behavior and context in socially believable robots and ICT interfaces[END_REF]. In the past ten years, significant research has been conducted in regards to robotics and autism, creating an emerging field of study that is only gaining momentum. Currently, there are many robots on the market that claim to help children with autism spectrum disorder (ASD) to develop learning and social skills, a claim that could radically change autism research (Pennisi et al., 2016). While this research is vast, it is also limited by scope, time, and resources, showing that more meaningful data needs to be collected in order to fully understand how robots can help autistic children in both the short and long-term.

Numerous studies have been conducted that explore how robots may positively impact detection and intervention methods for autistic children [START_REF] Cabibihan | Why robots? A survey on the roles and benefits of social robots in the therapy of children with autism[END_REF]. Having social robots to take the place of educators when applicable can alleviate a significant pressure from the already over-burdened educational system and parental involvement, while simultaneously ensuring that autistic children get the support they need to encourage development. There is rising evidence, which supports that autistic children have unique opportunities to use robots for therapeutic purposes [START_REF] Cifuentes | Social robots in therapy and care[END_REF][START_REF] Kumazaki | Optimal robot for intervention for individuals with autism spectrum disorders[END_REF], Grossard et al., 2018& Scassellati et al., 2007). Contrarily to human interactions, robots' predictability provides a highly structured and learning-driven environment to autistic individuals. These types of interactions with humanoid robots are likely to form consistent social situations in which certain social behaviors can occur [START_REF] Kumazaki | Optimal robot for intervention for individuals with autism spectrum disorders[END_REF]& Scassellati et al., 2007). Robots' design characteristics and functionalities can play a significant role in the efficacy of the therapeutic intervention [START_REF] Cabibihan | Why robots? A survey on the roles and benefits of social robots in the therapy of children with autism[END_REF].

The goal of this literature review is to explore recent literature regarding how these robots interact with and elicit progress and can positively impact autistic children both in the short-term and long-term, as well as navigate current and potential limitations of these studies and their implications. Table 3 offers a brief overview.

Characteristics of the robots

In the past decade, significant strides have been made to unite gaming and robotic technology with teaching autistic children, resulting in an emerging field of socially assistive robotics [START_REF] Grossard | ICT and autism care: state of the art[END_REF]. While some of the robots take on the form of the traditional, nonanthropomorphic shapes, including the Nao, Riby, QT Robot, IRobiQ, Caro, and Kibo, others take on human-like or animal-like characteristics, including Kaspar, Charlie, R 50 Alice "Mina", and KiliRo. The robots' embodiment includes android, human-like, animal-shaped, nonanthropomorphic colored toys: in any case, the shape of the robot should contribute to the reduction of the stress of the children during the experiment, making them comfortable and at ease (Ahmad et al., 2019). The uncanny valley concept has been widely used in robot's design. It refers to the phenomenon where a robot's resemblance to a human becomes almost too realistic, creating a sense of discomfort in human observers [START_REF] Bartneck | My robotic doppelgänger-A critical look at the uncanny valley[END_REF]. When a robot is very close to appearing human but still presents minor differences, notably in its movement, the social meaning associated to it can lead to unease [START_REF] Bartneck | My robotic doppelgänger-A critical look at the uncanny valley[END_REF]. This concept works in robot design because it emphasized the importance of achieving a balance between human likeness and avoiding the unsettling effect of the uncanny valley, guiding designers to create robots that evoke positive and relatable emotions.

Essentially, while autistic children generally have difficulty interacting and socializing with other humans, interacting with autonomous robots may remove the pressure associated with people, leaving the child less stressed and able to focus on other things [START_REF] Bharatharaj | Robot-assisted therapy for learning and social interaction of children with autism spectrum disorder[END_REF].

Understanding the individual needs of an autistic child is vital in assessing which robot may be right for them. However, as some may be less inclined to interact with a humanoid-robot like Kaspar, for example, due to the robot's uncanny qualities; there is no one-size-fits-all approach.

It is also important to note that while these robots are impressive, they are also relatively new, and continue to undergo significant changes in their physical appearance as well as their programming [START_REF] Grossard | A pilot study of the KIBO robot in children with severe ASD[END_REF]. Increasing the efficiency of therapy by encouraging an active and engaged interaction [START_REF] Costa | A comparison between a person and a robot in the attention, imitation, and repetitive and stereotypical behaviors of children with autism spectrum disorder[END_REF] examined how fifteen children with ASD interact with people vs. the QT robot in two separate interactions to measure levels of engagement through eye contact.

The participants gazed at the person in more instances. However, they gazed longer at the QT robot when they did look at it. Speakers 1 touch screen Touch sensors Sonars sensors IR sensors 1 RGB camera in the head LEDS Training emotion abilities and interpersonal interaction [START_REF] Yun | Social skills training for children with autism spectrum disorder using a robotic behavioral intervention system[END_REF] conducted a research in which four certified speech-language therapists utilized the IRobiQ as an intervention tool with four children with ASD over eight sessions. Both verbal and emotional expressions were gauged. They found positive results, as each child was able to progress in their ability to initiate conversation with the robot as well as express emotions.

Identification of social cues during interaction

One of the key areas of research regarding robots for autistic children is their capacity to identify signs when the child is in a state of acute stress, which is important because ASD symptoms are often exacerbated in stressful situations [START_REF] Ismail | Leveraging robotics research for children with autism: a review[END_REF].

The Charlie, NAO, TEO4, and Riby robots can detect, through the use of specific algorithms, certain physiological signs like elevated voice, breathing, and heart rate that can predict when a autistic child may need a reduction in stimuli or other external intervention [START_REF] Cifuentes | Social robots in therapy and care[END_REF][START_REF] Romero | Incremental and Radical Innovation: Design in Robotics for Autism. Teo and Riby robots. Evolutionary Development[END_REF]. Additionally, some robots are adept at identifying and adapting to the individual difficulty levels that students need based on repeated exposure and data collection, making them an assistive technological tool that progresses alongside the child [START_REF] Ismail | Leveraging robotics research for children with autism: a review[END_REF]. In the context of learning by imitation, robots where able to detect a social signature of autistic children through their motor behavior during motor imitation gaming (Boucenna et al., 2014).

Intervention of the robots

Studies show that one of the key ways in which a robot elicits improvement for autistic children is by promoting interaction between a child and another person, or what is known as social overture [START_REF] Schadenberg | Differences in spontaneous interactions of autistic children in an interaction with an adult and humanoid robot[END_REF]. Robots will have different ways of eliciting this interaction, including using a screen, speakers, lights, being remotely operated by someone through Wi-Fi, etc. Specifically, the NAO, Kaspar, Riby, QT Robot, KiliRo, and Kibo Robots are designed to facilitate interaction from autistic children through a combination of social play scenarios, engaging and collaborative activities, and predictable actions [START_REF] Cifuentes | Social robots in therapy and care[END_REF][START_REF] Romero | Incremental and Radical Innovation: Design in Robotics for Autism. Teo and Riby robots. Evolutionary Development[END_REF][START_REF] Costa | A comparison between a person and a robot in the attention, imitation, and repetitive and stereotypical behaviors of children with autism spectrum disorder[END_REF][START_REF] Grossard | A pilot study of the KIBO robot in children with severe ASD[END_REF]. In most cases, robots are not autonomous and controlled by an operator (i.e.: engineer, clinician, teacher or caretaker). Another goal of some of these robots is to facilitate standard modes of emotional expression, both in projecting normative expression and learning to interpret these expressions from others [START_REF] Lecciso | Emotional expression in children with ASD: a pre-study on a two-group pre-post-test design comparing robot-based and computer-based training[END_REF][START_REF] Bharatharaj | Robot-assisted therapy for learning and social interaction of children with autism spectrum disorder[END_REF]. Amongst the robots examined, the NAO, Kaspar, Charlie, Alice "Mina", QT Robot, IRobiQ, and CARO are designed to integrate emotional cues like facial expressions to facilitate imitation and understanding by autistic children [START_REF] Cifuentes | Social robots in therapy and care[END_REF]"Kaspar", 2020;[START_REF] Romero | Incremental and Radical Innovation: Design in Robotics for Autism. Teo and Riby robots. Evolutionary Development[END_REF][START_REF] Taheri | Human-robot interaction in autism treatment: a case study on three pairs of autistic children as twins, siblings, and classmates[END_REF][START_REF] Costa | A comparison between a person and a robot in the attention, imitation, and repetitive and stereotypical behaviors of children with autism spectrum disorder[END_REF][START_REF] Ismail | Leveraging robotics research for children with autism: a review[END_REF]. A third goal of robots designed for autistic children is to improve their learning skills, including TEO4 and KiliRo, which assist in learning numbers, alphabets, and recognizing others (Romero et. al.;[START_REF] Bharatharaj | Robot-assisted therapy for learning and social interaction of children with autism spectrum disorder[END_REF].

Of the studies examined, results indicated that consistent, structured exposure to robots yielded positive outcomes. Specifically, areas of joint attention, emotional understanding, elevated interaction, and learning development indicated some progress for autistic students [START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF][START_REF] Taheri | Human-robot interaction in autism treatment: a case study on three pairs of autistic children as twins, siblings, and classmates[END_REF]. Due to the nature of ASD, however, these results were difficult to accurately measure for several reasons, including the fact that they were highly dependent upon the initial level of functioning expressed by the participants and study's methodology. Furthermore, higher quality research needs to be conducted in order to yield results that may change the approach towards autistic children; as of now, robotics are viewed as a potentially effective supplemental element that may help when used in conjunction with parental, educational, and therapeutic to advance, it is likely that robotic assistants will become increasingly integrated into autism intervention programs.

Serious Games in ASD Care

Over the past decade, digital tools have been increasingly studied in the care of autistic children (Mazon, Fage & Sauzéon, 2018). New alternative developmental approaches based on play therapy are now being proposed, such as serious games. The number of studies regarding their use has rapidly increased in recent years [START_REF] Cohen | Autisme, jeux sérieux et robotique#: Réalité tangible ou abus de langage#? In Annales Médico-psychologiques[END_REF]. In his thesis in 2007, Alvarez proposes a definition of the serious game based on several theoretical approaches: "Computer application, whose objective is to combine both serious aspects (Serious) such as, non-exhaustively, teaching, learning, communication, or information, with ludic springs from the video game (Game). The purpose of such an association is therefore to move away from simple entertainment."

Thus, he explains that the serious game brings together two aspects: both "a video game scenario" and "a utilitarian scenario". The goal is to motivate the patient to perform the task by offering an attractive and pleasant game environment. The playfulness is a support for the patient to perform the task and improve their skills (Mélia, 2015).

In 2014, Grynszpan et al, conducted a meta-analysis that showed that serious games are an effective complementary tool in the management of autistic patients, particularly for the development of certain specifically targeted social skills (Grynszpan et al, 2014;Grossard et al, 2017;[START_REF] Cohen | Autisme, jeux sérieux et robotique#: Réalité tangible ou abus de langage#? In Annales Médico-psychologiques[END_REF]. In addition, a large portion of serious games for autistic children are aimed at improving social and communication skills [START_REF] Spiel | Agency of autistic children in technology research-A critical literature review[END_REF]. Due to easy access and the possibility of home treatment, serious games have many advantages for the care of individual patients. Indeed, their accessibility allows to increase the exposure to the rehabilitative exercises and to make the rehabilitation more intensive [START_REF] Flores | Improving patient motivation in game development for motor deficit rehabilitation[END_REF][START_REF] Freitas | Development and Evaluation of a Kinect Based Motor Rehabilitation Game[END_REF].

On the other hand, digital media have the advantage of being particularly attractive to autistic patients. Digital media, moreover, allows for recurrent presentation of information and thus provide a safe play setting for the child [START_REF] Knight | A review of technology-based interventions to teach academic skills to students with autism spectrum disorder[END_REF][START_REF] Mitchell | Using virtual environments for teaching social understanding to 6 adolescents with autistic spectrum disorders[END_REF]. Feedback is instantaneous and can be anticipated [START_REF] Moore | Computer-aided learning for people with autism-a framework for research and development[END_REF]. The clarity of digital activities allows children to focus their attention specifically on the task at hand and decrease distracting stimuli [START_REF] Moore | Computer-aided learning for people with autism-a framework for research and development[END_REF]. In addition, mobile technologies (smartphone and tablet) are particularly easy to use and suitable for everyday use [START_REF] Mazon | Utilisation des technologies mobiles auprès des enfants avec TSA[END_REF]. Furthermore, therapists with access to recorded digital data can assess patients' progress [START_REF] Bono | GOLIAH#: A Gaming Platform for Home-Based Intervention in Autism -Principles and Design[END_REF] remotely and customize the rehabilitation protocol as close as possible to each individual's skills, thus providing personalized training [START_REF] Rego | Serious games for rehabilitation: A survey and a classification towards a taxonomy[END_REF]. The increasing availability of digital tools for individuals with NDD has raised the urgent need to effectively evaluate their benefits and costs (Miguel Cruz et al., 2017). The U.S. Food and Drug Administration (FDA) recently granted clearance for EndeavorRxTM, an Akili video game therapy designed for ADHD, marking it as the first prescription treatment delivered through a video game [START_REF] Canady | FDA approves first video game Rx treatment for children with ADHD[END_REF][START_REF] Kollins | A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial[END_REF]. This innovative adaptation of serious games is exemplified by the transformation of Endeavour for Alzheimer's into Akili, specifically tailored for children with ADHD. Akili utilizes the captivating nature of gaming to enhance attention, executive functioning, and cognitive skills. By building upon the successful framework of Endeavour for Alzheimer's, Akili provides a personalized solution that addresses the specific needs of children with ADHD, offering an interactive and enjoyable approach to support their cognitive development and overall well-being [START_REF] Kollins | A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial[END_REF].

Chapter 3: How can we assess and score the quality of the design of an ICT tool?

This question was the subject of an article published in 2023:

Grossard, C., [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. Building the design ICT inventory (DICTI): A Delphi study. Computers in Human Behavior Reports, 9, 100261.

Summary:

The use of Information and Communication Technologies (ICTs) for individuals with

Neurodevelopmental Disorders (NDD) has significantly increased over the last few decades.

However, assessing the quality of these technologies is challenging due to a lack of consensus on their design. To address this, researchers used the Delphi method to create a trans-ICTs inventory called the Design ICT Inventory (DICTI). This inventory helps guide and evaluate the design of the four main ICTs implemented in NDD care: serious game/App, robotics, video modeling, and augmentative and alternative communication. After two rounds with feedback from 12 experts on ICTs and NDD, consensus was reached on 13 key items in the inventory, including customization, feedback, rewards, contextualized learning, motivation enhancement, difficulty management, accessibility improvement, clear instruction and content, attention capacity, clear goals, minimalistic graphics and audio, human interaction, and trustworthiness.

Introduction

Neurodevelopmental disorders (NDD) are a group of conditions characterized by delays in developmental domains such as social and communication skills, intellectual and executive functioning, motor skills and behavior (American Psychiatric Association, 2015). People with NDD may have mild to severe impairments in academic learning, social and personal functioning, and autonomy (American Psychiatric Association, 2015). According to the timing of the earliest clinical expression, they include intellectual disability (ID), Autism Spectrum Disorder (ASD), communication disorders (CD) that show first symptoms during infancy and toddlerhood, specific learning disorders (SLD), motor coordination disorders (MCD) and Attention Deficit/-Hyperactivity Disorder (ADHD) that usually start later during childhood (American Psychiatric Association, 2015). Such NDD are frequently combined with other NDD comorbidities, resulting in multidimensionally impaired children (Xavier & Cohen, 2020). The use of Information and Communication Technologies (ICTs) for people with NDD has increased over the last 20 years (Grossard et al., 2017). Many ICT supports are used with this population: computer, mobile devices like smartphone or tablet, screen, robots, or virtual and augmented reality.

They can take multiple forms as serious games or apps, assistive technologies, or immersive reality. They can target a wide range of skills or behaviors such as social and communication skills, academic knowledge, sensory and motor skills, autonomy and inclusion, emotion recognition, production, or regulation (Boucenna et al., 2014;Grynszpan et al., 2014;Valentine et al., 2020). They can be used in diverse settings including care centers, schools, or at home (Khan et al., 2019;Miguel Cruz et al., 2017). ICTs are generally well accepted by parents and professionals but also by children or adolescents with NDD (Richardson et al., 2018;Valentine et al., 2020). However, few studies have targeted adult users (Valentine et al., 2020).

ICTs seem to be promising tools to help people with NDD in their daily life. However, it is important to remember that these results have to be taken with caution because of the methodological limitations of the studies conducted in the field (Grynszpan et al., 2014;Khan et al., 2019;Moon et al., 2020). There are many reasons that can explain the difficulty to assess ICT tools: (i) the poor quality of studies with small sample sizes (Khan et al., 2019;Moon et al., 2020), (ii) the lack of framework to guide the design in ICTs, resulting in an important heterogeneity among ICT tools (Carlier et al., 2020;[START_REF] Khowaja | A framework to design vocabulary-based serious games for children with autism spectrum disorder (ASD)[END_REF] and (iii) a large variety of methods to assess these technologies (Grossard et al., 2017;Whyte et al., 2015). Guidelines aiming to improve studies' methodology based on evidence-based approach are not sufficiently developed (Zervogianni et al., 2020), causing literature to be more limited in regard to ICT tools' design. Indeed, an important component in evaluating and helping to improve the quality of ICTs research revolves around design choices. Reviews on how to design ICT tools for people with NDD are rare. Some authors have already proposed some frameworks, but they are often proposed to a specific population, a specific ICT and specific targeted skills, which prevents them from being widely used (e.g. Carlier et al., 2020 focus on the creation of a serious game to reduce anxiety in children with ADHD; Khowaja & Salim, 2020 focus on a serious game aiming to improve vocabulary in children with ASD). Moreover, one question remains: "what are the active components of digital health intervention?" (Hollis, 2017) where active components are defined as components that have the predicted impact on the targeted outcome. Currently, no study is able to answer that question. In particular, there is no scale that can assess and score the quality of an ICT tool in terms of its design.

The Delphi technique is "a structured process that uses a series of questionnaires or 'rounds' to gather information" (Jorm, 2015). This method is appropriate when there is a lack of evidence or incomplete knowledge (Powell, 2003). It allows obtaining an expert consensus and that can be used to determine which methodologies are appropriate in medical science (Jorm, 2015). Usually, consensus is defined by a percent of agreement with a threshold of 75%, however this definition varies from one study to another (Diamond et al., 2014). In a review including 80 Delphi studies, median scores above a predefined threshold and a high level of agreement (i.e., percent of overall rating are in the highest tertile) are the most frequent method used to achieve consensus (Boulkedid et al., 2011). Even if no agreement exists regarding best criteria for obtaining consensus, a measure of distribution and a central tendency should be included. Medians appear to be more robust than means and IQR are more robust than standard deviation [START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF]. The criteria of consensus should be given a priori with a limited number of rounds that should be stated prior to the Delphi study (Diamond et al., 2014;[START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF]. Participants received results after each round. Visual feedbacks as bar charts help with interpretation [START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF].

The Delphi method has the advantage of not requiring face-to-face contact, which facilitates wider group participation, and it allows recruiting experts, despite of their geographical location [START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF]. A clear explanation should be given as to why they are considered experts. In the mental health area, experts are generally professionals (Jorm, 2015). The panel of experts should be around 20 or more participants to assure a good stability of the results. However, Delphi studies in mental health have generally much smaller panels (Jorm, 2015). Recruited experts from different backgrounds allow to produce better quality solution than homogenous groups; but, concerning clinical interventions, specialists of the specific area seem to be more appropriate (Powell, 2003). The recruitment of experts should be done based on the definition of expertise and not only on the acquittance with the researcher (Powell, 2003).

The questionnaire is generally administrated by a web survey which allows to recruit experts everywhere in the world without needing to meet virtually or in person (Jorm, 2015). Lickert scale from 1 to 9 is the more common method used in Delphi studies (Boulkedid et al., 2011). The Delphi method has already been used with those with NDD (i.e. [START_REF] Ali | Optimizing an eHealth insomnia intervention for children with neurodevelopmental disorders: A Delphi study[END_REF] and for new technologies in healthcare (i.e. Polisena et al., 2018). Zervogianni et al. (2020) have already used a Delphi method to develop a consensus on what is good evidence for ICT for people with ASD, but their work did not focus on the design of ICT.

This study is based on the Delphi method and aims to fill the gap in assessing designs concerning ICTs by creating an inventory to rate it. We first constructed a trans-ICT inventory based on the literature named the Design ICT Inventory (DICTI). We refer to the trans-ICT inventory as a tool easily adaptable from one tech to another (e.g. from serious game to robotics) by keeping a common structure and specific examples to rate the inventory according to each specific tech or modality. We first described how we identified targeted components of digital intervention and linked them to each item of the inventory thanks to a review of literature. Then, we explained how we conducted the Delphi study by collecting experts' opinions from different backgrounds and ran three rounds of modification and experts' rating in order to obtain a consensus on the inventory. We finally discussed the interest of our work and its limitations regarding the need of validation and replication of these findings.

Materials and methods

Selection of the items for the trans-technology inventory based on a literature review

We first constructed the trans-technology inventory thanks to a literature review on ICTs and NDD. Between October 29th, 2020 and November 2nd, 2020, we explored the PubMed Database with the following key-words and combinations ("design" OR "methodology" OR "framework" OR "protocol") AND ("neurodevelopmental disorder" OR "developmental disorder" OR "developmental disabilities" OR "autism" OR "developmental disorders") AND ("new technologies" OR "digital health" OR "eHealth" OR "technology based intervention" OR "technology" OR "technologies" OR "Information and communication technology" OR "ICT" OR "robot" OR "innovative technology").

We used the following criteria to select the studies: (i) they discussed how to design a tool when creating one; (ii) they reported on ICTs; (iii) they targeted individuals with NDD; and (iv) the papers were written in English. We included journals' articles, book chapters, and conferences proceedings. We excluded papers that do not have a focus on design implications; papers describing the design of their tools without discussing it and its implication for the adaptation of technologies to people with NDD; and papers about cerebral palsy. In addition, we excluded papers focusing exclusively on sensor technologies (as eyes or movement trackers, sleep assessment devices) as well as papers focusing on prosthesis or orthosis. Finally, we excluded all papers describing tools that are not in direct interaction with people with NDD: (i) tele-practice tools not designed for this population; (ii) tools for data collection as fMRI, EEG …; (iii) devices dedicated to parents or clinician (as guidance or screening).

The diagram flow is shown in Fig. 1. We found 131 articles and after screening abstracts we kept 28 articles to construct the scale. In addition to the references listed, we identified 1 additional study that met out inclusion criteria. All articles are summarized in Table 1.

Then, from the 28 articles, we listed all design components or features that the authors defined as crucial for designing a tool for individuals with NDD (see Table 2). Finally, we kept all features cited in at least 3 papers, giving us 12 features for the inventory as follows: customization, feedback, rewards, contextualized learning, enhance motivation, manage difficulty, increasing accessibility, clarity of instruction and content, attention capacity, clear goals, minimalistic graphics, and audio and human interaction. Our team decided to add one last point about trustworthy, which can be defined as the level of trust people have in ICTs to achieve the goal they are made for (Langer et al., 2019). This is a very important feature in robotics but not really considered in the other ICTs.

Construction of the trans-technology inventory

Based on these 13 essential features (12 from the literature selection plus trustworthiness), we constructed an inventory easy to use and adaptable to assess the presence or absence of each item within the different ICTs. The inventory appears as a matrix with two dimensions:

As we aimed to obtain a trans-ICT inventory, the first dimension is composed of the most common ICT's we found in the NDD literature (i.e.

C. Grossard et al. Grossard et al., 2017, Powell et al., 2019;Whyte & Scherf, 2015). We classified them in 4 subcategories: (i) Serious games and Apps (SGA) which are games with an educative purpose (Whyte et al., 2015), (ii) Robots and more precisely assistive robotics and social robotics (Scassellati et al., 2012), (iii) Augmentative and Alternative Communication (AAC) which, among others, refers to a wide variety of technologies which supports communication in individuals with complex communication needs [START_REF] Wilkinson | Eye tracking measures reveal how changes in the design of displays for augmentative and alternative communication influence visual search in individuals with down syndrome or autism spectrum disorder[END_REF] and (iv) Video Modeling (VM) who are technologies aiming to support independent performance of individuals with special needs (Odom et al., 2015).

