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[Proceeding] Playable One-Switch Video Games for Children with Severe

Motor Disabilities Based on GNomon

Original Citation:
Aced Lpez S.; Corno F.; De Russis L. (2015). Playable One-Switch Video Games for Children
with Severe Motor Disabilities Based on GNomon. In: 7th International Conference on Intelligent
Technologies for Interactive Entertainment, Turin, Italy, June 1012, 2015. pp. 176-185
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This version is available at : http://porto.polito.it/2605010/ since: May 2015
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IEEE
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DOI:10.4108/icst.intetain.2015.259620
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Playable One-Switch Video Games for Children with
Severe Motor Disabilities Based on GNomon

Sebastian Aced Lopez Fulvio Corno Luigi De Russis

Politecnico di Torino Politecnico di Torino Politecnico di Torino
Corso Duca degli Abruzzi, 24 Corso Duca degli Abruzzi, 24 Corso Duca degli Abruzzi, 24
Torino, 10129 Italy Torino, 10129 Italy Torino, 10129 Italy
Tel.: +39 011 090 7191 Tel.: +39 011 090 7053 Tel.: +39 011 090 7170
Fax: +39 011 090 7099 Fax: +39 011 090 7099 Fax: +39 011 090 7099
E-mail: sebastian.acedlopez@polito.it E-mail: fulvio.corno@polito.it E-mail: luigi.derussis@polito.it