The second dimension is composed with the 13 items to rate. Each item can be rated using a Likert-scale between 0 (absence) and 2 (fully considered). To help raters score, each item was connected to targeted skills that ICTs design aims to support. We identified 10 targeted skills:

Delphi study validation

By using the first version of the DICTI that was theoretically constructed based on the literature review and inputs from our team, we conducted a Delphi study to improve the inventory with inputs from three independent external experts from each ICT's subcategory. We contacted 25 experts and found 12 who would help us with our research. Each expert was identified thanks to our network and the literature review. An individual was deemed an expert if she or he (i) had published at least 2 articles in peer review journals about one of the 4 domains of ICTs that we identified, (ii) had implemented specific ICTs in regards to educational and therapy purposes and published at least 1 one experimental study in a peer reviewed journal. We coupled each expert to an ICTs' subcategory depending on the field in which they have published about (SGA, robots, CAA or VM).

To perform the Delphi study, we created a specific online survey to collect survey responses and followed a three-round approach for the study (Jorm, 2015;[START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF]. The DICTI was sent to the experts with an online questionnaire that each expert had to fill out anonymously. No meetings with the experts were necessary. For the first round, experts had to rate each item twice on a Likert scale from 1 (totally disagree) to 9 (totally agree). The first rating concerned the item in its globality (all ICTs together), and the second rating concerned only the ICT they were expert in (the subcategory of ICT for which the expert was identified). For each item of the inventory, the experts could add additional comments. Participants responded within 2-8 weeks. All of the experts received a feedback on the results of the first round. As recommended by [START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF], we provided the score for each item given by the expert, a measure of central tendency (median of the score), and a measure of the distribution (inter-quartile range). We also included a visual feedback with a bar-chart to help the interpretation and the comments of the experts, if any.

Following this first round, conducted between the February 8, 2021 and the March 21, 2021, we worked on all the items to integrate all the comments of the experts' panel. For the second round, conducted between the 29th March and the April 30, 2021, we asked the experts to assess each item again as all of the items were modified following the first round. As for the first round, each expert had to rate each item twice on the same Likert scale previously mentioned. We defined consensus for a given item as the extent to which participants agreed with each other and agreement as the extent which participants agreed with each item. To validate an item, we wanted to reach agreement and consensus for this item. As both of them were reach after the second round, we didn't need a third round.

For the global rating (rating about all ICTs), we evaluated the consensus thanks to the interquartile range (IQR), which is an objective and rigorous way of determining consensus (Von der Gracht, 2012). Consensus is considered as reached if IQR <1.5. The agreement was evaluated thanks to the median that has to be superior to 7 and the percentage of agreement (% of score within the 7 to 9 area) that has to be superior to 90%. Each item that reached agreement and consensus was considered as appropriate. For the rating of the item by ICTs' subdomains (3 experts by ICT), we only used the median to evaluate the agreement with the item in order to be sure that each item of the inventory was adapted to each ICT. We obtained 100% response rate for each item for each round of the Delphi study.

Results

Twelve experts composed the panel (8 women and 5 men). They are from all over the world (USA = 4, France = 3, Australia = 1, Cyprus = 1, Switzerland = 1, Turkey = 1, United Kingdom = 1). They were equally distributed among the four subcategories of ICTS (three experts per domain). Their background included child psychiatry, special education, psychology, engineering, robotics, and computational science. Results from the first and second round for the global rating are presented in Table 3. Percentage of agreement represents the percentage of score within the 7 to 9 area of the Likert scale from 1 to 9.

No item was removed or added between round 1 and 2 as (i) a majority of the experts estimated that all items of the inventory were relevant (median for the global rating ≥7 for all items) and (ii) no experts suggested adding an item. However, agreement was not reach for all specific rating by ICT (see Table 4). Finally, every item was modified after the first round to include all the comments of the experts.

After round 1, we identified different types of modifications to be made. (i) Modifying titles of the items: items 6, 10 and 11 have been changed to better fit with all types of ICT (i.e., item 10 "Clear goals for short and long term" became "Clear steps or goals for short and long term" to better fit with AAC and VM). (ii) Adding examples: we completed each list of examples with new ones that were suggested by the experts. These features could be specific to an ICT (i.e., item 4, we added in VM "choice between first or third person view") or could be added for all ICTs (i.e. item 13, we added for all ICTs "Impact on the user and its environment should be consider (i.e. how to adapt the device to daily life)"). (iii) Adding precisions: some statements needed to be better defined to assure a good comprehension. It was mostly resolved by adding precisions for each unclear point (i.e. for robot and SG, the example "Provides encouragement" for the item 5 became "Provides encouragement (i.e. saying "good job!"). (iv) Adapting terminology: we modified some terms to better fit with the terminology of each ICT (i.e. using "symbols" instead of "pictures" for items related to AAC). All modifications between round 1 and 2 can be found in supplementary material.

Concerning global rating, a good level of consensus (IQR <1.5) and agreement (median >7) were reached for all the items after round 2. For each ICTs rating, agreement was also reached after round 2. The final version of the inventory can be found in Table 5.

Discussion

We conducted a Delphi study in order to reach a consensus about the features that well-designed ICTs tools for people with NDD should provide. The interest of this work is to consider that these features can be related to targeted skills that are considered by the most common ICT subcategories (AAC, robots, VM and SG/App). Based on that, we were able to develop a trans-ICT inventory, the DICTI, that can be used to improve the design of ICTs and compare tools in terms of design efforts. In order to facilitate the use of the inventory, we proposed different examples of characteristics that can be related to a specific feature and a specific ICT.

The Delphi technique allowed collecting experts' opinions in the four ICTs subcategories we identified. We asked the experts to assess the inventory twice: one global rating for all ICTs and one rating specific to the ICT falling in their field of expertise (Jorm, 2015;[START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF]. The global rating allowed us to be sure that each of the items of the inventory were relevant and adapted to a targeted skill we identified. After the second round, all items reached the threshold for IQRs and medians, and we defined to verify consensus and agreement. The specific rating was necessary to ensure that each item was adapted regarding to the targeted ICT. For each ICTs, the median of 7 was reached for all the items of the DICTI (Von der Gracht, 2012).

The creation of the DICTI pursues two main objectives. The first is to provide an efficient tool to guide the design of ICTs and/or gauge the ICT's adequacy to best practices found in the literature. This inventory is relatively short with only 13 items, and no experts suggested adding more features. We believe that the DICTI should be easy to use and relatively quick to rate. The particularity of this inventory is the providing of examples related to each ICT that illustrate each feature and so facilitates the comprehension of what they represent. The objective is to allow anyone to use this inventory without specific training. However, it can only be used after a rater practices using the ICT tool they want to rate. Researchers, NDD's professionals, C. Grossard et al. developers, engineers and users can use the inventory in order to develop tools adapted to people with NDD based on an international consensus and so that should be use in any country. Currently, most of the research in this area does not provide a simple tool that can be easily used to this purpose, whereas people with NDD, their families and professionals are asking for a tool to quickly evaluate if an ICT is adapted to people with NDD (Zervogianni et al., 2020). Some specific tools have been developed for one specific NDD or on specific skills, like reading or social skills, but they cannot be widely used (E.g., [START_REF] Khowaja | A framework to design vocabulary-based serious games for children with autism spectrum disorder (ASD)[END_REF] for vocabulary in children with ASD). Given the high rates of comorbidities between NDD, the use of this inventory should encourage researchers to develop tools adapted to all NDD (Xavier et al., 2020). In addition, most of the design inventories developed targeted one particular type of ICT's such as serious game or robots (e.g., Scassellati et al., 2012 for robots; Whyte et al., 2015 for serious games). This work supports the idea that a design framework can be constructed based on design aspects that are crucial components to consider when working with people with NDD.

The second objective of this inventory is to raise a consensus about which features composed a well-designed ICT for NDD. With a clear consensus, it becomes possible to define the main components an ICT should include. This should help the community in two ways if the inventory is well accepted. First, it should decrease the variability between studies. Currently, the design can widely vary from one tool to another, and it makes the comparison between them hard to make (Grossard et al., 2017). This leads to the second point for which DICTI can be useful, that is the assessment of technologies. The method to assess technologies differs from one paper to another; mostly because the objectives of the studies are defined by the skills they want to work on (i.e. attention, social skills, academic skills …) more than the specific features that should have an ICT (Hollis et al., 2017). Building a tool dedicated to the specific features of ICTs should help clarifying and reducing the heterogeneity in the field. With a better tool to understand the features of ICTs, it offers the possibility to better assess the effect of each of these features. We believe that this type of work will likely improve how we can deal with the question asked by Hollis (2017) and understand what the active components in ICTs are.

Limitations and future studies

A Delphi study only offers a consensus statement when no or little literature is available (Powell, 2003). In our case, it helps creating and then improving a Design ICT Inventory applicable to all subcategories of ICT that can be used with people with NDD. We contacted experts from different countries who worked on developing ICTs for people with NDD. None of the experts were design engineers despite of having worked with teams who developed or adapted ICT's to this population. We also did not involve peopled with NDD in the panel of experts.

We recruited 12 experts, which correspond to a usual sample size in health-related Delphi study [START_REF] Trevelyan | Delphi methodology in health research: How to do it[END_REF]. However, panels of less than 20 experts may produce unstable findings (Jorm, 2015). In order to compensate this small panel of experts, for the global rating, we used elevated thresholds to ensure that each item was relevant and were able to obtain consensus and agreement for each of them (Von der Gracht, 2012). We made a specific rating by ICT to verify that each item was adapted regarding each ICT. However, we only had three experts for each of the ICT, which does not allow us to rate consensus for each ICT. Moreover, the inventory needs to be validated with proper validation study to calculate interrater agreements in several NDDs and different ICT subcategories. This should be done in future research.

If the DICTI seems relevant to assess the design of an ICT, it is not sufficient in itself to assess the global quality of it. Our inventory is a complementary tool that should be used with other scales and methods that are relevant to create and assess an ICT. Indeed, participatory design is an important step that is necessary to ensure the ICT is adapted to the targeted population (Frauenberger, 2015). This can be made by consulting users and professionals during the design phase of an ICT through focus group (Tang et al., 2019). Involving both professionals and users is necessary as these groups may differ with regard to the relative importance they placed on varying components of an ICT tool (Parsons & Cobb, 2014). Usability studies are also needed to assess how users interact with the device and are a crucial step to adapt the ICT to the user and their environment [START_REF] Williams | Using ICT with people with special education needs: What the literature tells us[END_REF]. Finally, strong methodological studies assessing the efficiency and efficacy of ICTs in general are needed. Currently, ICTs appears promising but methodological limitations and small samples sizes do not allow to conclude about their effectiveness (Khan et al., 2019).

Conclusion

We constructed the DICTI in order to provide a simple tool to assess the design of current ICTs: robots, serious games and apps, AAC and video modeling. We then conducted a Delphi study in order to validate the items of the inventory. Finally, we obtained a trans-technology inventory with 13 items that were validated by 12 international experts.

We obtained a quick and easy tool to assess the design of ICTs. Future works should explore psychometric validation of DICTI study (e.g. inter rater reliability). We also think this type of work could be extended to other populations with special needs as well as to the general population.

Chapter , 2015). The comorbidity between NDD is frequently high (Xavier et al., 2020). E.g. [START_REF] Saito | Prevalence and cumulative incidence of autism spectrum disorders and the patterns of co-occurring neurodevelopmental disorders in a total population sample of 5-year-old children[END_REF] found that 88.5% of 5 years children with ASD have at least one co-existing NDD. This high ratio of co-occurring NDD reveals the need to consider all NDD when building tools or therapies for these populations.

The use of Information and Communicative Technologies (ICTs) has increased these last 20 years [START_REF] Grossard | ICT and autism care: state of the art[END_REF]. These technologies can be developed on a large variety of supports: computer, mobile devices like smartphone or tablet, screen, robots, but also wearable technologies as smartwatch, or virtual and augmentative reality. They can take multiple forms as app, serious games, assistive technologies, and immersive reality. They can target a wide range of skills or behaviors as social and communication skills, academic knowledge, sensory and motor skills, autonomy and inclusion, emotion regulation (Grynszpan et al., 2014;Boucenna et al., 2014;Valentine et al., 2020). They can be use diverse setting including care centers, schools or at home (Miguel Cruz et al., 2017, Khan et al., 2019). ICTs are generally well accepted by parents and professionals but also by children or adolescents with NDD (Valentine et al., 2020;Richardson et al., 2018). However, a few numbers of studies have targeted adult users (Valentine et al., 2020). Many reviews have been conducted in the field of ICTs in particular during the last 3 years (i.e. Hollis et al., 2017;[START_REF] Grossard | ICT and autism care: state of the art[END_REF]Khan et al., 2019;Moon 2019;Sandback, 2019;Sandgreen et al., 2020). However, many of them focus only on a specific NDD, often ASD, while the DSM-V reunites all NDD because they share some similar features (e.g. impact on neurodevelopment as a consequence of common cause or of a lack of opportunity to exercise fully the impacted domain). Moreover, the high rate of co-occurring NDD should be more systematically taken into account in order to have results that can be generalizable to a large population. Other reviews have focused on specific ICTs such as robots (e.g. Miguel Cruz et al., 2017), virtual reality (e.g. Park et al., 2019), app (e.g. Neary & Schueller 2018.), web-based interventions (Khan et al., 2019). To our knowledge, only Valentine et al. (2020) have focused on all NDD and included the different technologies. However, their review only focuses on the effectiveness of the intervention and the impact of their implementation on user and cost. Yet, an important part to evaluate and help to improve the quality of ICTs research concerns design choices. Reviews on how to design ICT tools are less frequent, even if some authors have already proposed some framework (e.g., [START_REF] Khowaja | A framework to design vocabulary-based serious games for children with autism spectrum disorder (ASD)[END_REF]Whyte, 2015). However, frameworks are often proposed for a specific population, a specific ICT and specific targeted skills, which prevents them to be widely used.

Due to the increasing number of digital tools towards people with NDD (Miguel Cruz et al., 2017), the need to find an effective way to evaluate them becomes urgent. This is a particularly important question regarding the benefit and the cost of these solutions. Recently, the U.S. Food and Drug Administration (FDA) has granted clearance for EndeavorRx, an Akili's video game therapy for ADHD, which make it the first prescription treatment delivered through a video game [START_REF] Canady | FDA approves first video game Rx treatment for children with ADHD[END_REF][START_REF] Kollins | A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial[END_REF]. In Germany, the Federal Institute for Drugs and Medical Devices has set up an assessment procedure in order to evaluate Digital Health Applications (https://www.bfarm.de/EN/MedicalDevices/DiGA/_node.html). Since December 2019, The Digital Healthcare Act introduced prescription of apps that are reimbursed by health insurers. In France, the government is currently supporting the creation of a Living and Learning

Lab in order to help innovative project leaders to design technologies and services that are adapted to people with NDD and to evaluate new technologies as well as innovative educational and pedagogical methods used with people with (NDD) (https://www.lillabneurodev.fr/).

In this context, we conducted a systematic meta-review of the literature. We aimed to answer the following questions:

Methods

Search procedure

Between 8 th and 11 th December 2020, we performed a computerized search of the Medline (PubMed version), IEEXplore, Scopus and ACM Digital Library databases. The search used the following keywords: ("review" OR "metareview" OR "metaanalysis" OR "systematic review") AND ("neurodevelopmental disorder" OR "developmental disorder" OR "developmental disabilities" OR "autism" OR "developmental disorders" OR "dyslexia" OR "ADHD" OR "specific learning disorders" OR "communication disorders" OR "intellectual disability " OR "attention disorders") AND ("new technologies" OR "digital health" OR "eHealth" OR "technology based intervention" OR "technology" OR "technologies" OR "Information and communication technology" OR "ICT" OR "robot" OR "innovative technology" OR "serious games" OR "virtual reality" OR "computer"). We screened all identified reports, studies and reviews by reading the titles and abstracts. In addition, the references' lists of the studies that met the inclusion criteria were reviewed to identify additional studies for inclusion.

Inclusion and exclusion criteria

The reviews included in the analyses met the following criteria: (i) they made a review of the literature, whatever type of review (state of the art, systematic review, meta-analysis, metareview) ; (ii) they reported on new technologies ; (iii) they targeted individuals with NDDs ; (iv) the papers were written in English. We included journals articles, book chapters, thesis and conferences proceedings. We excluded all papers about cerebral palsy and paper for those the diagnostic of the population were not clearly defined. Moreover, we excluded papers exclusively on sensor technologies as eyes or movement trackers, sleep assessment devices, as well as papers focusing on prothesis or orthosis. We also excluded Brain-Interface computer or neurofeedback technology and microswitch technology. Finally, we excluded all papers describing tools that are not directly in interaction with people with NDD: (i) telepractice tools; (ii) tools for data collection as fMRI, EEG...; (iii) devices dedicated to parents or clinician (as guidance, screening or diagnosis).

Figure 1 summarizes the flowchart of the study. We ultimately found 301 reviews that corresponded to our criteria.

Figure 1: Flowchart

We extracted from the reviews all the studies in which at least one participant with NDD has tested the ICT. We used the same exclusion criteria as we did for the reviews. Furthermore, we excluded studies that did not involve a test with the targeted population (i.e., studies on technical development). We finally we created a database including 1879 studies.

Each study was then classified regarding the ICT used in the experiment in (i) Serious

Games (SG) and apps, (ii) Video Modeling (VM), (iii) Augmentative and Alternative Communication (AAC), (iv) robots, or (v) other technologies (i.e.: reading tools, planners, DVDs or smart-objects).

Assessment of experimental methodology and ICT design

Given the number of studies, we decided to apply a random assessment of a subgroup of studies stratified by time and type of studies. We separated studies regarding the date of publication in 3 periods: until 2011, between 2012 and 2015 (included), after 2015 (excluded).

This separation allows us to obtain an equivalent number of studies for each period. For each category SG, VM, AAC and Robots, we randomly picked 15 studies per period for a total of 45 studies per categories. For each group of 15 clinical trials, 5 were rated by judge 1, 5 were rated by judge 2 and 5 were rated by both judges. Both judges and authors are female; one is a psychologist and PhD student and the other is a speech therapist and research engineer, both researchers' work focus on ICTs and children with NDD. Judges rated each study regarding the quality of the experimental methodology and the quality of ICT design. One study in the category SG and one in the category Robot present two tools. We so rated each tool separately for their design for 46 observations in the SG and in the robot categories. We used the scale developed by [START_REF] Connolly | A systematic literature review of empirical evidence on computer games and serious games[END_REF] to assess the experimental methodology of each study. This scale includes five dimensions; each rated from 1 to 3, assessing the type of study (Randomized Control Trial vs. controlled study vs. study without control and case study), the possibility to generalize results, the description of the sample, the trust in the result and the protocol quality.

To assess the design variables, we used the Design ICT Inventory (DICTI, [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF] assessing 13 features from 0 to 2 of the 4 main ICTs (AAC, VM, robot and SG):

customization, feedback, rewards, contextualized learning, enhance motivation, manage difficulty, increasing accessibility, clarity of instruction and content, attention capacity, clear goals, minimalistic graphics and audio and human interaction. We assessed the ICT design based on the description available on the article from our database; therefore DICTI scores may vary for a same ICT from one study to another (especially for robot). In some cases (2 studies), we found no description of the features of the ICT (i.e., a study describing the skills worked in the task but not the features of the program itself) or how the ICT was using in the study (i.e., the study describing a robot do not describe how the robot was programmed for the intervention) and rated NDA (No description Available) that was considered as a score of 0 in the statistical analysis. When an Internet link or a reference describing the design of the ICT was given in the article, we looked directly in the on the Internet or the other article to find information about the design. (ICC method = 0.80) and excellent for the design inventory (ICC design =0.9). ICC are globally good for each type of ICT (ICC>0.75) except for the methodological score for video modeling who can be considered as acceptable (ICC VMmethod =0.65).

ICT

Description of the best papers according to ICT categories

Given the number of studies, we decided to describe for each ICT the three most cited article from Google Scholar (in March 2023), as well as the 3 articles published in the highest impact factor journals according to the year of publication. In case of equality, 4 papers were described qualitatively.

Results

Distribution of selected studies across domain and time

Studies were published between 1968 (Colby, 1968) and 2021. We found 1879 studies on ICT used in NDD. Among them, 836 studies focus on SG, 276 focus on VM, 170 focus on AAC, 319 focus on robots and 268 focus on other technologies (Figure 1). Concerning the "other

Quality of design overtime

Regarding design quality of the studies, scores are similar across the 4 ICT (Robot: Mean=7.72, SD=4.32); VM: Mean=8.13, SD=2.17; SG: Mean=9.29, SD=4.69; and AAC: Mean=9.15, SD=4.65). There is no significant difference between ICTs (p=0.216, Welch's ANOVA). Range scores for all ICT varies widely for Serious Games (from 0 to 21) and Robots (from 0 to 19).

These variations are also presents for VM (from 4 to 14) and AAC (from 0 to 15). When we assessed the impact of year of publication on scores thanks to a Spearman correlation, it appears that scores globally increase with the year of publication. Regarding each ICT, this positive correlation is found for SG (p=0.003) but not for AAC (p=0.147), robots (p=0.537) and VM (p=0.407) (see details in figure 4).

Main studies by domain according to citations and impact factors

Tables 2 to 5 in the appendix summarize the three most cited article from Google Scholar as well as the 3 articles from the highest impact factor journals per domain, respectively robot, ACC, SG and VM. The experimental methodology and main results are described below.

We observed that (1) robotic studies have for the most part poor methodological quality, in particular small sample sizes, with the exception of random control trials [START_REF] Kim | Social robots as embedded reinforcers of social behavior in children with autism[END_REF][START_REF] Kumazaki | The impact of robotic intervention on joint attention in children with autism spectrum disorders[END_REF][START_REF] Huskens | Improving collaborative play between children with autism spectrum disorders and their siblings: The effectiveness of a robot-mediated intervention based on Lego® therapy[END_REF]. The targeted population is autistic individuals, and the primary targeted skills in these studies are social skills. The intensity and duration of interventions can vary, ranging from short interaction [START_REF] Kumazaki | The impact of robotic intervention on joint attention in children with autism spectrum disorders[END_REF][START_REF] Kim | Social robots as embedded reinforcers of social behavior in children with autism[END_REF] to longitudinal studies [START_REF] Robins | Robotic assistants in therapy and education of children with autism: can a small humanoid robot help encourage social interaction skills?[END_REF]. The majority of the interventions are delivered by the researchers who are in charge of controlling the robot through the Wizard-of-Oz technique, a popular remote control in human-robot interactions [START_REF] Steinfeld | The oz of wizard: simulating the human for interaction research[END_REF], and only a small percentage of the robots are fully autonomous [START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF][START_REF] Huskens | Improving collaborative play between children with autism spectrum disorders and their siblings: The effectiveness of a robot-mediated intervention based on Lego® therapy[END_REF]. The articles highlight in particular the possibility of pre-programming the robot and its appealing physical characteristics. However, most studies pointed out the robots' design weaknesses, which include limited adaptability to autistic children's needs, restricted motions and verbal repertoire, and the need for technical assistance.

(2) The methodological quality of AAC studies is also generally poor, mainly consisting of case studies or small group studies without controls. The targeted population is ASD and ID individuals and the primary targeted skill is always communication. The interventions primarily involve speech-generated devices on iPads or applications. The person in charge of delivering the intervention includes speech-language pathologists and teachers. The articles highlight the accessibility and cost availability of devices such as iPads and apps, however most AACs require prior training.

(3) SG studies methodological quality is good, including controlled studies [START_REF] Klingberg | Training of working memory in children with ADHD[END_REF]Temple et al., 2013;Francheschini et al., 2013) or random control trials and large sample sizes [START_REF] Klingberg | Computerized training of working memory in children with ADHDa randomized, controlled trial[END_REF][START_REF] Golan | Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia[END_REF]de Vries et al., 2014) although we observed a lack of participants' characteristics description in some studies [START_REF] Golan | Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia[END_REF]. These studies are also the most cited from the 4 ICTs domains, ranging between 800 and 2700 citations. The targeted population can vary including individuals with ADHD [START_REF] Klingberg | Training of working memory in children with ADHD[END_REF][START_REF] Klingberg | Computerized training of working memory in children with ADHDa randomized, controlled trial[END_REF] learning disorders (e.g. dyslexia) (Temple et al., 2002), and ASD [START_REF] Golan | Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia[END_REF][START_REF] Serret | Facing the challenge of teaching emotions to individuals with low-and highfunctioning autism using a new serious game: a pilot study[END_REF]de Vries et al., 2014). The Strengths include the games being related to social context and offering multiple feedbacks, while weaknesses in the design often includes the lack of multiplayer options and limited personalization. To date, EndeavorRx TM , a SG for ADHD, is the only FDA approved prescription treatment delivered through a video game [START_REF] Canady | FDA approves first video game Rx treatment for children with ADHD[END_REF]. It is not included in table 4 as the journal (The Lancet Digital Health) was too recent to reach a high impact factor [START_REF] Kollins | A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial[END_REF].

Finally, (4) VM methodology quality is poor, predominantly consisting of case studies, and small sample sizes. The duration of the intervention appears to be the most significant from the 4 ICTs and can vary from one-time a day exposition for three months [START_REF] Spriggs | Talking picture schedules: Embedding video models into visual activity schedules to increase independence for students with ASD[END_REF] to three times a day for 25 sessions [START_REF] Litras | Using video self-modelled social stories to teach social skills to a young child with autism[END_REF]. The targeted populations are individuals with ASD and ID and the targeted skills include social skills, communication, and autonomy. Videotapes are commonly used as support for these types of interventions, which are delivered by researchers, therapists, or participants' parents. VM design is often poorly described. However, most studies emphasize the lack of ICT personalization [START_REF] Charlop | Teaching autistic children conversational speech using video modeling[END_REF][START_REF] Charlop-Christy | A comparison of video modeling with in vivo modeling for teaching children with autism[END_REF], and feedback [START_REF] Horn | Teaching laundry skills to individuals with developmental disabilities using video prompting[END_REF][START_REF] Spriggs | Talking picture schedules: Embedding video models into visual activity schedules to increase independence for students with ASD[END_REF].

Discussion

In this review, we evaluated the methodological and design quality of a randomly selected group of 182 studies involving ICTs and NDD to assess digital technologies for health in NDD. By investigating these two main aspects in the creation of a digital therapeutics, we aimed to answer four questions that we will discuss in this section.

How are ICTs evaluated in clinical studies?

There is currently no standard framework for ICT assessments. Depending on the state of advancement of the research, there are different experimental phases. Feasibility and usability trials often take the form of case studies [START_REF] Liu | Feasibility of an autism-focused augmented reality smartglasses system for social communication and behavioral coaching[END_REF] or group studies without control (Bargagna et al., 2018), as the particular interest is on the feasible operation of the ICT. These studies often focus on the user's perception of the ICT, while usability studies mainly verify the usability of the ICT in terms of its adaptability [START_REF] Nielsen | Usability inspection methods[END_REF][START_REF] Serret | Facing the challenge of teaching emotions to individuals with low-and highfunctioning autism using a new serious game: a pilot study[END_REF][START_REF] Zou | A wizard of oz interface with qtrobot for facilitating the handwriting learning in children with dysgraphia and its usability evaluation[END_REF]. Gyori et al. (2015) proposed an initial phase involving neuro-typical individuals to improve their first ICT prototype, thereby avoiding any technical issues encountered when conducting a study with NDD participants. Indeed, it appears that even good conducted studies are not sufficient to users of digital technologies (Zervogianni et al. 2020). Users are also looking for other sources of empirical evidences as online review of other users or expert opinion.

Finally, efficacy trials investigate the impact of the numerical intervention on individuals'

outcomes. These studies have best quality in terms of experimental methodology, as they often are randomized control trials including a control group exposed to another settings [START_REF] Kim | Social robots as embedded reinforcers of social behavior in children with autism[END_REF][START_REF] Duquette | Exploring the use of a mobile robot as an imitation agent with children with low-functioning autism[END_REF]. Overall, studies improved their methodological assessment of ICT over the years. The scores of the methodological scale improved for VM, AAC and especially robots but not for SG. However, SG clinical trials appeared to have the best research methodology quality and VM had the lowest score on the methodological scale. To date only one single ICT, EndeavorRx TM SG has received a FDA approval in ADHD. In details, VM, AAC and robots mostly used case studies (e.g., VM: [START_REF] Horn | Teaching laundry skills to individuals with developmental disabilities using video prompting[END_REF][START_REF] Litras | Using video self-modelled social stories to teach social skills to a young child with autism[END_REF][START_REF] Spriggs | Talking picture schedules: Embedding video models into visual activity schedules to increase independence for students with ASD[END_REF]AAC: Reichle & Ward, 1985;[START_REF] Flores | A comparison of communication using the Apple iPad and a picture-based system[END_REF][START_REF] Gevarter | Comparing acquisition of AAC-based mands in three young children with autism spectrum disorder using iPad® applications with different display and design elements[END_REF]robots: Robins et al., 2009;[START_REF] Pioggia | Human-robot interaction in autism: FACE, an android-based social therapy[END_REF]Kozima et al., 2007), whereas SG are for the most part evaluated in group studies (e.g., Serret et.al (2014). For VM and AAC, case studies improved progressively with the use of multiple baselines becoming more and more frequent (e.g., VM: [START_REF] Charlop-Christy | A comparison of video modeling with in vivo modeling for teaching children with autism[END_REF]; [START_REF] Horn | Teaching laundry skills to individuals with developmental disabilities using video prompting[END_REF]; AAC: [START_REF] Reichle | Teaching discriminative use of an encoding electronic communication device and signing exact English to a moderately handicapped child[END_REF]. For robots, the majority of old studies had not a clear assessment of their effect on people with NDD, and were only feasibility studies reporting how patients reacted to the robot (e.g., [START_REF] Jordan | Robotic technology for teaching adolescents with autism spectrum disorder: a feasibility study[END_REF]. Few recent studies assessed robot's impact on patient's skills thanks to automatic/learning algorithm and direct observations (e.g., [START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF]. Few others include robots in a more naturalistic environment like classroom, which allows studying the effect of the robot on human-human interaction (Scassellati et al., 2012). The assessment of the quality of the studies differs across reviews. For example, Khan et al. (2019) Ganz et al., 2017). Despite these differences in methodology, most authors concluded that there is a lack of high quality studies in the field of ICTs, whatever the form they take (Zervogianni et al., 2020;Miguel Cruz et al., 2017;Hollis et al., 2017;Morin et al., 2018). In our meta-review, the quality of methodology for all ICT remained poor, even for recent publications compared to the standard of medical assessment. Gradually more RCTs can be found in the literature, however, not all of them are well conducted (Khan et al., 2019;Grynszpan et al., 2014). Most meta-analysis focusing only on RCTs could not use all the studies they reviewed to make their analysis as a lot of studies did not fill all the quality criteria to allow an analysis (e.g.; Moon et al., 2019 2017) reported that parents tended to say their child improved but independent observers who are more likely to be blinded to the intervention found no difference. The comparator used in group studies are classically treatment as usual, other ICT or waiting list (see Khan, 2019).

Even if RCTs is the gold standard in clinical research and in the scale we used [START_REF] Connolly | A systematic literature review of empirical evidence on computer games and serious games[END_REF], group studies or single cased studies can also correspond to Evidence Based Practice [START_REF] Bennett | The utility of single subject design research[END_REF]Morin et al., 2018;Root et al., 2017). Root et al. (2017) evaluated the quality of single case studies and group studies. From 29 studies included, only 10 of them where considered to have high or acceptable quality for the review.

The 10 studies selected provided sufficient proof to conclude that computer-assisted interventions meet the criteria of EBP in the field of teaching academics to children with ASD according to the National Technical Assistance Center on Transition criteria (2015, cited by Root, 2017). Finally, even if VM and AAC obtained the lowest methodological score in our review, they meet the standard for EBP in different reviews (Morien et al., 2018[START_REF] Steinbrenner | FPG child development institute[END_REF][START_REF] Wong | Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review[END_REF].

Another limitation is the difficulty to recruit large population (Parsons et al., 2019). Most studies have sample size under 10 participants and lack of information regarding participants characteristics (Root et al., 2017). Moreover, recruitments are very often realized in care centers (often just one), which focus on a targeted population in one geographical perimeter. Most studies explored only people without comorbidities (Grossard et al. 2017), which do not reflect the usual heterogeneity found in NDD (Xavier et al., 2020); for instance, in the field of autism, high-functioning populations are overrepresented (Grynszpan et al., 2014). These biases make it difficult to generalize the results (Grossard et al., 2017;Miguel Cruz et al., 2017;Pennisi et al. 2016). One solution to avoid these difficulties could be to develop technologies that could be easily used at home or in the child's environment like school setting. In this case, technologies must be affordable, easy to use and with technical support available.

What are the main design features in digital technologies for NDD?

Even if the number of design features increased for all ICT over the years, studies fail to treat design and efficiency equivalently. AAC, VM and Robot ICT did not improve DICTI score overtime, whereas SG improved it. However, SG was the only ICT in which the score at the methodological scale did not improve. Good studies describing design processes often proposed a very light assessment with the population targeted; conversely, good methodological studies often forget to describe accurately design features of the ICT. The need for personalization of digital technologies for users to engage them effectively reaches a consensus (robots [START_REF] Huskens | Improving collaborative play between children with autism spectrum disorders and their siblings: The effectiveness of a robot-mediated intervention based on Lego® therapy[END_REF][START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF]SG: Gollan et al., 2006;VM: Charlop & Milstein, 1989;[START_REF] Charlop-Christy | A comparison of video modeling with in vivo modeling for teaching children with autism[END_REF]. Personalization can occur in several ways: visual design (i.e. personalization of a characters, colors or sounds); adaptation of exercise or content (i.e. exercise order, difficulty levels and length); or adaptive algorithms to follow users. Hollis et al. (2017) reported that users prefer tailored or personalized messages, such as generic messages using their names. Users may also be able to personalize small features like gender and appearance of a « guide ». Allen et al. (2016) emphasize that personalization is crucial in therapeutic interventions to meet the patient needs. However, our review found limited studies on personalization. Among the four ICTs, the personalization feature is most explored on AAC devices, as it is an essential feature that allows to fit with the user's profile. Conversely, VM studies provided very few possibilities for user adaptation, as they are usually designed for specific contexts, populations, and cannot be modified by users. Robots and SG also offer limited options for personalization, such as sound modification or using the user's name.

However, our review found that personalization in robot studies primarily focused on therapist adjustment, rather than adapting the robot's visual preference to the user (Boucenna et al., 2014).

The case of robots is specific as often the visual aspect of the robot is predetermined and robot appearance has been chosen depending on the objectives of the training but also the possibility of actuation of the robots (Scassellati et al., 2012). Even when robots, like the Bioloid Robot could be assembled in various configurations like dinosaur or puppy, the study reported by Pennisi et al. (2016) only use its humanoid form. Similarly, studies did not discuss managing features like lights and sounds to align with user preferences.

The need for positive feedback and rewards to promote learning in children with NDD is now well established [START_REF] Horn | Teaching laundry skills to individuals with developmental disabilities using video prompting[END_REF][START_REF] Litras | Using video self-modelled social stories to teach social skills to a young child with autism[END_REF][START_REF] Spriggs | Talking picture schedules: Embedding video models into visual activity schedules to increase independence for students with ASD[END_REF]. This has been well identified in the field of serious games (Whyte et al., 2015). However, these two features do not appear in others ICTs. In addition, positive feedbacks are essential to help the user knowing when he is making the task correctly and maintain attention (Whyte et al., 2015). Most humanrobot interactions happen through visual cues (screens), sounds or actions; however, papers do not describe in which way the reaction of the robots supports the targeted behavior awaiting. In assistive technologies, video modeling is often compared to video prompting to support autonomy in daily tasks, but no study focus on positive feedbacks and rewards to promote the realization of these tasks. In AAC, the reward or feedback is considered given by the interlocutor but not by the ICT. In studies on VM, the question of reward is never addressed.

The absence of human interaction in most technology-based intervention could limit the effectiveness of the intervention, especially when the targeted skills are social skills (Sandbank et al., 2019). Our meta-review confirmed this view, as very few studies we evaluated support interaction between the user and other human, off line or online. Virtual Reality is often based on multiplayer games when serious games or Apps or essentially solo player game. Whyte (2015) supposed that the higher rate of generalization in VR could come from that difference. But this needs to be further explored.

Design features to support generalization are better addressed in ICTs and concern the importance of contextualized learning, accessibility, clarity of instructions and clarity of goals [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. Most studies focus specifically on this point, as they are particularly relevant to assure that people with NDD will be able to use the ICT. Visual characteristics of a display like color or symbol arrangement have to be taken into account because it can facilitate or impede the use of the device (Liang et al., 2018). In a same way, motors skills may sometimes be underestimated, even when they are necessary to use a device (Quezada et al., 2017). For instance, [START_REF] Strickland | An evolution of virtual reality training designs for children with autism and fetal alcohol spectrum disorders[END_REF] had to drop off the use of a joystick with 2 ASD children with moderate-level functioning.

Ethics are frequently documented considering that issues with privacy and security can arise with numerical tools [START_REF] Schultz | Contemporary issues in ethics and information technology[END_REF]. Additionally, the perception of the ICT is also often discussed and presented in a section named "social validity". This section is classically addressed through users, caregivers or teachers questionnaires. Social validity refers to the social importance and acceptability of treatment goals, procedures, and outcomes [START_REF] Foster | Assessing social validity in clinical treatment research: issues and procedures[END_REF]; its measures can provide essential data to both clinical and research agenda on evidencebased practices [START_REF] Strain | Lessons learned about the utility of social validity[END_REF]. In contrast, this feature is not used in robots or SG as there is no specific frame to address the question of the user's perception of the ICT's and it's robustness. Indeed, there are major variations on the way it is assess for both.

Clinicians and professionals of NDD are frequently involved in the development of ICTs (Allen et al., 2016). They bring the knowledge on the disorders but also on the organization and needs of the institutions they are working for; in that way, they can help to build a tool that is accurate (Guard et al., 2019). But more and more studies concluded to the necessity to involve the patients and their families in the conception of ICTs. They can participate to the design of the tools, the content but also be involved in a feasibility study to make sure the tool is correctly designed for the population. As an example, many tools do not focus on motor skills but require some that can be challenging for people with NDD (Allen et al., 2016;Quezada et al. 2017).

Including both professionals and users allow to take into account both their point of view that are often focused on different aspects of a tool; professionals are attached to the objectives and the content of the game when users are also looking into the personalization and gamification aspects (Tang et al. 2019). This can be achieved through a multidisciplinary and user-centered design approach (Carlier, 2020). If the implication of people with NDD seems greatly improve the quality of the design of the tools, their participation can be challenging. In this review, we did not looked at how to help people to participate in the design but more and more studies address this question (for a review, see [START_REF] Benton | Widening participation in technology design: A review of the involvement of children with special educational needs and disabilities[END_REF][START_REF] Börjesson | Designing technology for and with developmentally diverse children: a systematic literature review[END_REF] How to promote learning with ICTs?

Results regarding the effectiveness of ICTs are inconsistent throughout the literature (Hollis et al., 2017). It is especially difficult to draw and summarize conclusions, as studies, reviews and meta-analysis differ widely in their methodology. Some meta-analyses support the interest of ICTs for people with NDD (Grynszpan et al., 2014;Ganz et al., 2017). However, while digital training has shown improvements in some cases, most studies have found that ICTs are not more effective than traditional treatment (Khan, 2019). Still, there is evidence to suggest that ICTs are not detrimental to learning and may be preferred by individuals with ASD compared to traditional tools (Allen, Hartley and Cain, 2016).

However, these findings are not consistent across all ICTs and targeted skills. Pennisi et al. (2016) found that users with ASD often perform better with a robot than with a human, and certain ICTs such as VM may be effective for promoting autonomy skills (Waldman-Levi et al.

2019

). The use of iPads can promote certain targeted skills like instrumental requests but not others such as spontaneous social communication (Allen, Hartley & Cain 2016). Similarly, Ganz et al. (2017) found the use of high-tech AAC effective but significantly better for the expression of needs than for social closeness. A large part of studies focusing on feedback in digital therapeutics emphasized the need for clarity to communicate to the user if he/she is correctly progressing in the current task. Studies reporting about negative feedback always advised against it, as it can bring frustration or act like a reinforcer for the uncorrect answer (Whyte, Smyth & Scherf, 2015[START_REF] Strickland | An evolution of virtual reality training designs for children with autism and fetal alcohol spectrum disorders[END_REF]). Feedback must be clearly link to the user behavior to help the user engage with the ICTs [START_REF] Feil-Seifer | Toward socially assistive robotics for augmenting interventions for children with autism spectrum disorders[END_REF].

A consensus in the literature found that most studies fail to demonstrate maintenance and generalization of the targeted skills outside the specific context of the game (Grynszpan et al., 2014;Hollis et al., 2017;Ganz et al. 2017). Combining serious games with other activities may recommended a specific duration without explaining how it was determined (Khan, 2019;Parsons 2019), but feedback from families using these tools suggests that the recommended duration may be too long for many children (Parsons 2019). It is also important to consider the time needed by professionals to adapt the ICT to each user, as this can impact the length of the treatment period and potentially bias the results (Gyori et al., 2015).

Interestingly, Grynszpan et al. (2014) found a negative correlation between intervention duration and effectiveness, possibly due to interventions requiring user autonomy. Khan (2019) found that few interventions are therapists assisted (4 studies among 10), highlighting the need for technical support. Different degree of help can be found: distancial contact, face to face point or exclusively therapist-delivered. In many cases, there is an important need for technical support (Khanet al., 2019;Gyori et al., 2015). This support is often available during the study, but it's required even after the study (Allen et al. 2016). ICT can be valuable resources when care centers are far, but users and parents still need supports in using and adapting to the technology, notably when facing behavioral problems while using the digital tool with their child (Parsons, 2019).

Behavioral problems can arise with ICT use, necessitating caution and limiting usage with automatic shutdowns (Zervogianni et al. 2020;Parson et al. 2019). New technologies are generally accepted, but parents' attitudes may change over time. In the study of Parson (2019) on the TOBY App, parents reported new behavioral difficulties related to the device (i.e. sleep disturbance, too much interest in the iPad and behavioral problems when needed to stop).

Involvement of parents and users in the design development of the ICT can help address this.

Cost-effectiveness data on ICT is lacking (Hollis 2017). However, technologies must be affordable and accessible (Zervogianni et al, 2020). Some technologies are still too expensive as robots (Miguel Cruz et al., 2017) or AAC (Allen et al., 2016) to be purchased by care centers or low-income families. Tablets are often affordable but the price of the apps can be expensive (Allen et al., 2016). The use of games or apps that are not device-dependent allow to avoid cost and maximize accessibility (Dalton, 2016). However, it is important to evaluate the impact of a technologies compare to the cost. As an example, [START_REF] Strickland | An evolution of virtual reality training designs for children with autism and fetal alcohol spectrum disorders[END_REF] conduct experiment in VR with and without headset and reports that they did not find significantly different results between the two conditions that could justify the greater cost of the headset.

ICT is not always the solution for everyone with NDD, as preferences vary across individuals between ICT and paper-pencil condition or traditional picture exchange system (Allen, Hartley, & Cain, 2016;[START_REF] Lorah | A systematic review of tablet computers and portable media players as speech generating devices for individuals with autism spectrum disorder[END_REF][START_REF] El Zein | A comparison between iPad-assisted and teacher-directed reading instruction for students with autism spectrum disorder (ASD)[END_REF][START_REF] Allen | Caregivers' perception of the iPad's utility for Augmentative and Alternative Communication (AAC): a conflict between illusion and reality[END_REF] suggest that parents who own an Ipad are less positive about the use of an iPad for AAC than parents who do not own one.

Limitations

We decided to give a large overview of the field of ICTs in NDD as comorbidities between NDD are frequent, and NDD share common features (American Psychiatric Association, 2015; Xavier et al., 2020). Nevertheless, all NDD do have specificities and they are not addressed in this review. Even if this paper highlights the need for personalization, it does not develop the specificity for each NDD. However, there are already reviews that focus on specific ICTs in a given NDD.

Another limitation is that we assessed each ICT separately with the DICTI. However, some studies use more than one type of ICT at a time. This is the case for some studies involving robots (for example [START_REF] Wainer | Using the humanoid robot KASPAR to autonomously play triadic games and facilitate collaborative play among children with autism[END_REF] that also used collaborative games to support interaction between the patient and the robot. For this type of studies, we decided to assess the main ICT on which the paper focuses on.

A major limitation in our work is the lack of design description in a large part of studies.

This lack of description happens in old but also recent studies. Of course, we were not able to try all ICT we reviewed and so we used the DICTI in another way that it was created for as the DICTI supposed the possibility to try the ICT. We encourage future studies to better describe the design features of the ICT since this field needs to improve for ICTs that are not SG.

Conclusion

This meta-review emphasizes the necessity to develop standard methodologies to evaluate ICTs design and the type of clinical trials they are assessed in (feasibility, usability and efficacy studies). In this regard, we assessed the evolution over the last decades of ICTs' experimental methodology and design quality employed in digital technologies' interventions for individuals with NDD. The overall quality of ICT studies remains poor, but methodology quality has improved for robots, AAC, and VM compared to SG. There is a lack of high-quality studies in the field. User-friendly technologies and more high-quality studies are needed. From a design perspective, we noted that SG design quality has improved the most over the last years, despite having being the studies with the poorest methodological quality. The main features highlighted in the literature are personalization, adaptability, positive feedback, and human interaction.

Affordability and accessibility are also important to take into consideration, as some technologies are still too expensive for the public hospitals and low-income families.

Additionally, therapist assistance, and technical support are also crucial. Involving clinicians, professionals, users, and their families in the design process is important to provide technologies that are well accepted by NDD individuals and their families. The literature on learning with ICTs is inconsistent, but there is no evidence that ICTs are detrimental to learning for individuals with NDD, despite the need for more evidence-based studies to reach treatment recommendation.

Introduction

Autism spectrum disorder (ASD) is a complex neurodevelopmental disorder characterized by deficits in social skills and communication, restricted interests, and repetitive behavior (APA, 2013). Social skills training is a vital component of autism treatment, which focuses on minimizing maladaptive behaviors and facilitating the development of favourable social behaviors. Moreover, it can facilitate the acquisition of conversational skills (initiating, maintaining, and closing verbal exchanges), emotional skills (perceiving and understanding emotions) and social-cognitive skills, such as theory of mind [START_REF] Kruck | Étude sur l'efficacité des groupes d'habiletés sociales proposés aux enfants avec un trouble du spectre autistique[END_REF]. This can be done by teaching interpersonal skills to patients and promoting their generalization and maintenance [START_REF] Baghdadli | Entrainement Aux Habiletés Sociales Appliqué a L'autisme[END_REF]. Group-based psycho-social skills interventions are among the most commonly used methods to improve social skills in autistic youth [START_REF] Gates | Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis[END_REF]Reichow, Steiner & Wolkmar, 2012). However, despite their prevalent use, their efficacy remains inconclusive due to a lack of rigorous, well-designed research (Reichow, Steiner & Wolkmar, 2012;[START_REF] Mcmahon | Measuring changes in social behavior during a social skills intervention for higher-functioning children and adolescents with autism spectrum disorder[END_REF] as well as inconsistency regarding a universal definition of social skills and adapted scales and differences in therapeutic implementations for the intensity and duration of treatment [START_REF] Rao | Social skills interventions for children with Asperger's syndrome or high-functioning autism: A review and recommendations[END_REF]. However, a recent meta-view showed that the efficacy of the social skills group (SSG) was supported by suggestive evidence for improving social communication deficits and overall ASD symptoms in school-aged children and adolescents [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF].

Furthermore, the field of socially assistive robotics (SARs) has significantly increased in therapeutic interventions for autistic children (Grossard et al., 2918). The primary function of SARs in autism therapy is to facilitate the development and generalization of social skills (Scassellati, Admoni & Matarić, 2012). According to [START_REF] Tisseron | Robots, de nouveaux partenaires de soins psychiques[END_REF], a social robot is capable of impacting the affective state of its human interlocutor and thus potentially modifying his or her behavior. A considerable amount of research has shown that SARs can have positive therapeutic outcomes in autistic children by promoting social skills development [START_REF] Saleh | Robot applications for autism: a comprehensive review[END_REF][START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF][START_REF] Sartorato | Improving therapeutic outcomes in autism spectrum disorders: Enhancing social communication and sensory processing through the use of interactive robots[END_REF] and attention while decreasing stereotypic behaviors [START_REF] Tisseron | Robots, de nouveaux partenaires de soins psychiques[END_REF].