AbstractBeing able to play games in early years is very particular, children with motor disabilities often lack the ability
important for the development of children. Even though, children to use standard input devices such as keyboard, mouse or game
with physical disabilities encounter several obstacles that exclude controllers, and thus they are usually excluded from playing
them from engaging in many popular games. In particular, video games similar to those played by their peers. Moreover,
children with severe motor disabilities that rely on one-switch children with severe motor disabilities that rely on the use of
interfaces for accessing electronic devices find dynamic video
games completely unplayable. In this paper we present the
a single switch for accessing electronic devices, find dynamic
development and evaluation of GNomon: a framework, based video games completely unplayable.
on the NOMON interaction modality, that enables the creation
of dynamic one-switch games for children with severe motor
The problem is that dynamic video games are fast-paced
disabilities. The framework was designed following a series of games that require rapid decision-making and timely responses
guidelines elicited in close collaboration with a team of speech from the player for successful interaction; conversely, switch
therapists, physiotherapists and psychologists from one of the interaction (a.k.a. one-switch interaction) is typically based on
Local Health Agencies in Turin, Italy. Likewise, three mini games scanning, a selection mechanism that is not intended for time-
were developed for testing the playability of GNomon-based dependent tasks or rapid decision-making processes. In fact,
games. Finally, we conducted a series of trials with 8 children scanning requires the selectable elements to be stationary in
with severe motor disabilities assisted by the health agency, in fixed layouts and takes time to be operated, as will be explained
which we found that all of them enjoyed playing the GNomon- in detail in Section II. Dynamic games, on the other hand,
based mini games and that 7 of them were able to interact and are characterized by the presence of elements that can move
play autonomously.
around the screen and by offering complex visual scenes which
Keywordsaccessible games, one-switch interaction, assistive can change quickly. As a result, one-switch users have access
technology, children with disabilities, single switch selection. to static, time independent and barely interactive games.
There is therefore a clear need for dynamic video games
I. I NTRODUCTION
playable by children with severe motor disabilities that rely on
Play is the leading source of childrens development [1], the use of a single switch (from now on referred as the target
thus the ability to play games in their various forms is children) as they want to play games similar to those played by
very important during childhood. Nowadays, one of the most their peers without disabilities, as found by Hernandez et al.
popular forms of games among children are video games in a year-long participatory study reported in [5]. Additionally,
(see the United States and Europe statistics reported in [2] it has been shown (e.g., in [6] or [7]) how complex training
and in [3], respectively). Video games differ from other type environments such as video games, specifically dynamic or
of games because of their interactiveness; video games offer action ones, produce learning that transfers well beyond the
dynamic game mechanics, a wide variety of game genres and training task.
sophisticated interfaces that make them a unique entertaining
experience to actively engage in. Moreover, these games not The objective of this paper is twofold. First, we present
only entertain, but benefit players in cognitive, motivational, GNomon, a framework that enables the creation of acces-
emotional and social aspects in ways never before afforded, sible dynamic one-switch video games. The framework was
according to [2]. designed following a series of guidelines elicited in close
collaboration with a team of speech therapists, physiotherapists
However, this is not always the case for many children with and psychologists from one of the Local Health Agencies in
disabilities1 because they do not have the sensorial, cognitive Turin, Italy. The second goal is to report the results of the
or motor skills for accessing off-the-shelf video games. In evaluation of three GNomon-based mini games with 8 target
1 Although disability is a complex multidimensional experience that poses
users assisted by the health agency. These results, and the
several challenges for measurement, UNICEF [4] estimates that the 5.1% and associated discussion, allow us to tackle the research question
0.7% of children (aged 0 to 14) worldwide live with moderate to severe of whether it is possible to develop dynamic video games
disabilities and severe disabilities, respectively. playable by children with severe motor disabilities using just
a single switch as input device. only if they are literate. Mackay et al. proposed Dasher [12],
an information-efficient text-entry interface, driven by natural
This paper is organized as follows: Section II provides continuous pointing gestures which can be carried out through
useful background concerning accessible interfaces for persons single switches. Broderick and MacKay described NOMON in
with severe motor disabilities, with special focus on those used [13], a fast and flexible interface which serves as a substitute
by children, and the state of the art of video games based for any point-and-click activity on a computer screen. Belatar
on one-switch interaction. Section III describes the GNomon and Poirier presented HandiGlyph [14], an interface for mobile
framework, its design process and its final features, while devices to allow users with severe motor impairments to entry
Section IV presents the development of three mini games based text.
on it. Section V reports the playability evaluation of the mini
games with a group of 8 children with severe motor disabilities Alternative interfaces for one-switch users operated without
and Section VI discusses the results. Finally, the conclusions the use of single switches are attracting widespread interest.
extracted from this work are presented in Section VII. Researchers such as Harada et al. conducted a longitudinal
study on voice cursor control reported in [15], and a group of
the University of Malaga presented in [16] a brain-computer
II. BACKGROUND interface paradigm that allows to select several output com-
In this Section we present some relevant one-switch in- mands using only two mental tasks.
terfaces and alternative interaction mechanisms accessible by Unfortunately, previous works were mainly developed hav-
persons with severe motor disabilities of all ages, including ing in mind text entry or menu selection, contexts in which
children. We also review and classify several free online one- 1) selection sets are large and the occurrence of having to