Despite the recent growth in research on SARs for ASD interventions, their use in the context of groups of autistic patients is still underdeveloped. Based on this observation, it seemed interesting to expand on the field by exploring the feasibility of using a robotic interface in a

ADI-R com=15 ADIR soc=24 ADI-R rep=7 ADI-R com=11 ADIR soc=28 ADI-R rep=7 ADOS-2=14 ADI-R com=4 ADIR soc=16 ADI-R rep=5 ADI-R com=7 ADIR soc=11 ADI-R rep=5 ADI-R com=13 ADIR soc=17 ADI-R rep=6

Materials

The socially assistive robot QT

The SAR used during this study was QT, a humanoid robot developed by LuxAI that helps autistic children practice social and engagement skills [START_REF] Bettencourt | Migration is associated with baseline severity and progress over time in autism spectrum disorder: Evidence from a French prospective longitudinal study[END_REF]. Two studies have highlighted the effectiveness of using this robot to decrease stereotypic behaviors and improve social skills in autistic patients [START_REF] Puglisi | Social Humanoid Robots for Children with Autism Spectrum Disorders: A Review of Modalities, Indications, and Pitfalls[END_REF].

The R2C3 interface

The Wizard of Oz R2C3 interface [START_REF] Zou | A wizard of oz interface with qtrobot for facilitating the handwriting learning in children with dysgraphia and its usability evaluation[END_REF] was created as part of the iRecheck project, which combines a robot and a serious game-based approach to handwriting rehabilitation for children with dysgraphia [START_REF] Zou | THE IRECHECK PROJECT-Asocial ROBOT HELPING[END_REF]. The interface contains 120 different behaviors classified into 33 menus according to their use. In the interface layout, there is a login page as well as a control page. The login page collects the name of one participant, which can be included in some pre-programmed behaviors, facilitating the personalization of the robot-child interaction. The control page includes the 33 menus in two tabs: the scenario and game tab and the reaction tab (see supplementary material). To investigate the feasibility of the R2C3 interface features on the engagement and social behaviors of children during the SSG, QT is present in each session but is used in two different ways. During half of the sessions, the R2C3 interface is inactive and does not display verbal and nonverbal social behaviors other than eye blinking.

During the other half of the sessions, the interface is actively used. We used the Wizard of Oz paradigm, a human remote control of the robot, a popular design paradigm in human-robot interaction research [START_REF] Steinfeld | The oz of wizard: simulating the human for interaction research[END_REF], which allowed the therapist to display specific wanted verbal behaviors. The order in which the active or inactive conditions were implemented was randomized. Among the set of behaviors proposed by the interface, we used only the categories adapted to the context of the group (Table 2).

Positive reinforcement

The robot congratulates the participant.

"Bravo", "Well done", "So nice", "Congratulations"

Encouragement when facing difficulties

The robot comments on the participant's productions and encourages the participant to try again.

"Do your best", "Breathe", "I see you're trying", "Try again, you can do it"

Emotion recognition

The robot draws the participant's attention to his or her emotions.

"You look happy", "You feel bad?", "You look angry", "You look tired"

Interactions based on QT's opinion

The robot expresses a personal opinion and questions the participant.

"Hello, my name is QT, what is your name?", "Hello", "Goodbye", "Yes", "No", "Can you repeat", "I don't know, how about you?", "Why?", "It's hard, can you explain?"

Procedure

Experimental setup

The study took place in the research laboratory located at the child psychiatry department of the hospital. All sessions were filmed with three cameras from three different points of view (front, right, left) to obtain a good angle for each participant. Parental consent for video recordings was collected before the study. The experimentation room was set up in the same way for both groups (see images in the supplementary material). It included a children's table in the centre of the room, a chair for each participant and two chairs for the experimenters in charge of leading the group. The third experimenter was located in the back of the room and was in charge of controlling the robot with a tablet through the Wizard of Oz paradigm.

A whiteboard was used to present the visual schedule and take attendance (name labels and photographs of the children and experimenters and two photos of QT, one awake and one asleep, to illustrate the two robotic conditions). The robot was placed facing the participants next to the board.

Structure of the sessions

The sessions took place once a week in the early afternoon and lasted 30 minutes. We performed an introductory session before beginning the study so that the children could become acquainted with the experimenters and the robot and familiarize themselves with the room. This welcome session also aimed to gauge the level of each group in terms of comprehension, expression, behavior and social skills. Sessions were then spread out over 10 weeks.

During the sessions where QT was active, he was primarily a positive reinforcer for the children; he praised and encouraged them. He could also interact with them by greeting them at the beginning of the session and saying goodbye as well as questioning them ("What about you?", "Why?") and answering closed-ended questions ("Yes", "No", "I do not know"). During the sessions when QT was inactive, the experimenters explained to the children that the robot was tired and would only watch the session. To make it easier for the children to accept this idea, the experimenters had QT say, "I'm sorry, I'm tired" at the beginning of the session.

The sessions followed Ozonoff and Konstantareas' recommendations for social skills groups [START_REF] Baghdadli | Entrainement Aux Habiletés Sociales Appliqué a L'autisme[END_REF]. First, the groups were organized around a structured and predictable framework, and the sessions always took place in the same way (Table 3). A timetable in the form of pictograms was presented to the children at the beginning of each session and remained posted so that the experimenters could refer to it throughout the session.

Moreover, the proposed activities were adapted to the age and verbal level of the children. Thus, the difficulty levels of the games were not the same in the two groups. Similarly, the use of visual aids (pictograms, drawings, photographs) was systematic to support the children's understanding. Finally, the objectives for each session were progressive. All activities proposed during the 10 sessions are detailed in the supplementary material.

Outcome measures

Clinical measures

Social and communicative skills, as well as adapted and maladaptive behaviors, were measured directly after each session using the Autism Diagnostic Observation Scale (ADOS-2) module 1 [START_REF] Lord | Autism diagnostic observation schedule-2nd edition (ADOS-2)[END_REF]. The ADOS scores are organized into five domains: "A. Language and Communication", "B. Reciprocal Social Interaction", "C. Play", "D. Stereotypical Behaviors and Restricted Interests" and "E. Other Abnormal Behaviors". For this study, the domain "C.

Play" was not included because the games included in the ADOS were not used in the groups.

There is currently no scale available to measure the rate of children's engagement in a group setting. Studies on engagement have thus far focused on engagement in a dual situation (a child towards a robot), notably via metric measures (e.g., movement tracking) [START_REF] Anzalone | Evaluating the engagement with social robots[END_REF]. The rate of engagement was therefore measured by the number of times the child initiated a social interaction and the number of times the child responded to a social interaction. These social initiations and responses to social interaction requests could be verbal or nonverbal (phrases, single words, gestures, joint attention, etc.) and could be directed to QT, the adult, or another child. These data were counted for the same preference activity (described later) performed in each session. To limit bias, this activity was always presented in the same way and lasted the same amount of time (10 minutes). This rating was obtained based on the sessions' video recordings. At the end of each session, each experimenter was randomly assigned to rate the engagement scores of one of the participants. Qualitative ratings were also included at the end of each session in the form of clinical observation summaries.

Design assessment of the robotic interface using the Design ICT Inventory (DICTI)

The design of the R2C3 interface combined with the SAR QT was evaluated by the three experimenters using the Design ICT Inventory (DICTI) [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. DICTI provides an easy tool to assess the design of ICTs, including robots, serious games (SG) and apps, augmentative alternative communication devices (AAC) and video modelling (VM). The endorsement of the trans-technology inventory was carried out through a Delphi study [27] involving a panel of 12 experts in ICT. Consensus and agreement were achieved after two rounds of feedback for each of the 13 items of the inventory: customization; feedback; rewards; contextualized learning; enhanced motivation; managing difficulty; increasing accessibility; clarity of instruction and content; attention capacity; clear goals; minimalistic graphics and audio; human interaction; and trustworthiness. Each item was rated using a Likert scale: 0 (absence), 1 (partially considered) and 2 (fully considered) [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF].

Statistical methods

The statistical analyses were conducted using R 4.2.2 software using bilateral tests with a 5% level of significance. First, we described the sample of participants. The distribution of the quantitative variables was summarized using the mean and standard deviation. The distribution of the qualitative variables was reported as a number and percentage of occurrence for each level. Next, we sought to assess whether the activation of R2C3 had an average effect on the QT SAR and engagement scores. A Poisson mixed effects regression model was run for each score (package "lme4"). The model formula was "Score ~ QT + (1|Subject)". The subject was specified as ordered at random origin, and the absence of overdispersion was checked by the "performance" package. The independence between the session number and the presence of QT was controlled by the experimental design. Finally, the average evolution of scores across sessions was modelled using the same method. The formula of the models was as follows:

"Score ~ Session number + (1|Subject)".

Results

The social skills group

The presence of the QT robot did not prevent or disrupt the social skills group according to plan. All predicted sessions could be performed with the corresponding duration. The clinicians conducted all the sessions on their own without an expert technician present, and no technical malfunctions were experienced during the entire study period. The control of QT's behaviors by the Wizard of Oz R2C3 interface was fluent enough to allow adequate group dynamics. The presence of QT did not affect the impact of SSG on participants, who showed a significant improvement in social skills after the ten group sessions on ADOS-2 scores for modules A (Language and Communication) and B (Reciprocal Social Interactions) of the ADOS-2 scale (Figure 1a). Scores on modules A and B both decreased significantly by a factor of 0.959 (p = 0.028 *) and 0.936 (p < 0.001 *), respectively, with each new session. The SSG also increased children's engagement in the group. The number of responses to social interaction requests increased significantly (p <.001*) by a factor of 1.061 with each new session. In

Impact of QT and R2C3 during the sessions

The presence of the QT robot had a positive impact on children's engagement in the SSG.

We modeled children's number of social engagement initiations and responses to social interaction requests during the same activity and time frame of the sessions according to whether R2C3 was active (Table 5). The number of responses to social interaction requests was not significantly different (p = 0.62), but the number of engagement initiations was significantly different by a factor of 1.31 (p = 0.03) when the R2C3 interface was active. We also noted that the number of social initiations when the robot was active varied strongly from one child to another (Figure 2). For instance, for child n°4, the difference was more important when QT was active (delta = 6.75), whereas for child n°3, the social initiations were more important when QT was inactive (delta = -2). For the other four participants, the number of social initiations was higher when QT was active, but the difference was smaller than that for child n°4.

The activation of R2C3 with the QT social robot also did not improve children's social skills during each session group as measured by ADOS-2 scores on modules A (Language and Communication) and B (Reciprocal Social Interactions) for each session. Similarly, the activation of R2C3 did not improve children's negative behaviors as measured by ADOS-2 scores on modules D (Stereotypic Behaviors and Restricted Interests) and E (Other Abnormal Behaviors) (Table 5). which facilitated their social interactions and communication skills (Scassellati, Admoni & Matarić, 2012). Additionally, the robot's attractive humanoid allure provided a nonthreatening and consistent presence that led to increased motivation and participation in the SSG sessions (Robins, Dautenhahn, & Dubowski, 2009). We primarily used the positive reinforcement behaviors of R2C3. By doing so, we were able to position QT as a positive reinforcer that complemented the role of the therapists during the sessions [START_REF] Kim | Social robots as embedded reinforcers of social behavior in children with autism[END_REF].

From a usability standpoint, the interface was very simple to use even for nontechnological people. The clinicians conducted all the sessions on their own after prior training on how to use the Wizard of Oz R2C3 platform, which consisted of learning how to connect the interface to the robot through shared Wi-Fi, exploring the platform and the different menus and finally experimenting with launching the robotic behaviors during made-up scenarios.

This confirmed the usefulness of the Wizard of Oz paradigm for human machine interaction [START_REF] Tozadore | Wizard of Oz vs autonomous: Children's perception changes according to robot's operation condition[END_REF][START_REF] Rietz | WoZ4U: an opensource wizard-of-oz interface for easy, efficient and robust HRI experiments[END_REF].

R2C3 exploratory hypothesis on children's engagement

The second main experimental objective was to explore whether the active condition of the QT robot using R2C3 had an impact on children's engagement during SSG. Social interaction initiations were significantly higher when QT was active, meaning that using the robot with the R2C3 interface promoted social opening in autistic children. This result can be explained in part by the novelty effect and strong interest that QT aroused in the children during the first sessions [START_REF] Leite | As time goes by: Long-term evaluation of social presence in robotic companions[END_REF][START_REF] Sung | Robots in the wild: understanding long-term use[END_REF]. At the beginning of the study, the patients were very receptive to QT's positive reinforcement and reacted positively to each new intervention (looks, smiles, laughter). It is likely that this enthusiasm for QT motivated the children to invest in the group from the beginning and to continue to enjoy the sessions throughout the study. At the beginning of each session, they wanted QT to be "awake" (in response to the question, "How is QT today?", the children answered "Good!"; during the session, some children asked him, "QT, you are awake?") and could express their disappointment if the robot was inactive. In addition, according to the hospital caregivers, the children talked about QT outside the group by specifying his state during the session, either tired or awake. This attraction to QT persisted even after the children understood that it was controlled by the adult via a tablet ("You told QT to say that"). Until the end of the experiment, the patients enthusiastically mentioned QT before going to the group. However, in view of the heterogeneous results obtained, it seems difficult to generalize to all children an improvement of social Regarding children's engagement in the group, there was no significant increase in the number of responses when QT was active. Despite a strong interest in QT at the beginning of the experiment, as the sessions progressed, the patients were increasingly less sensitive to the robot's positive reinforcements. The experimenters often had to point out when QT had intervened ("Did you hear QT? He said he is proud of you!"). In addition, adult interventions seemed to have a greater impact on the children's behavior than the robot's behavior did. For example, when a child lost interest in the group, it was the adult's prompting that allowed the child to re-engage in the activity. Although some children sometimes called out to QT, the participants primarily solicited the adults and sought their attention. It is also important to note that the scoring of engagement (the number of responses to social interaction requests and the number of interaction initiations) was conducted during a single activity rather than the entire session, and this activity was particularly conducive to placing QT in the interlocutor position.

Based on the literature on social robots [START_REF] Tisseron | Robots, de nouveaux partenaires de soins psychiques[END_REF], we also hypothesized that the presence of QT would allow for a decrease in negative behaviors and an increase in positive behaviors of the children within the group. We found a positive effect on maladaptive behaviors during SSG, but it was not specific to sessions when QT was active as there were no significant differences in children's behaviors as a function of QT's status. The improvement in the children's behaviors seemed to be related to the establishment of a therapeutic framework within the group and to the progressive adaptation of the activities to the patients' cognitive and language level (Reichow, Steiner & Wolkmar, 2012).

R2C3 interface design improvement

Beyond these observations, we believe that the score of initiations significantly increased in contrast to the responses because of the limited capacities of the interface used, which seemed to favour the children's initiations. Indeed, QT was able to answer the children's questions but had difficulty engaging them in interactions (very few questions were available, and there was no possibility to rebound on a child's initiation). During the last activity, the participants showed real pleasure in questioning QT and learning more about him; they asked him questions spontaneously, were happy when he shared his tastes and expressed pleasure in giving him the pictogram corresponding to what they liked ("Do you like the fox, QT?", "Do you want some chocolate?"). However, the interactions were often limited to one response from QT without the possibility of rebounding on the response. The participants tended to respond more to the adults' prompts than to the robot's. Other aspects of the R2C3 interface could be improved when implementing it in an SSG. These limitations explain its moderate scoring of the DICTI [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. Due to the group scenario, the interface did not allow the robot to initiate interactions with more than one participant at a time. Nevertheless, the therapists were able to rebound on single child-robot interactions and generalize them to the rest of the group. They did so by involving the other participants in the child-robot interaction and creating a group dynamic between all participants based on the robot's interaction. Similarly, R2C3 lacked the ability to adapt the robot's behaviors to the specific needs of each patient by proposing, for example, different levels of complexity in the robot's responses. Globally, exchanges with QT were very limited by the lack of customization of its interventions. QT's comments were predefined, and therapists could neither modify nor add to them. For example, when a participant asked QT a question, the adult had to almost systematically rephrase it as QT could answer only closedended questions.

The R2C3 robot's intonation/prosody also lacked modulation and expressiveness, accentuating the artificial impression of its answers [START_REF] Park | Telling stories to robots: The effect of backchanneling on a child's storytelling[END_REF]. Similarly, the range of emotions offered by the interface was quite limited. R2C3 did not have the option to share his emotional state but only to comment on others' emotional states ("You look sad", "You look angry"). Furthermore, he could not express his agreement or disagreement to create reciprocal social interactions (e.g., "Me too", "Me neither").

Finally, the time lag between the Wizard of Oz control and the behavior execution made the reactions less spontaneous or even unsuitable for some activities. The computation of adaptive algorithms should improve QT's turn taking [START_REF] Skantze | Turn-taking in conversational systems and human-robot interaction: a review[END_REF]. Moreover, unlike other social robots such as SAR NAO [START_REF] Wigelsworth | A review of key issues in the measurement of children's social and emotional skills[END_REF], QT was limited in its movements (it could only move its arms), which restricted its use for certain physical activities.

Limitations

This study presents obvious limitations due to its exploratory design. A control group was not included, and the number of participants and duration of the study were limited. In addition, there is currently no scale that can effectively measure social skills in their entirety [START_REF] Wigelsworth | A review of key issues in the measurement of children's social and emotional skills[END_REF]. The ADOS-2 module was used to assess specific ASD domains, such as social skills, communication and maladaptive behaviors, based on the sessions' video recordings, but it may not be sensitive enough to detect changes in skills over time. Additionally, our study did not include a follow-up, and our evaluations focused on the children's behaviors within the group and not on the transfer of their skills to everyday life. The R2C3 interface displayed several limitations, primarily related to its design, which was not specifically intended for use in an SSG for autistic children. Because it was originally developed for the iReCheck project to rehabilitate writing skills in children with dysgraphia [START_REF] Zou | THE IRECHECK PROJECT-Asocial ROBOT HELPING[END_REF], certain features should be redesigned to be better suited for an SSG. The lack of customization/personalization of R2C3 appeared to be one of the main barriers in child-robot interactions during SSG.

Personalizing the interface could enhance the user experience, increase the efficiency of the interaction, and ultimately facilitate the naturalness of the social exchange [START_REF] Anzalone | Towards partners profiling in human robot interaction contexts[END_REF]. We believe the interface could be improved to fit the needs for an SSG based on the overall promising results of the current study.

Conclusion

We investigated the feasibility and usability of the R2C3 robotic interface and the impact of the SAR QT in an SSG for autistic children. Our observations revealed that it is feasible to include the R2C3 Wizard of Oz interface in combination with the SAR QT in an SSG. The robot's social reinforcement complemented the clinicians' effectiveness during the sessions.

From a usability standpoint, the interface is suited for non-technological participants.

Quantitatively, our results suggest that the use of QT in active mode leads to a significant increase in social interaction initiations but does not show a significant improvement in responses to social interaction requests and ADOS scores. Both the active and inactive conditions demonstrated a significant improvement in the participants' social skills after the ten group sessions. This study presents possibilities for future research on the benefit of SARs in SSG for autistic children pending some improvements of the R2C3 interface. Future research should take into account the possibility of personalizing the interface, the latency between behaviors, and additional specific social behaviors.

Introduction

Autism Spectrum Disorder (ASD) presents deficits in social skills and communication prerequisites such as imitation and joint attention (APA, 2013). These acquisitions are necessary for the development of more complex social skills and can have a significant impact on the academic and socio-professional integration of autistic individuals [START_REF] Tomasello | Understanding and sharing intentions: The origins of cultural cognition[END_REF]. Enabling autistic children to develop their social skills from an early age is therefore a major challenge for their developmental trajectory. Several reviews recommend specific work to develop the field of social interactions [START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF]. Social skills training aims to improve communication, the expression of feelings and interactions, by transmitting interpersonal skills to patients and promoting their generalization and maintenance [START_REF] Baghdadli | Entrainement Aux Habiletés Sociales Appliqué a L'autisme[END_REF].

In recent years, there has been a significant rise in the development and utilization of Information and Communication Technologies (ICTs), notably serious games (SG) in the care of ASD (Grossard et al., 2017;[START_REF] Kokol | Serious game-based intervention for children with developmental disabilities[END_REF]Tsikinas & Xinogalos, 2019). SGs are described as a combination of education and entertainment [START_REF] Grossard | ICT and autism care: state of the art[END_REF], utilizing gaming elements like storylines, long-term goals, and rewards, while offering enjoyable educational experiences (Whyte, Smyth & Scherf, 2014). These games are accessible through various platforms, including tablets, smartphones, and computers, making them widely available. The potential of SGs lies in their versatility, providing training opportunities across a wide range of skills in different settings (Grossard et al., 2017). Most SGs for ASD care focus on social skills development, such as interaction, collaboration, and adaptation to specific contexts; most specifically they target facial emotion recognition or production (Grossard et al., 2017). Studies have found that SG are effective for the development of social skills and in providing supports that create immersive social situations, in comparison to therapy as usual [START_REF] Grossard | ICT and autism care: state of the art[END_REF].

In a review, Grossard et al. (2017) referred to 31 serious games that aim to teach social interactions. However, SGs face some limitations in their research and application. First, the current available SGs are mostly developed for high-functioning autistic individuals (Grossard et al., 2017). Some literature also points it out to be the case in random controlled trials with the exclusion of severe autistic children (comorbid intellectual disability (ID) or challenging behaviors), which are not representative of the clinical population in clinical practice [START_REF] Salomone | Use of early intervention for young children with autism spectrum disorder across Europe[END_REF][START_REF] Hyman | Identification, evaluation, and management of children with autism spectrum disorder[END_REF]. Secondly, SGs clinical validation does not often meet the evidence-based medicine standards (Grossard et al., 2017), limiting the generalizability and lasting effects of the results. For the exception of some controlled studies [START_REF] Klingberg | Training of working memory in children with ADHD[END_REF]Temple et al., 2013;Francheschini et al., 2013) or random control trials including large sample sizes [START_REF] Klingberg | Computerized training of working memory in children with ADHDa randomized, controlled trial[END_REF][START_REF] Golan | Systemizing empathy: Teaching adults with Asperger syndrome or high-functioning autism to recognize complex emotions using interactive multimedia[END_REF]de Vries et al., 2014). Additionally, there is a lack of game design description and rationale behind its development. Finally, the clinical validation and playability/game design are not compatible (Grossard et al., 2017).

The design of serious games (SGs) is of significant importance when applied to autism care. The unique characteristics of autistic individuals necessitate a design that fit the needs and heterogeneous profiles of autistic individuals (Allen et al., 2016). A recent meta-review evaluating the evolution of ICTs design and research methodology implications over the last decades, revealed that SGs design strengths include games related to social context, multiple feedbacks, multiplayer options and possibility to personalize the digital platform (Grossard et al., submitted). Furthermore, autistic individuals often have diverse sensory preferences and sensitivities [START_REF] Quill | Instructional considerations for young children with autism: The rationale for visually cued instruction[END_REF]. Therefore, game developers must consider factors such as visual and auditory stimuli and overall sensory experience to ensure that the game is comfortable and engaging for autistic users. Finally, affordability must also be taken into consideration, since apps can sometimes be expensive. Of note, only EndeavorRx TM , an Akili's video game therapy for ADHD [START_REF] Canady | FDA approves first video game Rx treatment for children with ADHD[END_REF][START_REF] Kollins | A novel digital intervention for actively reducing severity of paediatric ADHD (STARS-ADHD): a randomised controlled trial[END_REF] has been approved for therapeutic use by the U.S. Food and Drug Administration (FDA) (Allen et al., 2016), making it the first SG to be Checklist internalizing, externalizing, and total problems [START_REF] Jouen | GOLIAH (Gaming Open Library for Intervention in Autism at Home): a 6-month single blind matched controlled exploratory study[END_REF]. An encouraging study to investigate more GOLIAH was given by [START_REF] Billeci | An integrated EEG and eye-tracking approach for the study of responding and initiating joint attention in Autism Spectrum Disorders[END_REF] as they found a correlation between the improvement in performing joint attention tasks after training with GOLIAH and a "normalization" of brain activity and connectivity profiles recorded in quantified EEG.

Furthermore, this article aims to evaluate and provide feedback on the design quality of the SG e-GOLIAH through the Design ICT Inventory (DICTI, [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF].

e-GOLIAH platform description

As [START_REF] Dawson | Randomized, controlled trial of an intervention for toddlers with autism: The Early Start Denver Model[END_REF]. It is designed for early, intensive and home-use and allows regular therapeutic assessment [START_REF] Bono | GOLIAH#: A Gaming Platform for Home-Based Intervention in Autism -Principles and Design[END_REF]. The SG aims at improving the social skills and communication of autistic children through games involving joint attention and imitation. These two skills are the keys to early social interaction and communication [START_REF] Jouen | GOLIAH (Gaming Open Library for Intervention in Autism at Home): a 6-month single blind matched controlled exploratory study[END_REF][START_REF] Tomasello | Understanding and sharing intentions: The origins of cultural cognition[END_REF]. The serious game offer a simple, playful and colorful graphic design, adapted to autistic children. This favors the accompaniment of the child outside the clinical environment, while maintaining the link with health professionals. Indeed, the therapist, via the platform, identifies the child's difficulties and follows their evolution and compliance with the sessions. It is an innovative method of intervention in the natural environment, centered on the child, practiced at home and involving the parents.

In addition to the classic role of guidance, some e-GOLIAH games are designed to practice joint actions directly with the helper in a fun and interactive way. Indeed, unlike most SGs where the child plays alone or isolated, e-GOLIAH promotes interaction and cooperation by coupling two connected tablets (the child's and the caregiver's). Thus, the games offered by e-GOLIAH constrain the interaction between partners since it is limited to two players. This forced collaboration encourages the child to perceive the adult as a communication partner (Cohen et al., 2017).

Descriptions of the games

e-GOLIAH is composed of ten mini games: six games practicing imitation skills (Figure 1)

and four games practicing joint attention skills (Figure 2) where the child and the parent can play together with the use of two connected tablets. Please refer to [START_REF] Bono | GOLIAH#: A Gaming Platform for Home-Based Intervention in Autism -Principles and Design[END_REF] for the games' description. Objectives of the study

Primary objective

• Evaluate the cost-utility at 12 months of the management of children diagnosed with ASD

using the e-GOLIAH game in the home, compared with usual care.

• Measurement of the incremental cost-utility ratio (ICER) at 12 months for the management of patients with ASD using the therapeutic game e-GOLIAH at home plus usual care, compared to the measure of the 12-month incremental cost-utility ratio (ICER) of managing patients with ASD using the e-GOLIAH therapeutic game in the home, compared to usual care alone, will be derived from the EQ-5D-5L/EQ-5D-Y scale.

Secondary objectives

1-Medicoeconomic

-Evaluate the cost-effectiveness of managing patients with ASD using e-GOLIAH vs. to the usual management at 12 months of follow-upExplore the annual ASD-related out-of-pocket expenses of the cost of illness of the two groups studied.

-Evaluate the consequences of generalizing the management of children diagnosed with ASD using with e-GOLIAH, compared to usual care, from the point of view of the Health Insurance over a period of over a period of 3 years.

2-Clinical

-Evaluate at 6 months and 12 months the impact of the management of children diagnosed with ASD using the e-GOLIAH game used at home, compared to a usual care, on:

-Child and parent quality of life (EQ-5D-5L/EQ-5D-Y by proxy)

-

Methods & Design

Participants

This study will include 150 young children with ASD aged 4 to 6 years old and at least one caregiver who will be recruited across 12 centers in France.

The eligibility criteria will include:

(a) Autistic children more or less mild cognitive deficit by the Autism Diagnostic Interview (ADI-R) [START_REF] Rutter | ADI-R. Autism diagnostic interview revised[END_REF] or the Autism Diagnostic Observational Scale (ADOS-2) [START_REF] Lord | Autism diagnostic observation schedule-2nd edition (ADOS-2)[END_REF], (d) Taking medication that may cause visual or cognitive impairment (APS, neuroleptics, etc.) or may interfere with study assessments;

(e) Degenerative diseases or any other disease that could interfere with the evaluations planned during this study (known epilepsy and/or history of seizures, etc.);

(f) Photosensitive people in order to avoid situations likely to induce epileptic seizures in them.

Sites recruitment

Recruitment will be national via the network of Autism Resource Centers involved in the study. Table 1. describes the planned recruitment in each center. Following the signature of the consent form by the two parental authority holders or by the only parental authority holder present, the inclusion visit will consist of explaining and training the parents in the use of e-GOLIAH, in the connection to the CURAPY.COM platform after having created their account and that of their child. The inclusion visit will also collect the variables at T=0, namely:

• EQ-5D-5L and EQ-5D-Y proxy scales (children)

• EQ-5D-5L scale (parents)

• Vineland-II scale (if not done at the screening visit)

• CARS scale

• SRS scale

• Parenting Stress Index scale

Description of the planned statistical methods including the timing of planned interim analyses

A patient-tracking chart will highlight the number of eligible patients and the number of patients actually included in total and in each of the two arms. For each group and at each evaluation date, the qualitative variables will be described by their number, percentage and missing data per response modality and the quantitative variables by their number, mean, standard deviation. Quantitative variables with asymmetric behavior will be presented with their median and interquartile range (25th percentile -75th percentile).

In accordance with the recommendations, the calculation of the Number of Subjects Needed (NSN)necessary subjects (NSN) was carried out based on assumptions on the primary endpoint. We used the formula proposed by Glick, where the numbers and standard deviations of costs and results are equal in the 2 groups (Glick, 2011).

Thus, with a power of 80%, we formulate the following hypotheses:

• Maximum acceptability threshold: €60,000 (Court of AuditorsCour des comptes 2017, HAS 2014)

• Cost difference: 1000€ AND ±1000€

• Utility gap (QALY gain): 0.04 AND SD ±0.03 (Van Steensel, 2014) • Correlation coefficient between cost and utility: -1.

That is 63 subjects per group:

We will take into account 20% of those lost sight ofdropouts by considering the difficulties that parents (or children) may encounter playing with e-GOLIAH for the duration of the intervention. That is 75 patients per arm.

In total, the Number of Subjects Needed (NSN) is 150; the number of participating centers is 12

and each center will include at least 13 patients. Patients will be randomized individually with stratification by center. For the sake of safety, we are opening 12 centers to maximize the chances of recruitment.

Medico-economic analysis

The medico-economic analysis will be conducted according to international recommendations [START_REF] Husereau | Consolidated health economic evaluation reporting standards (CHEERS) statement[END_REF]) and the French National Authority for Health (HAS 2011).

The cost-utility and cost-effectiveness analyses will be performed at 12 months.

Cost-utility analysis:

Considering that quality of life is related to the health status of these ASD patients (Kuhlthau 2010 García-Villamisa, 2010), a cost-utility analysis is preferred (HAS 2011).

a) Type of analysis:

The analysis will consist of a comparison of the two patient management strategies:

-Strategy 1 = control group: "Usual treatment" and -Strategy 2 = intervention group: "Usual treatment + the e-GOLIAH game".

The perspective will be collective (households, health care providers, health system and community) with a time horizon of 12 months from inclusion (without discounting of costs and consequences).

(b) Outcome criterion:

The outcome criterion will be lifetime weighted by preference scores (QALY). The preference scores will be derived from the EQ-5D-5L validated in France.

c) Analysis population:

The population directly concerned is the set of children affected by ASD, followed in one of the centers participating in the clinical investigation and who will meet the selection criteria cited in the paragraph "Description of the population".

d) Costing method:

Direct medical and non-medical costs related to the management of patients or their complications, to the implementation and operation of the innovation, by type of consumption and by patient in each group will be considered. Production and productivity losses will be documented even if the patients are not of working age. Nevertheless, we believe that it would be useful to systematically collect them in the framework of this PRME, as such a study has never been done in France. We will include them in a complementary analysis. The intangible costs will not be measured as such since they will be captured indirectly by the utility measure based on QALYs.

Discussion

This new e-GOLIAH clinical trial will be randomized and controlled. The experimental group will have access to e-GOLIAH at home in addition to their usual care. At the first meeting with the parents of both groups, we will administer an initial questionnaire to establish a profile of the family dynamics around playing. We will also evaluate the child's social and language skills using the Child Development Inventory (CDI). This information will allow us to report on the evolution of the children throughout the study. It will also be compared between the two groups in order to evaluate the impact of the use of e-GOLIAH in regards to imitation and joint attention skills, as well as the impact on the parents' stress levels.

Based on a previous pilot study of the GOLIAH serious game [START_REF] Jouen | GOLIAH (Gaming Open Library for Intervention in Autism at Home): a 6-month single blind matched controlled exploratory study[END_REF], results

appear to be mixed and require careful interpretations. First, 40% of the planned sessions were completed, indicating that participants were able to engage with the platform. This also indicates that the serious game usable and acceptable to autistic children and parents. Secondly, participants who trained with GOLIAH showed improvements in their ability to perform tasks related to the targeted skills, joint attention and imitation in most of the associated games. The results suggest that the platform has the potential to effectively enhance these precursors of social skills, which are important to develop more complex social skills. However, Both the group using GOLIAH and the control group showed significant improvements in various aspects, including Autism Diagnostic Observation Schedule scores, Vineland socialization score, Parental Stress Index total score, and Child Behavior Checklist scores. This suggests that both groups benefited from some form of intervention, but it's unclear if GOLIAH was more effective in this regard. Perhaps the most significant finding is that there was no significant difference between the GOLIAH group and the control group in terms of addressing core symptoms of autism. This suggests that while GOLIAH may improve specific skills, it may not be more The SG e-GOLIAH's design quality was assessed using the DICTI [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF], resulting in a total score of 15 out of 26 (refer to Table 4), indicating a moderate rating.

Noteworthy features include its user-friendliness even for non-technical users, and the ability to adjust difficulty levels from 1 to 3, allowing parents to gradually tailor the game complexity to their child. Moreover, clear visual instructions guide parents through each game, and specific sound feedback indicates correct or incorrect answers. After each successful game, an animated avatar provides non-verbal positive feedback, potentially enhancing the child's motivation and engagement during gaming sessions. Conversely, in line with the literature examining SG, the platform lacks personalization options [START_REF] Charlop-Christy | A comparison of video modeling with in vivo modeling for teaching children with autism[END_REF], verbal positive feedback [START_REF] Spriggs | Talking picture schedules: Embedding video models into visual activity schedules to increase independence for students with ASD[END_REF], and task reminders, which could also serve as external stimuli to maintain the child's engagement and promote learning.

Conclusion

This protocol presents the upcoming clinical evaluation of the serious game e-GOLIAH.

The randomized trial will also examine the viability of a home-based digital intervention, led by parents, with the objective of enhancing participants' social interactions and decreasing parental stress through the practice of imitation and joint attention skills. Furthermore, an assessment of cost-effectiveness will be conducted twelve months after the implementation of e-GOLIAH at home, in comparison to the standard treatment protocol. Finally, the design quality assessment of the SG shows promise, with a moderate score of 15 out of 26. This highlights its positive features, including user-friendliness, clear instructions, and adaptability in difficulty levels.

Additionally, it's worth noting that incorporating features such as personalization, verbal feedback, and task reminders, as suggested in the literature, could further enhance its potential promoting learning.

Chapter 7: General Discussion

The research project of this thesis was to take a multidisciplinary approach including clinical and engineering perspectives to the development and implementation of ICTs in the care of individuals with NDD, and most specifically autistic children. The exponential growth of digital tools providing innovative approaches to ASD care has been the subject of significant research over the last decades (Grynszpan et al., 2014;Hollis et al., 2017;Miguel Cruz et al., 2017;Khan et al., 2019;[START_REF] Grossard | ICT and autism care: state of the art[END_REF]. However, there is currently no standard framework to evaluate ICTs, and this increase has created an urgent need to investigate the design quality of the relevant technologies and their clinical impact on outcomes.

The development of the Design ICT Inventory [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF] aimed to fill in this gap by providing a framework to ICT developers and researchers to take into consideration specific features related to the heterogeneous profiles and needs of individuals with NDD. For the purpose of this first project, through a Delphi study, and with the support of twelve ICT experts, we were able to develop the first framework to assess ICTs' design. We then evaluated the evolution ICT design and study methodology of the existing literature of clinical trials implementing digital tools in the care of individuals with NDD. We conducted a meta-review of ICTs applied to individuals with NDD, where we applied the DICTI [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF] for ICT design, and the methodology Connolly scale [START_REF] Connolly | A systematic literature review of empirical evidence on computer games and serious games[END_REF] to several randomly assigned study groups regarding the most frequent ICT (SG, VM, robots and AAC). We also summarized the most cited studies and articles from journals with the best impact factor. Our results revealed that AAC, VM and robots' design quality did not improve overtime, whereas SG' quality score did. In parallel, we were interested in assessing the methodology design quality of these clinical trials with the use of the Connolly scale [START_REF] Connolly | A systematic literature review of empirical evidence on computer games and serious games[END_REF].

Our results pointed out that the overall research methodology quality improved over the years for VM, AAC and specially robots, but not for SG, who in contrast appear to have the best ICT design quality. We observed that most clinical trials have poor methodologies due to the nature of the study design. While Randomized Controlled Trials (RCTs) are considered the gold standard for research quality to assess the effectiveness of interventions, the field of ICTs includes alternative experimental designs prior to conducting an efficacy trial. Initial phases, including feasibility and usability trials, are essential to evaluate the implementation of ICTs NDD care. These studies do not require high quality study design and often take the form of case studies [START_REF] Liu | Feasibility of an autism-focused augmented reality smartglasses system for social communication and behavioral coaching[END_REF] or group series without control group (Bargagna et al., 2018). The improvement of research design could be explained with the time frame evolution of the different experimental phases of such research. However, despite of the methodology improvement over the years, we observed that most studies have a small number of participants (Parsons et al., 2019), a challenge that persists.

From the engineering design perspective, we found an agreement between the available literature and DICTI results. First, the number of design features has increased over the last decades leading to more sophisticated and more technologies adapted to the needs of individuals with NDD. There is also a consensus to the need for ICT personalization, allowing the users to engage effectively with the digital tools, i.e.: personalization of visual design (characters, backgrounds, sounds or colors), content, and messages, have proved to have an impact on users' engagement and satisfaction (Allen et al., 2016). However, most ICTs do not include personalization options, which could be due to the complexity of the algorithms permitting such adaptations. Additionally, positive feedback and rewards are now well established as they have been linked to promoting learning in children with NDD [START_REF] Horn | Teaching laundry skills to individuals with developmental disabilities using video prompting[END_REF][START_REF] Litras | Using video self-modelled social stories to teach social skills to a young child with autism[END_REF][START_REF] Spriggs | Talking picture schedules: Embedding video models into visual activity schedules to increase independence for students with ASD[END_REF]. However, these features mostly appear in SGs. This field has likely benefited from the enormous effort in research design coming from the gaming industry for children and adolescents developing typically. SG design improvement stands out, potentially due to its success in the economic market, which has led to more funding and easier experimentation. This virtuous circle in serious games contrasts with other ICTs that lack financial support and face more challenges in the experimentation and implementation of the digital devices. In the case of individuals with NDD, positive feedback is necessary to keep the user in track of their work while also maintaining their attention (Whyte et al., 2015).

Furthermore, contextualized learning, accessibility, clarity of instruction and goals have also been linked to a better usability of the digital tool (Grossard et al., 2017).

The overall perception of the ICT is often documented in ICT clinical trials (Allen et al., 2016), as they provide knowledge of the disorders but also the needs of the individuals and the institutions they work for (Guard et al., 2019). Most studies include a social validity section, which presents the perception of the ICT addressed by NDD users, caregivers or teachers.

Contemporary issues regarding privacy and security have highlighted the importance of ethics when developing and implementing ICT care devices with NDD people [START_REF] Schultz | Contemporary issues in ethics and information technology[END_REF]. Ensuring confidentiality and security of personal data collected during ICT interventions, while also obtaining users' consent, is of outmost importance. Additionally, as we have seen with the development of any new technology, affordability remains a challenge for individuals with low socioeconomic situations. Addressing these inequalities and providing affordable ICTs can prevent disparities in therapeutic and educations opportunities [START_REF] Schultz | Contemporary issues in ethics and information technology[END_REF]. Third, in alignment with the development of artificial intelligence language processing tools (i.e.: ChatGPT), addressing emergent issues of misinformation and misbehaviors are critical when developing autonomous algorithms, specially applied to social robots [START_REF] Kaloudi | Comparison of risk analysis approaches for analyzing emergent misbehavior in autonomous systems[END_REF].

Our second exploratory project involved the implementation of a social robot in a social skills group setting for autistic children (Bettencourt et al., 2023, submitted). A remarkable amount of research has shown that social robots can have positive therapeutic outcomes for autistic children by promoting the development of social skills [START_REF] Saleh | Robot applications for autism: a comprehensive review[END_REF][START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF][START_REF] Sartorato | Improving therapeutic outcomes in autism spectrum disorders: Enhancing social communication and sensory processing through the use of interactive robots[END_REF]. Indeed, autistic children face deficits in the development of social skills that prevent them from creating reciprocal and adapted relationships, and affect their overall wellbeing.

Despite the growth of social robots research in ASD individual care, the implementation of a robot within a group setting remains underdeveloped. We therefore became interested in investigating the feasibility and usability of the Wizard-of-Oz Rehabilitation Robotic Companion for Children and Caregivers (R2C3) interface developed by our colleagues, aiming to improve handwriting difficulties for children with dysgraphia [START_REF] Zou | THE IRECHECK PROJECT-Asocial ROBOT HELPING[END_REF]. Due to the already existing social behaviors included in the robotic interface, we selected specific behaviors, which we thought could complement the groups' activities and dynamics. Most particularly, we chose the positive reinforcement, encouragements, emotions' recognition and expression categories, and finally a conversational category to collect participants' feedback. We created the social skills group curriculum based on Ozonoff and Konstantareas' recommendations (Baghdadli et al., 2013), including structured and predictable sessions, visual supports, and activities facilitating emotion recognition, communication and problem solving scenarios. Each activity was centered on crucial social skills including imitation, joint attention and turn taking, which are necessary for the development of more complex social skills [START_REF] Tomasello | Understanding and sharing intentions: The origins of cultural cognition[END_REF].

Results revealed that the robot did not prevent the effectiveness of the social skills group. All children presented more social openings towards the other children and researchers in the group as the sessions progressed. Additionally, we found no differences between the active and inactive robotic interfaces. However, we observed that the use of the robot resulted in increased engagement and interaction initiations. Our results also revealed the impact of the novelty effect on children's engagement prior and during the intervention [START_REF] Leite | As time goes by: Long-term evaluation of social presence in robotic companions[END_REF][START_REF] Sung | Robots in the wild: understanding long-term use[END_REF]. Nonetheless, we observed several limitations in the interface, primarily related to its design. Consistently with the literature, the lack of personalization appeared to be the main barrier in the social interactions within the group.

Additionally, the robot was only able to answer open-ended questions, limiting the spontaneity and complexity of the social exchanges. Generally, it's believed that a robot's behavior significantly impacts a user's engagement, task performance, and collaboration in therapeutic and educational settings [START_REF] Oertel | Engagement in human-agent interaction: An overview[END_REF]. In a recent study using multimodal dataset in humanrobot interactions (HRI), results revealed that certain behavioral aspects related to task and/or social engagement have the ability to predict learning outcomes, and these aspects are occasionally separate from task performance (Nasir et al., 2022). This research has created new perspectives in robot's design regarding machine-learning engagement detection models.

Although the feasibility nature of the study did not allow us to draw conclusions on the efficacy of the social robot on the participants' social skills, usability and feasibility results, in addition to the effect on the participants' engagement, are promising. To maintain a constant interest in the robot and create more complex and fluid interactions, the design of the interface, notably the possibility to customize the interface is primordial [START_REF] Anzalone | Towards partners profiling in human robot interaction contexts[END_REF]. Generally, it's believed that a robot's behavior significantly impacts a user's engagement, task performance, and collaboration in therapeutic and educational settings [START_REF] Oertel | Engagement in human-agent interaction: An overview[END_REF]. In a recent study using multimodal dataset in human-robot interactions (HRI), results revealed that certain behavioral aspects related to task and/or social engagement have the ability to predict learning outcomes, and these aspects are occasionally separate from task performance (Nasir et al., 2022).

This research has created new perspectives in robot's design regarding machine-learning engagement detection models. Future work should take into consideration DICTI results and the observations of this study, but also include clinicians specialized in ASD to develop a robotic interface adapted to the needs of a social skills group dynamic. Finally, our upcoming work also includes the evaluation of e-GOLIAH SG, aiming to improve children's imitation and joint attention, and decrease parental stress while improving the parent-child relationship and

Conclusion

This thesis demonstrates the potential of ICTs in NDD care. Additionally, it emphasizes the complexity of design choices and research methodology implications when developing and evaluating therapeutic digital devices for neuro-atypical populations.

The absence of standard evaluation framework for ICTs motivated the creation of the Design ICT Inventory (DICTI), a tool that aids ICT developers in considering the heterogeneous profiles and needs of NDD individuals. Our meta-review assessing the evolution of ICT design and research methodology over the last decades revealed the lack of high quality studies, despite of the promising results often presented. However, ICTs are not detrimental to therapeutic rehabilitation and learning, but due to most studies design, it is not possible yet to make generalizable conclusions. ICT designs appear to have improved over time, including more features within the platforms. In contrast, research methods limitations persist due to the nature of the research designs and recruitment challenges. Personalization, positive feedback, contextualized learning and accessibility, emerged as the most important features in ICT development.

The experimental project focused on the implementation of a social robot in social skills group for autistic children, illustrating the potential for engagement and interaction initiation, while also highlighting the robotic platforms' design limitations. Consistently with the literature examining ICTs in ASD interventions, we point out to the importance of personalizing ICT devices for optimal engagement and social interactions with autistic children. Finally, we aim to continue exploring the impact of ICTs in ASD care with the evaluation of the serious game e-GOLIAH. This will be done through a high quality randomized controlled trial to maximize the accessibility of digital interventions that can be implemented through an online platform (curapy.com) at the homes of autistic children. -How QT feels today Musical imitation: an adult makes a drum rhythm, and each child imitates it in turn; then the children each try to propose a rhythm Symbolic puppet play: the adults offer the children a situation of conflict between two puppets, and the children suggest solutions Among the pictograms, the children take turns choosing a food to compose their pizza and ask QT questions about their preferences n°7 : QT inactive -Attendance: each child puts his or her photo and that of the adults present on the table next to the corresponding first name -QT says he's tired today (photo of QT sleeping on board) Musical imitation: an adult makes a drum rhythm, and each child imitates it in turn; then the children each try to propose a rhythm Symbolic play with puppets: the adults present to the children a situation of conflict between two puppets, and the children suggest solutions Among the pictograms, the children take turns choosing ingredients to make their pie; the children share their preferences with the group and question others n°8 : QT active -Attendance: each child puts his or her photo and that of the adults present on the table next to the corresponding first name -How QT feels today Musical imitation: an adult makes a drum rhythm, and each child imitates it; the

0:!No!feedback! 1:!Feedback!but!is!not! clearly!related!to!a!goal! 2:!Feedback!clearly!related! to!a!goal! J Specific!sound!when!the! answer!is!correct! J Progression!bar!/!timer! J Specific!sound!when!the! answer!is!correct! J Progression!bar!/!

  : neurodevelopmental disorders, autism spectrum disorder, information communication technologies, design, efficacy, social robots, serious games. ! Résumé La croissante focalisation de la recherche sur les Technologies de l'Information et de la Communication (TIC) dans les approches thérapeutiques et éducatives pour les enfants atteints de Troubles Neurodéveloppementaux (TND) soulève des questions cruciales quant à la conception de ces outils et à leur efficacité. Les TIC sont suggérées comme offrant de nouvelles opportunités pour améliorer les compétences sociales et de communication, le fonctionnement cognitif et la qualité de vie globale des enfants ayant des besoins particuliers. Le travail de cette thèse est structuré autour de deux parties intégrant des perspectives d'ingénierie et cliniques. La première partie de l'évaluation a examiné comment les TIC pour les soins des TND sont conçues en termes de design. Pour répondre à cet objectif, nous avons créé le premier inventaire transtechnologique avec le soutien d'une validation Delphi, visant à évaluer la conception des TIC thérapeutiques et éducatives pour les soins des TND. Nous avons également réalisé une méta-analyse systématique nous permettant de contextualiser l'évolution de la recherche sur les TIC en ce qui concerne les implications pour les choix de conception et de méthodologie de recherche. La perspective clinique a exploré deux interventions thérapeutiques des TIC pour la formation aux compétences sociales du Trouble du Spectre de l'Autisme (TSA). Pour répondre à cet objectif, nous avons mené une étude de faisabilité et d'utilisabilité d'une intervention robotique dans un groupe de compétences sociales. Enfin, nous avons finalisé le protocole d'un essai contrôlé randomisé d'une intervention de jeu sérieux délivrée à domicile, étudiant son efficacité et ses implications médico-économiques. En conclusion, cette thèse démontre que les TIC peuvent être des outils adaptés pour fournir des approches innovantes pour le traitement des personnes atteintes de TND. Cependant, elle souligne l'importance significative des choix de conception lors du développement d'outils thérapeutiques numériques. Elle le fait en fournissant le premier Inventaire des TIC, qui englobe une vision coordonnée entre les perspectives d'ingénierie ! et cliniques. Le DICTI vise à fournir un outil simple pour guider les développeurs de TIC à prendre en compte les objectifs cliniques liés aux caractéristiques de conception. De plus, elle vise à apporter une contribution précieuse au domaine des TIC en proposant deux outils technologiques thérapeutiques mis en oeuvre dans les soins du TSA. Le développement du DICTI est d'une pertinence importante dans l'évaluation de l'interface robotique, car il nous a permis de proposer une version plus adaptée pour une future étude de reproductibilité.

Figure 1 .

 1 Figure 1. Global burden of Autism-Spectrum Disorder by country or territory, 2019. (a) Age-standardized prevalence rates (per 100,000) by location, both sexes combined, 2019 (b) Age-standardized DALY rates (per 100,000) by location, both sexes combined, 2019. DALY disability/adjusted life-year (Solmi et al., 2022).

  (2020) developed and tested how the Caro robot could help 20 children with lowfunctioning ASD learning basic psychosocial skills through interacting with the robot. They found that the ASD students displayed more positive responsiveness and physical orientation towards the robot than the human teachers. KiliRo Semiautonomous 2 degrees of freedom in each leg Head can move down, up, right and left Tail can move right and left One speaker attached on the robot Learning and social interaction abilities Bharatharaj et al. (2018) observed how ten participants with ASD interacted with the KiliRo robot over the course of three sessions in comparison to interaction with other humans. Results indicate that participants were more interactive with the robot than with humans in the 12 types of social engagement examined. Kibo Programmable, add-on parts Teaches coding and sequencing Albo-Canals et al. (2018) conducted a research in which twelve participants were observed in a one-week period over a series of four sessions in which the robot worked towards helping them learn cause-and-effect. Of the twelve participants with severe ASD, only two completed 80% or more of the sessions. Despite overall positive participants' engagement with the KIBO robot, more studies are necessary.

  interventions. Short-duration robot-based interventions, typically consisting of about 8 sessions lasting approximately 30 minutes each, have shown potential in aiding social communication. These interventions have demonstrated meaningful improvements, at least immediately following the intervention period (Kouroupa et al., 2022) While the use of robotic assistants in therapy and education of autism children is still a relatively new field, it has shown promise in improving social interaction skills. As technology continues

Fig. 1 .

 1 Fig. 1. Flow-chart of the study search.

  (i) what are the main ICTs designed for healthcare of NDD? (ii) Does research has improved overtime in terms of experimental methodology quality and ICTdesign quality in studies focused on individuals with NDD? (iii) Based on the best publications according to citations or journal impact factors, are they some active components in ICTs that appear clinically relevant; and (iv) how are digital therapies included in the treatment of people with NDD?

  technologies", most of the studies focus on assistive technologies as reading tools, planners, or refers to specific technologies as DVDs or smart-objects. Skills targeted are social skills, academic skills, autonomy-independence (including vocational skills), communication, executive functioning, behavior (as anxiety or stereotypies) and motor skills. Scientific interest regardingQuality of experimental methodology overtimeExperimental methodology quality of the studies varies significantly across the 4 ICT domains (SG: Mean=8.67, SD= 2.69; Robots: Mean= 7.74, SD=2.55, AAC: Mean= 7.41, SD=2.6; VM: Mean= 7.11, SD=1.5) , with a small advantage for SG (p= 0.011, Welch's ANOVA).. Scores for all ICT varies widely as all domains reach the minimum score for this scale (5/15) as the maximum score for AAC and almost the maximum score for SG, Robots and VM (14/15). These variations occur whatever the years of publication. However, when we assessed the impact of the year of publication on Connolly scores thanks to a Spearman correlation, it appears that scores globally increase with the year of publication. Regarding each ICT, this positive correlation is found for robots (p=0008), VM (p=0.027) and AAC (p=0.048) but not for SG (p=0.92) (see details in figure3).

Figure 3 .

 3 Figure 3. Scores at the methodological quality scale (Connolly et al., 2012) by years of publication

Figure 4 .

 4 Figure 4. Scores at the design quality scale (Grossard et al., 2023) by years of publication

  duration of interventions can vary from 4 weeks to 15 weeks. The targeted skills are executive functions, reading skills, and social skills. The interventions are typically delivered by researchers or clinicians, and sometimes do not require adult supervision or facilitation. The design quality scores are also relatively high, with significant description of the gaming platform.

Figure 2 :

 2 Figure 2: Distribution of engagement initiation scores according to the active or inactive condition of R2C3. The diamonds correspond to the means of the initiation scores. The red boxes correspond to the sessions where QT is "tired", and the blue boxes correspond to the sessions where it is active.

  to continue the exploratory work of[START_REF] Jouen | GOLIAH (Gaming Open Library for Intervention in Autism at Home): a 6-month single blind matched controlled exploratory study[END_REF] with GOLIAH SG, by presenting the protocol of a randomized controlled trial which will evaluate the efficacy of the SG, determine the feasibility of a parent delivered home-based intervention as well as evaluate the cost utility of 12 months after e-GOLIAH + treatment as usual (TAU) versus TAU alone. The previous work included 14 autistic participants and 10 controls, ages 5 to 7. Results found that children and parents engaged in 40% of the sessions. The 11 games were successfully utilized, leading to enhanced task performance timing and improved imitation scores within the majority of imitation games for participants trained with GOLIAH. Notably, the GOLIAH intervention had no impact on Parental Stress Index scores. At the conclusion of the study, both groups displayed significant improvements in Autism Diagnostic Observation Schedule (ADOS-2) scores, Vineland socialization score, Parental Stress Index total score, and Child Behavior

  part of the European research project FP7, the team of the MICHELANGELO consortium associated with the universities of Pisa, Southampton, Paris 6 and the team of the child and adolescent psychiatry department of the Pitié-Salpêtrière Hospital, developed GOLIAH, a digital game platform for autistic children. e-GOLIAH, a more user-friendly version that is accessible online, has been developed by MindMaze in collaboration with the Center de Ressources Autisme Ile de France and the CHU Pitié-Salpêtrière Hospital, via the Autism and New Technologies call for projects launched by FIRAH in 2016. This version is distributed on the curapy.com platform, which allows for simplified accessibility and large-scale distribution. e-GOLIAH is inspired by the principles of the ESDM (Early Start Denver Model,

FigureFigure 2 .

 2 Figure 1. Imitation games

  Adaptive symptoms (Vineland-II, Sparro, Balla & Cicchetti, 2005) -Autistic symptoms (CARS, Reichler & Schopler, 1971) -Social interaction progress (Social Responsiveness Scale, John N. Constantino, 2012) -Parental stress (Parental Stress Index, Abidin, R. R. (1983). French adaptation, by children and their caregivers at home.

  (b) Aged 3 to 6 years; (c) Family ready to get involved in the constraint of using the SG 5 times / week at home (d) Signature of the consent by the 2 holders of parental authority or the only holder of parental authority present (e) Affiliation to a social security scheme (except AME) Exclusion criteria (a) Children with behavioral problems; (b) Unstabilized comorbid organic pathology; moderate and severe cognitive deficit (Intellectual Quotient less than 55); (c) Multi or poly handicap;

  effective than the standard treatment used in the control group.The study concludes by emphasizing the need for further research, particularly in a larger randomized controlled trial with younger participants. While initial results are encouraging, more rigorous testing is needed to establish a significant efficacy of GOLIAH in the training of social skills, notably imitation and joint attention.

  each child puts his or her photo and that of the adults present on the table next to the corresponding first name -How QT feels today -Dance activity: the children take turns proposing movements, and others imitate them -From a picture of a situation involving basic emotion, the children describe what is happening and identify the emotion in question -QT tries to guess and asks for explanations -From the pictograms, the children take turns choosing their favourite sport and asking QT questions about their preferences n°4 : QT inactive -Attendance: each child puts his or her photo and that of the adults present on the table next to the corresponding first name -QT says he's tired today -Imitation of facial expressions: the children imitate the facial expressions of others and suggest one to the group -Repeat photos from the previous week: the children must again identify the emotions and then reproduce one of the scenes with an adult (difficult activity, especially for younger children) -From the pictograms, the children take turns choosing their favourite season and activities they can do at this time of year (difficult activity, too many considerations) each child puts his or her photo and that of the adults present on the table next to the corresponding first name -QT says he's tired today -Song: the children sing with the help of Makaton gestures following the rhythm and intensity proposed by one of the adults -From a social picture presenting a specific emotion, the children describe what is happening in the photo and identify the emotion in question. Then, the children act out the situation with the adults -The children take turns choosing one of their favourite toys from pictograms n°6 : QT active -Attendance: each child puts his or her photo and that of the adults present on the table next to the corresponding first name.

  These interventions showed positive effects on outcomes including social communication deficits, global cognitive abilities and adaptive behaviors. Additionally, results strongly suggested that parent-mediated interventions led to improvements in disruptive behaviors among early school-aged children. The effectiveness of social skills groups was also suggested to improve social communication deficits and overall ASD symptoms in school-aged children and adolescents. Notably, only four meta-analyses demonstrated statistically significant pooled effect sizes in a sensitivity analysis that focused on randomized controlled trials with low risk of detection bias.Table 2 summarizes the main interventions and the level of evidence supporting them (from Gosling et al., 2022).

Naturalistic developmental behavioral interventions (NDBIs) could be the most promising interventions according to a recent therapeutic review taking into account the study's methodology quality

Table 2 . Overview of therapeutic approach in autism: evidence according to symptom targets (Gosling et al. Mol Psy 2022)

 2

	Method	Age (years old)	↘ overall ASD symptoms"	↗ social communicat ion"	↘ repetitive/ restricted symptoms"	↗ expressive language"	↗ receptive language"	↗ adaptative behaviors"	↗ overall cognition"	↘ disruptive behaviors"
	Early Intensive Behavioral Intervention	< 6	ns	Suggestive		Weak	Weak	Suggestive	Suggestive	ns
	Developmental Intervention	< 6	Weak	Suggestive		ns	ns
	Naturalistic Behavioral
	Developmental	< 6	ns	Suggestive	ns	Weak	ns	ns	Weak	ns
	Intervention
	Social Skills Group	> 6	Suggestive	Suggestive	Weak					ns
	Cognitive Behavior Therapy	> 6		Weak
	TEACCH	< 6		ns		ns	ns	ns	Weak
	Parent Mediated Intervention	< 6	Weak	Suggestive		ns	ns	ns	Weak	Highly suggestive
	Techonology Mediated Intervention	Various		Weak (>6) ns (>6)		ns	ns	Weak (13-19)		ns

TEACCH= Treatment and Education of Autistic and related Communication-handicapped Children; ns= not suggestive

Table 3 . Main robots used with autistic individuals

 3

	Robots	Description	Targeted skills	Relevant studies
	Nao	50 cm tall	Joint attention	In Chevalier et al. (2016), authors explored the
		25 degrees of freedom	Imitation	relationship between perceptive-cognitive and
		2 cameras	Turn taking	sensorimotor abilities of participants with their ability to
		Microphones	Eye-contact	positively engage with the Nao robot. They found that
		Speakers	Pointing	those participants with strong visual dependency had
		Touch sensors	Basic academic skills	more success interacting with the Nao robot than the
		LEDS	Facial expressions	participants with stronger proprioception integration.
		Sonars	Verbal communication
		WIFI and Ethernet connection	Improve spontaneous social interaction
		Software allows personalization	Improve robot responses to children's
		Can be used in classroom, hospital,	affective state and engagement.
		etc.
	TEO4	80 cm tall	Social skills, positive emotions, self	Bonarini et al. (2016) recorded 11 children with ASD
		2.5 h autonomy	expression.	engaging with free-play with the robot TEO4 over a
		Possibility to stick different faces		course of 43 sessions of approximately 12 minutes each.
		magnetically		They found generally positive trends in terms of
		Dedicated to children with ASD		communication with, manipulation of the robot,
		Distance sensors		externalization of need, positive emotion, creativity, and
		Touch sensors		body stereotypes.
		1 camera
		Autonomous reactions but can also
		be drive by an operation
		Can move and speak.

Table 1

 1 Characteristics of the studies used to construct the trans-technology inventory.

	Authors, year	Study design	Targeted population	Type of support	Targeted skills
	Allen et al. (2016) Carlier et al. (2020) Dalton (2016) Dawe et al., 2019 Ganz et al. (2017) Grossard et al. (2017) Grynszpan et al. (2014) Guard et al. (2019) Gyori et al. (2015) Hollis et al. (2017) Khan et al. (2019) Liang and Wilkinson (2018) Light and McNaughton (2012) Miguel Cruz et al. (2017) Moon et al., 2020 Morin et al. (2018) Odom et al. (2015) Park et al. (2019) Parsons et al. (2019) Pennisi et al. (2016) Powell et al. (2019) Quezada et al. (2017) Root et al. (2017) Sandbank et al., 2020 Scassellati et al. (2012) Tang et al. (2019) Whyte & Scherf (2015) Zervogianni et al. (2020)	Systematic review and case study Case study Interviews Systematic review Meta analysis Systematic review Meta-analysis Case study Group of studies Meta-review Meta-analysis Group of studies Review Systematic review Meta-analysis Systematic review Systematic review Systematic review Case study Systematic review Interviews Group studies Systematic review Meta analysis Review Interview Systematic review Interview	ASD ASD ASD and ID ASD ASD Developmental disabilities ASD ADHD ASD all NDD ASD Down syndrome Complex communication needs ASD ASD ASD ID ASD ASD ASD ASD ADHD ASD ASD ASD ASD ASD ASD ASD	Tablets Tablets Robots Robots Tablets Serious games Serious games Tablets Smartphones All digital interventions Web based interventions (tablet and computers) Computers with eye tracking Apps Robots Smartphones Tablets and smartphones All supports Virtual reality Tablets Robots Serious games Tablets Computers All supports Robots Serious games Computers All supports	Communication Learning skills Anxiety Social skills All skills Communication Social skills Social skills Social skills Pain evaluation Social skills Daily living skills All skills All skills Communication Communication Language All skills All skills Communication All skills All skills Visual motor Language Social skills Social skills Self management of ADHD Motor skills Academic skills All skills Social skills Emotion recognition All skills All skills

ASD: autism spectrum disorder; ID: intellectual disability.

C.

Grossard et al.

motivation, identify the targeted task, learning, generalization, social context, attention, fatigability, repetitive behaviors, social interaction, and accessibility. Then, we offered indications for rating items and provided examples for each of the four subcategories of ICTs.

Table 2

 2 List of features found in the 28 studies from the literature review.

	Essential features
	Features	Examples	Studies
	Customization: learner's control and choice Feedback must be clear that the goal has been reach Rewards Gamification with storyline: to enhance motivation and contextualized learning Evolving task: increasing gradually the level of difficulty for each exercise and from an exercise to another in function of the player Simplicity to use to promote accessibility	Customize the characters and the environment Customize pictures Control some function in the game like duration or order of the exercises Nonlinear gameplay Different pathways in function of the profile Personalized messages Personalized content as possibility to photograph objects in AAC Specific sound when the answer is correct No negative feedback Progression bar There should not be penalty points Obtain new objects System of points to obtain objects or customize the game Providing encouragement Including a companion or an enemy in the game Real life scenario Joke or humor The storyline must not be too complex to avoid the child losing the main goal of the game Downloadable gaming resources Construct the game to automatically adapt to the level of the player Allow the user to adapt manually the difficulty. This adaptation must be easy and quick: if the change of level is difficult or time consuming between games, there's a risk of losing the player. The game must be challenging but accessible Scaffolding: providing assistance to help the player when a task is hard or new. Then decrease the scaffolding Implementing « auto correct » and « multi-choice options » to support player during difficult games Minimize the number of gestures require Simple gesture needed Familiar hardware i.e. Repetitive placement of buttons Easy to use even for non-technologically advanced people Be compatible with accessibility features available like zoom or voiceover on iPad	Carlier 2020; Whyte 2015; Grossard (2017); Dalton, 2016; Tang (2019); Parsons (2019); Powell (2019); Zervogianni (2020); Hollis (2017); Allen (2016); Strickland 2007; Carlier 2020; Whyte (2015); Grossard (2017); Tang 2019; Powell (2019); Strickland 2007; Carlier 2020; Whyte (2015); Grossard (2017); Tang 2019; Powell (2019) Whyte (2015); Tang (2019); Carlier (2020); Grossard (2017); Parsons (2019); Powell (2019) Carlier 2020; Whyte (2015); Grossard (2017); Tang 2019; Powell (2019); Zervogianni (2020); Allen (2016) Dalton, 2016; Parsons 2019; Khan 2019; Zervogianni 2020; Guard 2019; Quezada 2017; Strickland 2007; Liang et al., 2018; Light et al., 2012

Table 2

 2 (continued )

	Essential features
	Features	Examples	Studies
	Clarity of the instructions and content Attention capacity Clear goals at short and long term Minimalistic graphics and audio: keep the environment pleasant but avoid non-essential cues Human interaction during the game Non-essential features Predictability: effects must be predictable even if the content can be serendipitous Repeatability	Taking into account required motor skills and action (drag, swipe …) Taking into account visual-perceptual characteristics of the display regarding visual skills of the population Taking into account cognitive skills as non-verbal comprehension, memory … Simplicity to use for parents or caregivers: avoid time consuming apps Short instructions Tutorial Language suitable to developmental age Visual symbols easily comprehensive (Light 2012 AAC) No figure of speech Reminders during tasks Using video instead of pictures could help representing actions Diminish transition time between games (i.e. loading) Using dynamic stimuli to keep the player awake Avoiding unnecessary distractors One unique goal per gaming session (Carlier, 2020) Differentiate immediate goal (like goal of a game) and long term goal (like goal of the story) Avoid non-essential animations to avoid repetitive behaviors Giving the possibility to turn off music or sound effects separately Giving possibility to customize graphics as character font or background color Cooperative multiplayer games increase prosocial behaviors Integrating other player may favorize engagement Possibility to receive encouragement from families or friends A random object appears at the end of each task Practice	Carlier 2020; Grossard (2017); Powell (2019); Strickland 2007; Light et al., 2012 Carlier 2020; Grossard (2017); Strickland (2007) Carlier 2020; Whyte (2015); Tang 2019; Powell 2019 Carlier 2020; Dalton, 2016; Powell (2019) Carlier 2020; Whyte, 2015; Powell 2019 Carlier, 2020 Carlier, 2020; Grossard, 2017

Table 3

 3 Results of experts' global rating for Delphi rounds 1 and 2.

	Round 1: global rating
	Items	1	2	3	4	5	6	7	8		9	10	11	12	13
	Median IQR % agreement Round 2: global rating 7 2.5 75 Items 1 Median 9 IQR 1.25 % agreement 91.6	8 2.5 75 2 9 1.25 91.6	8.5 2 91.6 3 8 1.25 91.6	7 2 83.3 4 8 1 91.6	7.5 2.25 75 5 8 1 100	8 3.25 58.3 6 9 1 100	7.5 2.25 75 7 9 1 100	9 1 83.3 8 9 1 100	8.5 2 83.3 9 8.5 1 100	8 2.25 75 10 8.5 1.25 91.6	9 1.25 83.3 11 9 1 100	8 2.25 83.3 12 9 1 100	9 1 100 13 9 1 91.6
	Item 1: Possible customization by the user; 2: Feedback; 3: rewards; 4:contextualized learning; 5: Enhance motivation; 6: Manage difficulty or complexity; 7: Increasing accessibility:simplicity to use and autonomy; 8: clarity of the instructions or content; 9: Attention capacity; 10: Clear steps or goals for short and long term; 11: Easy to process and modify graphics and audio: keep the environment pleasant but avoid non-essential elements; 12: Human Interaction; 13: Trustworthy.
	Table 4 Median of experts' specific rating by ICT for Delphi rounds 1 and 2.
	Round 1: specific rating
	Items		1	2	3	4	5	6	7	8	9	10	11	12	13
	Robots Serious games & Apps AAC VM Round 2: specific rating Items Robots Serious games & Apps	8 9 9 9 1 8 9	3 8 9 6 2 8	4 9 9 7 3 8	7 8 9 9 4 8	7 6 6 8 5 8	6 9 4 7 6 8	6 9 9 8 7 8	8 9 9 9 8 9	6 9 9 7 9 8	5 8 9 7 10 7	6 9 9 9 11 7	6 9 9 7 12 8	7 9 9 9 13 7

Table 5

 5 Final version of the Design ICT Inventory (DICTI).

	C. Grossard et al.
	Features and (TS) Targeted Skills	Rating	Serious games and Apps	Robots	AAC	Video Modeling
	1. Possible customization by the user	0: No personalization 1: Partially considered	-Customize the characters and the environment -Ability to modify length or order of the exercises	-Appearance of the robots (size, color, form etc.) -Characteristics of the robot (gesture, way to control it	-Customized audio and video -Customized messages	-Customized audio and video -Customized messages
				…)
	TS: motivation 2. Feedback TS: identify the targeted task 3. Rewards TS: motivation and learning	2: Fully considered 0: No feedback 1: Feedback but is not clearly related to a goal 2: Feedback clearly related to a goal 0: No rewards 1: Social reinforcement (applause) or points only. 2: Rewards like objects, videos, song	-Different pathways in regard to the user's profile -Personalized messages -Specific feedback (i.e. sound or visual bar) when the answer is correct -Progression bar/timer -Provide visual feedback on progress within the app (i.e. learning map) -Possibility to provide only positive feedback -Social reinforcement (i. e. applause) -Visual or auditory rewards (video, pictures, songs …) -Points	-Control duration or order of the exercises -Different pathways in regard to the user's profile -Personalized messages -Specific feedback (i.e. sound, gestures, body postures, colors) when the answer is correct -Each feedback is related to a targeted skill -Possibility to provide only positive feedback -Social reinforcement (i.e. applause, dance, emotional expressivity) -Visual or auditory rewards (video, pictures, songs …)	-Possibility to arrange the position of the navigation bar -Possibility to select a preferred set of graphic symbols and/or create individualized symbols (i. e. by taking a photo) -Auditory feedback when choosing symbols -Sentence construction: automatic adaptation of grammar and syntax -Social reinforcement (i.e. at the end of a task in VM) -Visual or auditory rewards (video, pictures, songs …)	-Ability to select model/actor in video -Opportunity for the user to auto-correct (i.e. including a step to check what was already done) -Social reinforcement (i.e. at the end of a task in VM) -visual or auditory rewards (video, pictures, songs …)
	Features and (TS) Targeted skills	Rating	Serious games and Apps	Robots	AAC	Video Modeling
	4.Contextualized learning TS: generalization and social context 5. Enhance motivation TS: motivation 6. Manage difficulty or complexity	0: None 1: Scenario not clearly linked with user's environment 2: Clear link between scenario and user's environment 0: None 1: Partially considered 2: Fully considered 0: No difference between levels 1: Changes in difficulty without adapting to the player	-Introduction of real-life scenario -Downloadable gaming resources -choice between first-or third-person view -Includes a companion or enemy in the game -Contains jokes or humor -Provides encouragement (i.e. saying "good job!") -The game automatically adapts to the player's performance -Allow the user to adapt manually the difficulty	-Scenario must be designed to allow children to draw connections between themselves and their everyday life -scenario are associated with everyday life activities to encourage interaction -Robot must be friendly (i.e.: adapted size and appearance) to engage with the children -Provides encouragement (i.e. saying "good job!") -being non-judgmental -Adapt scaffolding according to scenario and user capacities (i.e. robot can first initiate the interaction, then just support it) -Possibility to manage the linguistic difficulty to fit with the user's skills	-AAC can include video modeling -technology offers option to select grid-type display or VSD -Add hotspot to VSD by drawing on the screen -available pre-stored vocabulary to illustrate common context -Ability to communicate individualized and preferred topics -Integrated a variety of functions of communication (i.e., telephone, play situation …) -Choose between different types of symbols (pictures, photographs, traditional orthography/written words) to fit with the level of comprehension of the user -Choose between the number of symbols presented in each communication page and in the entire communication book	-Opportunity to create sequences featuring the user as the model (video-self modeling) -Ability to create videos featuring user's actual environment. -choice between first-or third-person view -Provides encouragement -Motivating factors such as humor or encouragement can be added to videos Possibility to see each sequence (video prompting) or all tasks at once (video modeling) -Possibility to manage the linguistic difficulty to fit with the user's skills (continued on next page)

Table 5

 5 (continued )

	C. Grossard et al.
	Features and (TS) Targeted skills	Rating		Serious games and Apps	Robots	AAC	Video Modeling
	TS: accessibility and learning	2: Changes in difficulty in regard to the player (manually or automatically)	-Adapt scaffolding (i.e. provides full support at the beginning of a new task and then diminished it) -Evolving task with increasing difficulty -Possibility to manage the linguistic difficulty to fit with the user's skills -Ability to modify the speed of displaying stimuli	-Ability to modify the speed of displaying stimuli	-Possibility to manage the linguistic difficulty of the vocabulary to fit with the user's skills	-Ability to modify the speed of displaying stimuli
	Features and (TS) Targeted skills	Rating		Serious games and Apps	Robots	AAC	Video Modeling
	7. Increasing accessibility: simplicity to use and autonomy TS: accessibility 8. Clarity of the instructions and content TS: accessibility 9. Attention capacity TS: Attention and fatigability	0: None 1: Partially simple (i.e. simple gestures but time consuming) 2: Easy to use and easily accessible 0: None 1: Language adapted but not visual 2: Visual and language adapted 0: None 1: Adaptation of duration OR stimuli to keep the user engaged 2: Adaptation of duration AND the user engaged stimuli to keep	-Simple to use for parents or caregivers (avoids time consuming apps) -Minimizes the number of gestures/click required -Simple actions needed to interact with the support (i.e. keystroke or tapping are easier than drag or swipe)-Easy to use even for non-technologically advanced people -Not related to a specific device or operating system -Contains a tutorial -Language suitable to developmental age -Visual symbols easily comprehensive -Reminder during tasks -Uses stimuli to keep the player engaged -Adapts the length of tasks -Diminish transition time between games	-Simple to use for parents or caregivers (avoids time consuming by favoring autonomy of the robots) -Minimizes the number of gestures required -Simple actions needed to interact with the robot, adapted to the user -Easy to use even for non-technologically advanced people -Language suitable to developmental age -Reminder during task -Robot's actions must be simple and easily understood by the user -Adapts the length of tasks depending on the population and scenario -Uses stimuli to keep the player engaged	-Simple to use for parents or caregivers (avoids time consuming apps) -Minimizes the number of gestures/click required -Simple actions needed to interact with the support (i.e. keystroke or tapping are easier than drag or swipe) -Integrate word prediction to support easy access -Easy to use even for non-technologically advanced people -Not related to a specific device or operating system -Language suitable to developmental age -Visual symbols easily comprehensive -Using animated symbols instead of pictures to help representing actions -Allows real time communication (i.e. with pre-registered sentences, prediction of words/ sentences) -Relieve working memory by keeping the current sentence visible while looking for the next image	-Simple to use for parents or caregivers (avoids time consuming apps) -Minimizes the number of gestures/click required -Simple actions needed to interact with the support (i.e. keystroke or tapping are easier than drag or swipe)-Easy to use even for non-technologically advanced people -Not related to a specific device or operating system -Can be watched on devices with built in accessibility features -Language suitable to developmental age -Videos are easily understood -Using videos instead of pictures to help understanding actions -Adapts the length of the video -Uses stimuli to keep the user engaged
	Features and Targeted skills (TS)	Rating	Serious games and Apps	Robots	AAC	Video Modeling
	10. Clear steps or goals for short and long term	0: None	-Favorized one unique goal per gaming session	-Favorized one unique goal per gaming session when possible, according to the situation	-Clear and simple organization (i.e. clearly identify category inside a folder by provide a	-Each step should be easily identified by the user (i.e.: One video could be related to one step) (continued on next page)

Table 5

 5 (continued )

	C. Grossard et al.
	Features and Targeted skills (TS)	Rating		Serious games and Apps		Robots	AAC	Video Modeling
	TS: accessibility and learning 11. Easy to process and modify graphics and audio: keep the environment pleasant but avoid non-essential elements TS: repetitive behavior and attention	1: Limited number of steps/goals in a session OR clear goals 2: Limited number of steps/goals AND clear steps/goals 0: None 1: Minimalistic graphics OR sounds 2: Minimalistic graphics AND sounds	-Differentiation between the immediate goal (goal of a game) and long-term goal (goal of the story) -Avoids non-essential ani-mations to prevent repet-itive behaviors -Gives the possibility to customize graphics as character's font or background color -Gives the possibility to turn off music or sound effects separately -Animations, sounds and color should be appropriate to the targeted user (in terms of age, skills …)	-Differentiation between the immediate goal (i.e. joint attention) and long-term goal (enhance social skills) -Avoids non-essential ani-mations to prevent repeti-tive behaviors -Has controls for the sounds -Animations, sounds and color should be appropriate to the targeted user (in terms of age, skills …)	compilation of images instead of one single related image) -Thumbnails are clearer than symbols -Limiting the number steps (i. e. number of location levels) -Has controls for the sounds -Gives the possibility to customize graphics as character's font or background color -Animations, sounds and color should be appropriate to the targeted user (in terms of age, skills …)	-Differentiation between the immediate step (i.e. open the fridge) and long-term goal (i.e. make a sandwich) -Has controls for the sounds -Control over the video (location, actors, props) -Gives the possibility to customize video elements such as graphics, font or background color -Animations, sounds and color should be appropriate to the targeted user (in terms of age, skills …)
	Features and (TS) Targeted skills	Rating		Serious games and Apps	Robots	AAC	Video Modeling
	12. Human interaction TS: social interaction and motivation 13. Trustworthy TS: motivation and accessibility	0: None 1: Exchange with one person 2: Multi-users exchange 0: None 1: Partially considered 2: Fully considered	-Cooperative multiplayer games with caregivers -Cooperative multiplayer games with peers -Possibility to receive encouragement from family, caregiver, or friends -Assures safety and cybersecurity if needed -Is robust: avoids bugs and latencies -Clear goals and operation of the device -Impact on the user and its environment should be consider (i. e. avoid obsession with the ICT, how to adapt the device to daily life)	-Cooperative multiplayer games with caregivers -Cooperative multiplayer games with peers -support interaction between the user and others according to the user capacity -Assures safety and cybersecurity if needed -Is robust: avoids bugs and latencies -Clear goals and operation of the device -Behavior of the robots must be predictable and understandable to enhance trust -Impact on the user and its environment should be consider (i.e. how to adapt the device to daily life)	-Ability to exchange messages with caregivers or family through social media channel and text messaging -Ability to exchange messages with peers through social media channel and text messaging -Assures safety and cybersecurity if needed -Is robust: avoids bugs and latencies -Clear goals and operation of the device -Impact on the user and its environment should be consider (i.e. how to adapt the device to daily life)	-Ability for caregiver or family to create videos -Ability for user to exchange videos with peers -Assures safety and cybersecurity if needed -Is robust: avoids bugs and latencies -Clear goals and operation of the device -Impact on the user and its environment should be consider (i.e. how to adapt the device to daily life)

4: Have ICT design and research methodology improved over the last few decades? Introduction Neurodevelopmental

  disorders (NDD) are a group of conditions characterized by delays in developmental domains such as general cognition, social skills, communication skills, behavior, motor functioning, attention and executive functioning. These disorders start manifesting in early childhood, but diagnosis depends on developmental maturation and the expression of the full symptomatology. They result in mild to severe impairments in autonomy and social, academic and personal functioning. According to the earliest clinical expression, they

	include intellectual disability (ID), Autism Spectrum Disorder (ASD), communication disorders
	(CD) that show first symptoms during early childhood, and specific learning disorders (SLD),
	motor coordination disorders (MCD) and Attention Deficit/Hyperactivity Disorder (ADHD) that
	usually start later (American Psychiatric Association

Table 1 . ICC for rating using the methodological scale and the design scale

 1

		ICC methodology scores	ICC design scores
	All	0.80	0.9
	VM	0.65	0.94
	AAC	0.79	0.75
	SG	0.75	0.94
	Robots	0.95	0.99

Inter rater agreement was assessed using intraclass correlation. They are summarized in table 1 (supplement material). Global ICC was considered good for the methodological scale

  based their assessment on the Critical Appraisal Checklist for RCTs ; Grossard at al. (2017) used a scale based on a work by Connolly et al.

(2012); Ganz et al. (2017) used the adaptation by Maggin, Briesch and Chafouleas (cited by Ganz et al., 2017) of the basic design standards for single-case research proposed by What Works Clearinghouse (U.S. Department of education, 2016, cited by

Table 1 . Participants' characteristics

 1

	Participants	n°1	n°2	n°3	n°4	n°5	n°6
	Group	A	A	A	B	B	B
	Age (y/o)	10.4	9.6	9.9	8.7	8.1	6.4
	Gender	F	F	F	M	M	F
	ASD Diagnosis
	validated by
	ADI-R or ADOS-
	2

Table 2 : R2C3 interface behaviors examples (Zou et al., 2022) Category Description Examples

 2

Table 4 : Results of the effect of the sessions on the ADOS module scores and engagement rates

 4

	Sessions effect
	Score	Estimate	exp (Estimate)	Stf. Error	z value	Pr (>|z|)
	ADOS_A communication	0.042	0.959	0.019	-2.195	0.028
	ADOS_B social interaction	0.066	0.036	0.017	-3.937	0.000
	ADOS_D restricted interests	0.215	0.806	0.057	-3.776	0.000
	ADOS_E abnormal
	behaviors	0.047	0.954	0.032	-1.498	0.134
	Responses to social requests	0.059	1.061	0.011	5.606	0.000
	Social engagement initiations	0.038	1.039	0.021	1.851	0.064

Table 5 : Impact of the robot's active condition on ADOS-2 scores and engagement rates

 5

	Variable	Estimate	exp (Estimate)	Std. Error	z value Pr (<|z|)
	ADOS_A communication	0.01	1.01	0.11	0.09	0.93
	ADOS_B social interaction	-0.08	0.92	0.1	-0.87	0.39
	ADOS_D restricted interests	-0.25	0.78	0.3	-0.85	0.40
	ADOS_E abnormal behaviors	-0.14	0.87	0.18	-0.76	0.45
	Responses to social requests	-0.03	0.97	0.06	-0.50	0.62
	Social engagement initiations	0.27	1.31	0.12	2.24	0.03

Table 1 . Expected recruitment across the centers

 1

	City	X of patients expected	Total recruitment 9x
		per month	patients)
	Strasbourg	0.69	13
	Montpellier	0.69	13
	Nice	0.69	13
	Versailles	0.69	13
	Amiens	0.69	13
	APHP-SU, Paris	0.69	13
	APHP Necker
	Paris	0.69	13
	Nancy	0.69	13
	Toulouse	0.69	13
	Tours	0.69	13
	Poitiers	0.69	13
	Paris 14th	0.69	13

  N/A=!not!available;!JADD=!Journal!of!autism!and!developmental!disorders;!Mol!Autism=!Molecular!autism! !AAC=Augmented+assisted+communica1on;+ASD=Au&sm)spectrum)disorder;)ID=Intellectual)disability;)JADD=!Journal!of!autism!and!developmental!disorders;!Mol!Autism=!Molecular!autism;!SMART='Sequen,al' mul$ple'assignment;!SGD=Speech)generated)device;"N/A="not"available! ASD=Au&sm#spectrum#disorder;#ID=Intellectual#disability;#JCPP=Journal+of+child+psychology+and+psychiatry;(Mol(Autism=(Molecular(autism;(SG=Serious*game(

	timer! J Social!reinforcement!(i.e.! applause)! J Visual!rewards!(video,! pictures,!…)! Robots! AAC! J!Adapt!scaffolding!(i.e.! robot!can!first!initiate! the!interaction,!then! just!support!it)! J!Choose!between!symbolic! J Voices!feedback!when! choosing!pictures! J Sentence! construction:!automatic! adaptation!of!grammar! and!syntax! J Social!reinforcement! (i.e.!at!the!end!of!a!task! in!VM)! J Visual!rewards!(video,! pictures,!…)! images,!written!words,! pictograms,!or!photos!to!fit! with!the!level!of! comprehension!of!the!user! J Simple!to!use!for! parents!or!caregivers! (avoids!time!consuming! by!favoring!autonomy! of!the!robots)! J Minimizes!the!number! of!gestures!required! J Simple!gesture!needed! J Easy!to!use!even!for! nonJtechnologically! advanced!people! J Simple!to!use!for!parents!or! caregivers!(avoids!time! consuming!apps)! J Minimizes!the!number!of! gestures!required! J Simple!gesture!needed! J Easy! to! use! even! for! nonJ technologically! advanced!people! J Not! related! to! a! specific! device!or!operating!system! J Language!suitable!to! developmental!age! J Reminder!during!task! J Robot's! actions! must!be!simple!and! easily!understood!by! the!user! J Language!suitable!to! developmental!age! J Visual!symbols!easily! comprehensive! J Using!video!instead!of! pictures!to!help!representing! actions! receiving( training,#some# J!Opportunity!for!the!user!to! autoJcorrect! J Social!reinforcement!(i.e.! at!the!end!of!a!task!in!VM)! J visual!rewards!(video,! pictures,!…)! Video!Modeling! Possibility!to!see!each! sequence!(video!prompting)! or!all!tasks!at!once!(video! modeling)! J Simple!to!use!for!parents! or!caregivers!(avoids!time! consuming!apps)! J Minimizes!the!number!of! gestures!required! J Simple!gesture!needed! J Easy! to! use! even! for! nonJ technologically! advanced!people! J Not!related!to!a!specific! device!or!operating!system! J Can!be!watched!on!devices! with!built!in!accessibility! features! J Language!suitable!to! developmental!age! J Videos!are!easily! understood! J Using!videos!instead!of! visual'and' to#the#control#group( J Social!reinforcement!(i.e.! applause)! J Visual!rewards!(video,! pictures,…)! J Points! J Real!life!scenario! J Downloadable!gaming! resources! Serious!games!and!Apps! 2:!Clear!link!between!game! 0:!No!rewards! 1:!Social!reinforcement! (applause)!or!points!only.! 2:!Rewards!like!objects,! videos,!song! 0:!None! 1:!Limited!context! and!context! Rating! 0:!No!difference! between!levels! 1:!Changes!in!difficulty! without!adapting!to!the! player! 2:!Changes!in!difficulty! in!regard!to!the!player! (manually!or! automatically)! J Construct!the!game!to! automatically!adapt!to!the! level!of!the!player! J Allow!the!user!to!adapt! manually!the!difficulty! J Adapt!scaffolding!(i.e.! provides!full!support!at!the! beginning!of!a!new!task!and! then!diminished!it)! J Evolving!task!with! increasing!difficulty! 0:!None! 1:!Partially!simple!(i.e.! simple!gestures!but! time!consuming)! 2:!Easy!to!use!and!easily! accessible! J Simple!to!use!for!parents!or! caregivers!(avoids!time! consuming!apps)! J Minimizes!the!number!of! gestures!required! J Simple!gesture!needed! J Easy! to! use! even! for! nonJ technologically! advanced!people! J Not! related! to! a! specific! device!or!operating!system! 0:!None! 1:!Language!adapted! but!not!visual! 2:!Visual!and!language! adapted! J Contains!a!tutorial! J Language!suitable!to! developmental!age! J Visual!symbols!easily! comprehensive! J Reminder!during!tasks! understanding!actions! accurately)a*er) communicate! addi$onal( &"Android)," interven'on,*and*rela've* pictures!to!help! Features!and!Targeted! 3.!Rewards! TS:,motivation,and, learning, 4.Contextualized! learning! TS:,generalization, and,social,context, Features!and! targeted!skills!(TS)! 6.!Manage!difficulty! TS:,accessibility,and, learning, 7.!Increasing! accessibility! :! simplicity!to!use! and!autonomy! TS:,accessibility, 8.! Clarity! of! the! instructions!and! content! TS:,accessibility, ! skills!(TS)! Rating! Serious!games!and! Apps! Robots! AAC! Video!Modeling! 13.!Trustworthy! ! TS:,motivation,and, accessibility, 0 :!None! 1 :!Partially!considered! 2:!Fully!considered! J Assures!safety!and! cybersecurity!if!needed! J Is!robust:!avoids!bugs! and!latencies! J Clear!goals!and! operation!of!the!device! J Assures!safety!and! cybersecurity!if!needed! J Is!robust:!avoids!bugs!and! latencies! J Clear!goals!and!operation!of! the!device! J Assures!safety!and! cybersecurity!if!needed! J Is!robust:!avoids!bugs!and! latencies! J Clear!goals!and!operation! of!the!device! J Assures!safety!and! cybersecurity!if!needed! J Is!robust:!avoids!bugs! and!latencies! J Clear!goals!and! operation!of!the!device! ! ! Table&2.&Best&papers&exploring&robots&in&NDD&according&to&cita7ons&or&impact&factor&journals! ! ! ! ! ! Authors( (Years)! Study& design! Inclusion) criteria' (Most& cited&or& best% journal)! NDD! Age$ (y/o)! N" total! Dura%on( Intensity! Targeted( skill! Type%of% support! Person' delivering)the) interven'on! Main%results! Methodology*quality! Design'quality! Score& (max=15! Strength! Weakness! Score& (max=26)! Strength! Weakness! Best%papers%according%to%cita/ons! Robins'et' al.$(2005)! Single' case% design! 857$%mes! ASD! 5"10! 4! 101#days;# each%trial% lasted'as' long%as%the% child&was& OK! Social' skils! Robot:& ROBOTA&&& Wizard"of"Oz# interface! Inves&gator,in, charge'of' teleopera(on*! Repeated'exposure' to#an#interac*ve# small%humanoid% robot%increased% basic&social& interac(on*skills*in* children)with) au#sm.! 6! Longitudinal+ studies! Difficulty)to) generalize)the) results'due'to' small%sample% size.! 4! Possibility)to) teach&the&robot& sequences'of' ac#ons'and' vocabulary* through' machine( learning( algorithms! Most%of%the% robo$cs' features,) including( speech& processing,+ mo#on%tracking% and$learning$ were$not$used.! Kim$ al.!(2013)! RTC$ cross% over! 481$%mes! ASD! 4"12! 24! 3"sessions;" intensity' N/A! Social' skills! Robot:&PLEO& &"Wizard"of" Oz#interface! Three%adults% not$related$to$ the$children! Children)with) au#sm&showed& posi%ve(social( behaviors*towards* the$robot,$and$the$ robot%was%effec,ve% in#reinforcing)social) behaviors*in*the* children.! 13! RCT,%large% sample'of' par$cipants*in* comparison*to* most%robo(c% interven'ons.! The$study$did$ not$include$a$ follow"up# assessment'to' determine(the( long"term% effects&of&the& robot% interven'on)on) social'behavior' in#au&s&c# children.! 11! Appealing) characteris)cs;+ Possibility)to) pre$program$ PLEO%and%% instantaneously! play%any%one%of% 13!custom,(pre" recorded,! motor%and% sound&scripts& on#the#robot.! Kumazaki( al.$(2018)! RTC! Mol$ au#sm& IF2018!:" 5.869! ASD! 5"6! 68! (30! ASD! &"38" TD)! 5"min"robot" interac(on! Social' skills! Robot:& CommU%&% Wizard"of"Oz# interface! Inves&gator,in, charge'of' teleopera(on*! Par$cipants+ demonstrated* be#er%JA%during% their&interac*on& with%the%robot! 14! Study&design! Dura%on(of( interven'on! 5! characteris)cs;+ realis'c)design) of#the#eyes#and# its$mobility$ facilitate(eye( contact&and& joint&a(en*on! Lack%of% different( degrees&of& social' complexity! Reichle' &"Ward" (1985)! Case% study! 355# !mes! ID# communica(on) delay! 13! 1! 57#trials;# intensity' N/A! Communica)on! SGD:%The$ Sharp& communicator! Speech" language' pathologist! The$child$was$ able%to%use%the% SDG$with$ nonsigners(and( used%sign% language'with' signers' 5! Mul$ple' baseline(design( and$detailed$ data$collec)on! Single'case'! 6! Direct'select' encoding( reduces'the' !me$required! to# Device& requires'prior' training! An#et#al.# (2017)! Group& study&no& control! Mol$ au#sm&& IF2017:( 5.872! ASD,%minimally% verbal! !3"6! 10! 8"sessions" of#30"min! Communica)on! AAC#mobile' app:$Yudee! Teacher! Effec%ve'tool'for' helping( minimally'verbal' children! 8! Interrater' agreement,) procedural* integrity.! sample'size,'no' follow"up,$ limited'to' classroom( environment,* no#collect#data# of#parental# 18! possibility)to) add#more# pictures,*large* repertoire' accessible((iOS( prior%training% (8x30&min& sessions)! Gollan&et& al.$(2006)( RCT( 838# !mes( ASD( 15J45( 75( weeks;& intensity' performance*before*the* very%a'rac)ve( N/A$$$$$$$$$$$$$( Social' skills( voices,(compared(to(their( descrip(on( to#adult( graphics,*not* Reading( states%from%both%faces%and% 12( Large&RCT( par$cipants'+ 12( context,(adapted( n,#2D#sta)c# SG:$Mind$ emo$ons'and'mental' Lack%%of% Related'to'social' personalisa#o 10#J!15# recognize)complex) Limited' Intensive( improved)in)their)ability)to) verbal'needs,' Par$cipants+significantly+ children's+ synchronized, Limited'verbal' capaci%es! Duque%e& al.$(2008)! Single" case%vs.% 3" controls! 391$%mes$! ASD! 4.4"5.5! 4! 22" exposi'ons) at#a#rate#of# three%&mes% per$week$ during'7' weeks;& dura%on(of( sessions& N/A!! Social' skills! Robot:&Tito&&& Wizard"of"Oz# interface! Inves&gator,in, charge'of' teleopera(on*! Children)exposed)to) the$robo(c$ mediator)showed) reduced&repe((ve& plays&with& inanimate'objects' of#interest#(their# favorite)toy),)and) had$no$repe**ve$or$ stereotyped# behavior)toward) the$robot.! 10! N/A! Difficulty)to) generalize)the) results'due'to' small%sample% size.! 8! Robot's' appealing( characteris)cs* for$interac+ng$ with%children% with%ASD! Robot's'limited' mo#ons& capabili'es! Best%papers%according%to#journal#impact#factor! Scassella'( al.$(2018)! Group& study& no# control! Science& Robo$cs' IF2018:! 14.034! ASD! 6"12!! 12! 1"month;" 30"min$ everyday! Social' skills! Autonomus( robot:&Jibo&! None:& child/robot+ interac(on! A"er%training,%many% children)invest)the) robot%as#a#friend# and$improve$their$ capacity'for'joint' a"en%on,( communica(on)and) commitment(even( without'the'robot.! 12! Intensity(and( length'of'the' interven'on.** Demonstra*on+ of#directly# assessed% improvements+ in#social#skills.! Unconstrained, home% environment) can$lead$to$ greater& varia%ons)in) environmental+ condi&ons;)no) control'group;' interven'on) mixed&a&robot& and$screen$ games! 16! Fully% autonomous( robot,&capable& of#adap'ng#to# the$strengths$ and$ weaknesses'of' each%child.% Adapted'to' parents(for(in( home% interven'ons.! The$interac+on$ between&the& need$for$ autonomy(and( the$need$for$ adapta%on( creates' addi$onal( technical) challenges.! Appealing) Huskens' al.!(2015)! RCT$! JADD$ IF2015:! 4.101! ASD! 13"May! 6"(3" ASD$ &" 3TD)! 5"sessions;" 30"min$ once%a% week! Social' skills! Robot:&Nao& &"TiViPE-a" visual' programming) environment! Inves&gator,in, charge'of' teleopera(on*! Robot"mediated' Lego%therapy%was% not$effec(ve$in$ improving) collabora've* behaviors*of* children)with)ASD,) although(parents( social'validity' reported' improvements+in+ their&children's& collaboratory)play.! 10! Mul$ple' baseline,& adequate' treatment' integrity,) interrater' agreement( scores,'post' interven'on) measures,( sufficient) informa(on) provided(for( replica(on.! No#control# group,'low' intensity'of' interven'on,* does%not% report&of&long& term%effect%of% interven'on) does%noot! report&on& treatment' fidelity.! 10! Robot%provides% clear& instruc(ons,+ prompts'and' Limited' possibility)to) adapt%to%the% children's+ needs%and% preferences,) limited' behavioral* repertoire' (prompts(and( Table&3.&Best&papers&exploring&AAC&in&NDD&according&to&cita9ons&or&impact&factor&journals! Authors( (Year)! Study& design! Inclusion) criteria' (Most& cited&or& best% journal)! NDD! Age$ (y/o)! N"total! Dura%on( Intensity! Targeted(skill! Type%of% support! Person' delivering) the$ interven'on! Main%results! Methodology*quality! Design'quality! Score& (max=15)! Strength! Weakness! Score& (max=26)! Strength! Weakness! Flores!et# al.$ (2012)! Case% series! 386$ !mes%! ASD,%ID! !! 5! 5"weeks,"3" hours/day,+ 5" days/week! Communica)on! iPad%%+%SGD% Pick%a%Word% app! Teacher! Par$cipants+ benefited'from' both%the%app% and$picture" based& communica(on.* Nevertheless,* there%was%no% consistent( pa#ern'across' 6! Data$collec)on$ and$reliability,$ including( treatment' integrity,) interrater' agreement(and( social'validity.(! Single'case,' Only% communica(on) behavior)was) addressed;' study&se(ng! 6! Accessibility*of* the$iPad$(cost$ &"availability)"! Procedures) for$$ac'va'ng$ the$iPad$and$ programming) the$app.! Xin$&$ Leonard( (2015)! Case% study& mul$ple" baseline( design! JADD:% IF2015'' IF#4.101! ASD,%ID! 10! 3! Two$10" min$ sessions&2& days/week) for$2-3" weeks! Communica)on! iPad,& SonoFlex!App! Teacher! Using&SonoFlex& increased) students'( responses'to' teachers') ques!ons,&social& comments.) However' ini#a#ng& requests'is' 7! The$study$used$ mul$ple' methods(to( measure' changes(in( communica(on.! Small%sample% size,&no&follow& up,$and$no$ examina'on)of) speci&fic( features(of(the( iPad%based% interven'on.! 12! Accessibility*of* the$iPad$(cost$ &"availibility)"! Fixed&icon& size%and%all% related' vocabulary* Comparing*the*effects*of* Table&4.&Best&papers&exploring&serious&game&in&NDD&according&to&citations&or&impact&factor&journals& Authors( (Year)( Study( design( Inclusion( criteria( (Most( cited(or( best( NDD( Age( (y/o)( N( total( Duration( Intensity( Targeted( skill( Type(of( Main(results( Methodology(quality( Design(quality( Score( Score( Francesch ini!et.al& (2013)( Control led$ study( Current' biology( IF2013:( 9.916%( Dysle xia( 8J12( 20( 9"sessions" of#80#min# per$day( Reading( skills( an#ac%on#video#game#to#a# Wii#video# game:& Rayman! Raving' nonac%on&video&game& training.(Ac+on(video( game%improve%reading% skills%in%dyslexic%children% 10( Using&a& Lack%par(cipants'% placebo(in( descrip(on+small+ NA( NA( NA( the$control$ sample'size( group( Rabbids( more%than%in%the%control% support( (max Strength( Weakness( (max Strength( Weakness( group( visible'on'the' same%screen.! journal)( =15( =26)( 3D#world,# ( possibility)to) posi%ve( reinforcement,! reinforcement),, need$for$ technical) assistant&to&be& present'to' program'the' robot.! Best%papers%according%to%cita/ons! Kasari&et& al.$ (2014)! RCT$ (SMART)! 418$ !mes! ASD! !5"8! 61! 24#1"hour% sessions& during'6' months! Communica)on! SGD! Therapist! Using&SGD&as&an& ini#al& interven'on) proved'to'be' more%impac*ul% than%the% interven'on) without.( Addi$onally,+ implemen'ng) an#adap&ve# interven'on) with%the%SGD% subsequent(to( the$first$phase$ yielded&be(er& post"treatment' results.(! 14! Rigorous(design( the$par(cipants.! Best%papers%according%to%journal%impact%factor! GoTalk'app:' symbol'is" GoTalk:( significantly+ lower.! BEST&PAPERS&ACCORDING&TO&CITATIONS& Klingberg) et#al.# (2005)( RCT( 2782$ !mes( ADH D( 7J12( 53( Five%weeks,% 40Jmin$ average& Execu&ve( func%on( SG:$ CogMed( Treatment(group(improved( working(memory(compare( to#control'group( 15( RCT$( N/A( 14( Visual(and(verbal( No( multiplayer,( static( Serret! et.al& (2014)( Group& studyn o" control( Two$1Jhour% adapt%the%level%of% Mol$ au#smIF 2014:& ASD( 6J18( 33( sessions& per$week$ over%four% Social' skills( SG:$ JeS$mule( Children)improved)their) emo$on's(recogni$on(skills( a"er%training( 12( Include( children)with) IQ<80( No#control#group( 20( difficulty,*the* No# player'can'make' mul$player( choice&and& 6.338( weeks.( personalized, feedback( graphics,(no( his/her'character,' !me( storytelling( clear&feedbacks( Two$par(cipants$ showed'more' Naturalis)c+ enlarged(and( Bu#on"based& Control'and'experimental' allowing(for(the( evalua&on)of) mul$ple' interven'ons* and$their$ sequencing;* longitudinal;+3" months'follow" up.! Only%two"thirds' of#the# recruitment) target&were& involved(in(the( study.! 4! N/A! N/A! Gevarter' et#al.# (2014)! Case% study! JADD:% IF2014' 4.032! ASD! 3.1"3.6! 3! 5-8"weeks" 2-3" sessions/' week! Communica)on! Apple%iPad%+% GoTalk'app'+' Scene%and% Heard&&App! Cer$fied' special( educa&on) teacher! rapid&acquisi+on& with%the%Scene% and#Heard# photographical+ hotspot&&than& with%the%GoTalk% Widgit&symbol& bu#on.! 5! environment,* procedural* integrity,) interrater' agreement,) hotspot,' naturalis)c+ representa(on! selec%ng(a( symbol'led'to' confusion! No#control# group,'small' Easily' customizable-based&on& Temple&et& al.$(2003)( Contro lled$ study( 1244$ !mes( Dysle xia( 8J12( (20$ dysle xics,& 12# processing( TD)( 8"weeks;" intensity' N/A( Reading( skills( SG:$$Fast$ For$Word$ Language( increased)ac*va*on)in) during'phonological' fMRI( mul$ple'brain'regions' 8( behavioral* measure'and' Small%control% group( 13( processing( N/A( Auditory( reading(performance,(and( Using&both& improved)language,) 32# Remedia'on*resulted*in* with%children%with$ASD( condi&ons! photographical+ s"muli'when' weeks.( the$use$of$Braingame$Brian$ training( three%AAC% Small%sample% size,&no&control& group,'! GoTalk:(6( Scene% and$ heard:'9! darkened' when%pressed%%% configura)on! Scene%and% heard&app:& Scene%and% heard&app:" Addi$onal) Klingberg) et#al.# (2002)( Contro lled$ study( 1813$ !mes( ADH D( 7J15( 14( 20(min(per( day,(4±6( days(a( week,(for( at(least(5( Execu&ve( func%on( SG:$ CogMed( Training'significantly' improved)working)memory) and$visuo$spa+al$skills( 11( LowJdose% version(of( the$same$ game%as% placebo( Small%sample%size( 14( Visual(and(verbal( feedback( group&improved&in&working& Large&sample& No( multiplayer,( static( graphics,(no( storytelling( de#Vries! et.al& (2014)( RCT( JCPP$ IF2015:( 6.284&( ASD( IQ# >80( 8J12( 90( (( Execu&ve( func%on( SG:$$ Braingam e"Brian( memory&and&ADHD& symptoms.(The(high( a"ri%on(rate(and(the( absence'of'clear'effect'of' the$training$do$not$support$ 15( of#children# with%a% control'group' using&a&non& adapta%ve( N/A( 15( Limited' 3D#world#with#an# ac#ons'of'the' a"rac%ve( player'inside' storyline*and* the$game,$no$ beau%ful(graphics( mul$player(
	training.(! BEST&PAPERS&ACCORDING&TO&JOURNAL&IMPACT&FACTOR(	parents.!	auditory) feedback!

Table 5 . Best papers exploring video modeling in NDD according to citations or impact factor journals

 5

	Authors (Year)	Study design	Inclusion criteria (Most cited or best journal)	NDD	Age (y/o)	N total	Duration Intensity	Targeted skill	Type of support	Person delivering the interventi on	Main results	Methodology quality (max=15 Score Strength Weakness	Score (max=26)	Design quality Strength	Weakness
									Best papers according to citations
	Charlop -Christy et al. (2000)	Case series	1146 times	ASD	7-12	5	Duration varied from weeks to months dependin g on the child, 170 minutes of VM	Social skills	Videotap e	Therapists	Comparing video modeling and in vivo training. Video modeling led to faster acquisition of tasks and promote generalization	6	Multiple baseline	small and heterogeno us sample	5	Target behavior are displayed at a slow pace, cost efficiency	No personalisati on, no reinforceme nt, no features to support motivation
											Increased
										One	performance on						No model of
	Ozonoff et al. (1995)	Controlle d study	943 times	ASD (IQ>7 0)	12-14	9	18 weeks	Social skills	Videotap e	primary leader with three additional	Theory of Mind Tasks and ratings of social behavior in the training	9	Control group	small sample	11	Videotape d of the participant s	the targeted behavior, no possibilities to modify
										staff	group but not in						the difficulty
											the control group
							Duration
	Charlop & Milstein (1989)	Case series	733 times	ASD	3-8	3	varied, biweekly during the VM phase, each video was presented three times at a time; was 45 length video average	Commu-nication	Videotap es	Therapist	Children acquired conversational speech after exposure to the modeling procedure and generalized to all of the probes	7	Evaluatio n at 15 months follow-up after training	The frequency of training was not described and duration depends on the time each child criterion acquisition meet the needed to	2	Cost efficiency	No personalisati on, no reinforceme nt, no features to support motivation
							sec.

papers according to journal impact factor

  ID=Intellectual disability; ASD=Au sm spectrum disorder; ID=Intellectual disability; JADD= Journal of autism and developmental disorders; Int J Behav Consul Ther=Interna onal Journal of Behavioral Consulta on and Therapy

											2 of the 3
	Horn et al. (2008)	Case studies	Int J Behav Consul Ther: IF2008 4.796	ASD + ID	17-29	3	Twenty-fvie 15-minute sessions, no more than twice a week	Autono my	Video tape	Researche rs	participants to performing the learned how to wash clothes with the use of video prompting alone and one needed the least--to-most prompting	6	Multiple baseline	Small sample with heterogeno us profile	6	Possible to adapt the difficulty by shortening the video	No feedback, no reward inside the video, no features to support motivation
											skills
	Litras et al. (2010)	Case study	Autism res: IF2010: 4.633	ASD	3	1	25 sessions; three times a day; 5 to 3 minute videos	Social skills	Video Modeling : video tape	Participant 's parents	The child increased vocal communicative behavior and social raction engagement/inte	6	Multiple baseline	Small sample	15	Videotape d of the participant s, cartoon animation , clear goal motivation to support	No feedback, only adapted to this participant
											High school
											students with
											autism were able
											to transition
											within and
											between novel
											activities thanks
	Spriggs et al. (2015)	Case studies	JADD IF2015: 4.101	ASD + ID	17-19	4	One daily session for 3 months	Autono my	Video Modeling : My Pictures Talk	Teacher	to video modeling. Students exhibited high generalization to rates of	7	Multiple baseline	Small sample	12	Possible to personaliz e and easily VM modify the	No features to support motivation, no feedback
											the static visual
											activity schedules
											and novel task
											exemplars after
											the embedded
											video model was
											removed

Acknowledgements

Acknowledgements ................................................................................................................... Abstract ......................................................................................................................................

Acknowledgements

We thank Eliada Pampoulou (Cyprus University of Technology), Oliver Wendt (University of Potsdam,Germany/Purdue University, USA), Christos Nikopoulos (Autism Consultancy Services), MaryAnne Romsky (Georgia State University) for participating in the expert group.

Funding

This work was supported by the Ministry of superior education, research and innovation, France and by the Institut Universitaire d'Ingénierie en Santé, France.

Data availability

Data will be made available on request.

Publications Original articles related to the thesis:

Grossard, C., [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]

Declaration of competing interest

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.chbr.2022.100261. * all the papers found in our literature review AAC and SG remained stable overtime, interest regarding VM decreased, whereas interest regarding robots slightly increased.

Figure 2. Numbers of studies for each ICT by years of publication

help with generalization (Whyte, 2015). In this way, [START_REF] Grossard | Guideline development for technological interventions for children and young people to self-manage attention deficit hyperactivity disorder: Realist evaluation[END_REF] proposed downloadable gaming resources like quizzes, as a complementary form of work to digital therapeutic and educational interventions. The potential of digital health interventions is not fully utilized, which may contribute to the lack of clear advantages over traditional methods (Grossard et al., 2017).

The active components of ICT tools are not well investigated (Hollis 2017). This question is more addressed with robots, for which most of the studies focus on the technological characteristics and their potential impact on their use in therapeutic and educative interventions (Miguel Cruz et al. 2017). But, Hollis (2017) (Dalton, 2016). Engineers should now develop ICT that can automatically adapt difficulties, exercises, graphical design, and attention levels based on the player's responses and behavior.

How are ICTs included in treatment plans for people with NDD?

The use of ICTs in usual treatment of people with NDD is still unclear due to a lack of information about its use once the studies end. Few studies have included a longitudinal followup (Scassellati et al., 2012), which is important for understanding the user's motivation. Some studies, especially in robots, have only involved one single interaction with the user. However, children with NDD are sensitive to novel stimuli and repeated interactions are necessary to assess if the amount of exposure can significantly modify the response of the user (Scassellati et al., 2012).

The duration of exposition to an ICT varies widely between studies, with some lasting as little as 5 minutes per day and others lasting up to 2 hours per week (Khan, 2019). However, there is no consensus on the best duration for these interventions. Some studies have

Chapter 5: Can social robots be included and beneficial in a social skills group for autistic children?

group setting previously developed for children with dysgraphia [START_REF] Zou | THE IRECHECK PROJECT-Asocial ROBOT HELPING[END_REF]. To this end, the present study involves the SAR 'QT' controlled through the Wizard of Oz R2C3 interface implemented in an SSG for autistic children. The Wizard of Oz paradigm allows the use of such platforms in unstructured scenarios, so the therapist is continuously in control of the robot's behaviors through teleoperation via a tablet [START_REF] Tozadore | Wizard of Oz vs autonomous: Children's perception changes according to robot's operation condition[END_REF][START_REF] Rietz | WoZ4U: an opensource wizard-of-oz interface for easy, efficient and robust HRI experiments[END_REF].

The purpose of this exploratory study is to qualitatively explore the feasibility and usability of the Wizard of Oz robotic R2C3 interface [START_REF] Zou | A wizard of oz interface with qtrobot for facilitating the handwriting learning in children with dysgraphia and its usability evaluation[END_REF] on SSG dynamics and measure its effect on the engagement of children within the group under two conditions: an active interface and an inactive interface. The most frequently used definition in studies investigating engagement is found in [START_REF] Sidner | Explorations in engagement for humans and robots[END_REF] and describes engagement as "the process by which interactors start, maintain and end their perceived connection to each other during an interaction. It combines verbal communication and nonverbal behaviors, all of which support the perception of connectedness between interactors" [START_REF] Oertel | Engagement in human-agent interaction: An overview[END_REF]. The concept of engagement holds great significance in human-machine interaction as it not only aids in the design and implementation of interfaces but also facilitates the development of advanced interfaces that can adapt to users' needs [START_REF] Anzalone | Evaluating the engagement with social robots[END_REF].

As predicted by the literature [START_REF] Gates | Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis[END_REF], we expect that SSG will improve children's social skills as well their engagement within the group. Our exploratory hypotheses are as follows: (1) it is feasible to implement the R2C3 robotic interface in an SSG for autistic children, (2) the presence of the QT robot will positively impact children's engagement and will

(3) improve children's social skills and decrease their maladaptive behaviors during the SSG sessions.

Methods

Study design

This is an exploratory feasibility study that implements the SAR QT with the Wizard of Oz R2C3 interface [START_REF] Zou | THE IRECHECK PROJECT-Asocial ROBOT HELPING[END_REF]. The experiment corresponds to an intraparticipant design where each participant is exposed to both conditions (active and inactive R2C3 interface). The proposed activities are tailored to the abilities of each group of children. The primary variable of this study is children's engagement in the group. The study was approved by the local university ethics' committee (IIQCASSGS).

Participants

Participants were recruited from the children's outpatient unit of the Child and

Adolescent Psychiatry Department at the Pitié-Salpêtrière Hospital. The inclusion criteria included an ASD diagnosis validated by the Autism Diagnostic Interview (ADI-R) [START_REF] Rutter | ADI-R. Autism diagnostic interview revised[END_REF] or the Autism Diagnostic Observational Scale (ADOS-2) [START_REF] Lord | Autism diagnostic observation schedule-2nd edition (ADOS-2)[END_REF], age 6 to 11 years, absence of SSG intervention in therapeutic care and consent of at least one of two legal representatives. The exclusion criteria included severe intellectual disability, multiple disabilities, major behavioral disorders, degenerative disease or other disease that could interfere with the evaluations planned during this study (e.g., known epilepsy and/or history of seizures). We recruited six participants and formed two social skills groups, taking into account the age of each participant. Group A included children from 9 years 6 months to 10 years 4 months, while Group B included children from 6 years 4 months to 8 years 7 months. The sample consisted of 4 girls and 2 boys. See Table 1 for the participants' characteristics. contrast, the number of social engagement initiations did not increase significantly across sessions (p = 0.06) (Table 4, Figure 1b).

Assessing the design of R2C3

The design of R2C3 (combined with QT) was evaluated post intervention using the DICTI [START_REF] Grossard | Building the design ICT inventory (DICTI): A Delphi study[END_REF]. As shown in Table 6, the total score was 15, for a maximum of 26. We observed several positive points: the interface was very easy to use even for nontechnological people, the positive reinforcements were varied and adapted, and the appearance and reactions of QT made it attractive and engaging. However, there was no possibility of customizing the interface to adapt to different profiles or of managing complexity (e.g., by adapting scaffolding according to the scenario and user capacities-i.e., the robot can first initiate the interaction, then just support it-or by modifying the speed of displaying the stimuli). Additional qualitative comments will be presented in the discussion.

Discussion

The social skills group

We expected that the SSG would improve some of the children's social skills [START_REF] Gates | Efficacy of group social skills interventions for youth with autism spectrum disorder: A systematic review and meta-analysis[END_REF][START_REF] Gosling | Efficacy of psychosocial interventions for Autism spectrum disorder: An umbrella review[END_REF]. The results support the effectiveness of SSG interventions.

Qualitatively, we were able to observe a real benefit of the sessions on the social skills of the children within the group. These observations are consistent with the literature on SSG for autistic children [START_REF] Kruck | Étude sur l'efficacité des groupes d'habiletés sociales proposés aux enfants avec un trouble du spectre autistique[END_REF]Bohlander, Orlich & Varley, 2012). As the sessions progressed, the children produced more social openings for adults and other participants, whereas in the first few sessions, there was no interaction between the children and few responses to the adults' social interaction requests. We also observed an improvement in roletaking skills. We believe that the recommendations for SSG [START_REF] Baghdadli | Entrainement Aux Habiletés Sociales Appliqué a L'autisme[END_REF] in this study help to explain the improvements observed. However, the improvement of social interactions between the children can also be explained by the researchers' progressive adaptation of activities to the participants' cognitive and language levels. This was the case for the emotion recognition activity. At first, we asked the children to describe and interpret images, which was difficult for a certain number of the children and not playful enough to truly involve them in the activity. We then transitioned to a symbolic game using puppets, where the adults simulated problematic social situations (e.g., jealousy, frustration, sickness). This allowed all children to participate and to interact with each other through the puppets ("Are you okay, Grandpa?", "Are you sick, Mickey?", "Can we share?", "It's ok to feel hurt"). Finally, beyond the improvement of social skills, this group was reported to be a real moment of pleasure for the children. All participants came to the sessions enthusiastically, and the hospital care team told us on several occasions of the participants' fondness for the group and QT. Overall, this positive outcome is in line with studies that reported positive therapeutic outcomes with SAR in autistic children by promoting social skills [START_REF] Saleh | Robot applications for autism: a comprehensive review[END_REF][START_REF] Scassellati | Improving social skills in children with ASD using a long-term, in-home social robot[END_REF][START_REF] Sartorato | Improving therapeutic outcomes in autism spectrum disorders: Enhancing social communication and sensory processing through the use of interactive robots[END_REF].

Feasibility and usability of the R2C3 interface and SAR QT

Our observations revealed that the feasibility and usability of the R2C3 interface and SAR QT within an SSG for autistic children was good overall. The inclusion of the robot in the group elicited positive reactions and engagement towards the intervention from the children, Methods and Design: 150 children aged 3 to 6 years old diagnosed with ASD and their parents will be recruited into this single blind, randomized controlled trial using a serious game, e-GOLIAH. Eligible participants will be randomized to the treatment group "GOLIAH", which will provide therapy as usual plus the digital game home-based intervention and the control group will receive therapy as usual for 12 months. The GOLIAH group will receive two interconnected tablets per household, one for the child and one for the parent. e-GOLIAH gaming platform design will be evaluated with the Design ICT Inventory (DICTI).

Discussion: This randomized controlled trial will determine the effectiveness of the SG e-GOLIAH as a complementary tool to ASD treatment. This trial will also determine the feasibility of a parent delivered home-based intervention aiming to improve the participants' social interactions by practicing imitation and joint attention skills. Additionally, we will evaluate the cost-utility 12 months after the e-GOLIAH was implemented at home, versus treatment as usual alone. The SG design quality was assessed using the DICTI, resulting in a moderate score of 15 out of 26. Noteworthy features included its simplicity to use, clarity of instructions and difficulty management.

Trial Registration: This research is registered on the site http://clinicaltrials.gov/ under the number registration No. NCT05271955.

Keywords: Autism Spectrum Disorder, serious games, home based intervention, parent delivered intervention, social skills, imitation, joint attention

• Medicoeconomic data

During the inclusion visit, socio-demographic information and details of usual treatment will be collected (consultation, number, frequency and type of rehabilitation, school inclusion, School Life Assistant (number of hours), home educator (number of hours), other care.

Vineland II (in case not done during the selection visit)

Collection of personal data (NIR, DN and sex: child and parents) (separate file)

Clinical Outcome measures

The following clinical variables will be assessed in the experimental and control groups at entry and at 6 months:

• Adaptive symptoms will be measured with the Vineland-II (Sparro, Balla & Cicchetti, 2005):

it is a socio-adaptive behavior scale with four dimensions, three of which will be considered: socialization, communication, and daily living skills; and a composite adaptive behavior score that combines these three dimensions). This scale will be completed during the interviews with the parent or the referring educator.

• Autistic symptoms will be measure with the CARS Child Autism Rating Scale (CARS, Reichler & Schopler, 1971) consists in 15 items will be evaluated with a 4-level Likert scale.

• Social interactions will be measured with the Social Responsiveness Scale (SRS, John N.

Constantino, 2012). This is a questionnaire about the child that will be completed by the parents or the referring educator during the interviews.

• Parental stress levels will be measure with the Index Stress Parental (Abidin, R. R. (1983).

French adaptation, Bigras et LaFrenière, 1996), which consists in a standardized questionnaire with two dimensions regarding the stress associated to the child and to the parents.

Medico-economic outcomes

Primary endpoint: cost-utility, based on 3 elements:

1. Collection of consumption (excluding social security) in the case report form (CRF)

2. Personal data from the Health Insurance (SNDS)

EQ5D questionnaire

The child's acceptability to the game e-GOLIAH at home will be evaluated qualitatively during the interviews with the parents or the referent educator and quantitatively from the times of use counted by the tablet.

treatment financial burden. Based on previous results [START_REF] Jouen | GOLIAH (Gaming Open Library for Intervention in Autism at Home): a 6-month single blind matched controlled exploratory study[END_REF], the implementation of the SG platform is promising. Alongside the challenges posed by the COVID pandemics, the e-GOLIAH project has encountered administrative obstacles that have impeded its initiation. These Tables 2 to 5 summarize the three most cited article from Google Scholar as well as the 3 articles from the highest impact factor journals per domain, respectively robot, ACC, SG and VM. The experimental methodology and main results are described below. The children propose solutions to the situations proposed with the help of the adult Among the pictograms, the children take turns choosing ingredients to prepare a recipe from a shopping list. The children ask questions to each other and ask QT about his preferences n°10 : QT inactive -Attendance: each child puts his or her photo and that of the adults present on the table next to the corresponding first name -QT says he's tired today Musical imitation: an adult makes a drum rhythm, and each child imitates it; the children each try to propose a rhythm to the group Symbolic play: the children and adults play with puppets and create a story by proposing solutions to problematic social situations Among the pictograms, the children take turns choosing a toy for a friend's birthday from a shopping list and ask questions to their peers