switch games suitable for our target children. repeat an input is low, 2) selection sets are known and static,
Persons that live with severe motor disabilities caused 3) single elements can be arranged in fixed positions to
by traumatic injuries (e.g., spinal cord injury), diseases (e.g., enhance selection speed and effectiveness, 4) each element
Lou Gehrigs disease) or congenital conditions (e.g., cerebral has a computable probability of being the next to be selected,
palsy) usually interact with computers using assistive direct given the previous selections. Consequently, when the afore-
selection or using scanning interfaces. Direct selection refers mentioned one-switch selection mechanisms and principles are
to the action of somehow pointing (e.g., with the finger or utilized to enable our target children to interact with video
with the gaze) at any desired item for selecting it, whereas games, the resulting experience is often trivial, static or boring,
scanning allows the selection of one element at a time from as illustrated in the following review of several free games
an arrangement of selectable elements, in sequential order. (games listed in a popular non-profit website2 ). The criteria for
Specifically, scanning works by sequentially highlighting the including the games in the review was that they can be played
selectable elements (or groups of elements) and waiting a short with just a two-state single switch. We identified three major
time (i.e., scanning delay) on each of them for an input to categories of one-switch video games and the main barriers
occur. Such an input is usually the activation of a single switch, that prevent children to enjoy them:
which consists in just a click with timing information (i.e., 1) Action/Reaction games. The goal on these simple games
the moment of the click, but its duration). Finally, an element is to press the switch to obtain some effect (e.g., when
is selected if it is the one currently highlighted when the input the switch is pressed, a football player kicks a ball3 ).
event occurs. Although scanning is considered slower and more These games are used to teach the children how to use
cognitively taxing than direct selection, generally consists the switch and to associate it to a trigger for different
of a much simpler and inexpensive set up and it requires actions. The downside of many action/reaction games is
considerably less motor control to be used efficiently (see [8] the lack of interactiveness for cognitively able children
for more details about scanning as an interface method). Thus, due to the fact that they cannot make any decision to
scanning interfaces operated through single switches are very affect the outcome of the game, as the effect of pressing
popular among our target children. the switch at any time is always the same.
Over the years, much research has concentrated on im- 2) Scanning based games. Most of the available one switch
proving one-switch selection mechanisms for enhancing the games (e.g., chess, memory, battleship, etc.) fall under
interaction capabilities of persons with severe motor disabili- this category. These are usually more complex than ac-
ties of all ages. In the book of Beukelman et al. [9], the authors tion/reaction games as scanning allows to select more
discuss diverse alternative access options to address complex than one element (or action) from an arrangement of
communication needs, such as different scanning control tech- options. However, it is not possible to interact with video
niques while Jennifer Angelo, in [8], systematically compares games that do not have a static arrangement of selectable
three basic modes of scanning (e.g., automatic, inverse and elements, a fixed scanning order and suitable game me-
step) for supporting one-swtich interaction of persons with chanics to allow enough time to make any selection even
cerebral palsy. Other studies, such as [10] and [11], have after a complete scan.
focused on designing entire systems to provide one-switch 3) Click timing games. This category of one switch games
users accessibility to computer applications, which is essential includes those in which the player has to press the
for participating in modern information society. In the last switch with high precision to perform an action in a
decade, alternative input methods for empowering one-switch 2 http://www.oneswitch.org.uk, last visited on April 30, 2015
users to interact with electronic devices have been explored, 3 http://www.specialbites.com/switch-activated-games/
specially for text entry. However, the interfaces specifically penalty-shootout-cause-and-effect-switch-game.html, last visited on April
designed for text entry maybe slow, and are usable by children 30, 2015
 very specific moment. The problem with many of these
games, such as Poto & Cabenga4 and Strange Attractors5 ,
is that they are not fully accessible to children with severe
motor disabilities because such games require a speed and
precision that these children often do not have.
To our knowledge, we are the first to address the question
of whether it is possible to develop dynamic video games
playable by children with severe motor disabilities using only
a single switch as input device.
Fig. 1. This figure shows an example of the clocks used in GNomon for
selecting game objects (right) and the original NOMON clock (left). The
III. GN OMON appearance of the new GNomon clock is based on the original design but
with important modifications suggested by the experts: enlarging the clock,
GNomon is a framework that enables the creation of thickening all clock lines, placing marks at clock quarters, rendering more
accessible and dynamic one-switch video games (the first idea eye-catching the red noon hand and making the moving clock hand pointier.
about it was presented as a work in progress by Aced Lopez
et al. in [17]) . It is based on the NOMON one-switch mode
of interaction, which allows to select one of many elements
from the screen without extra special hardware (e.g., expensive by guiding important design choices and proposing features
eye trackers) and without requiring them to be arranged in any on behalf of the children assisted by them. In total, we con-
particular configuration or to be stationary. ducted five meetings with the experts for testing and collecting
suggestions to improve the framework. Thus, several features
In a very inspiring publication [13], Broderick and MacKay of GNomon, mainly related to specific accessibility issues,
present in detail the operation and evaluation of NOMON, were adapted to follow their valuable recommendations. The
therefore we report just the main aspects of its operation here: recommendations are the following:
NOMON associates a small visible clock face to each 1) Providing additional indicators for facilitating interaction.
selectable element on the screen and places it next to the In particular, four circular marks were placed in the
element. clock quarters (the three oclock, six oclock and nine
Every clock has one black hand which rotates at the same oclock) to facilitate the interaction of children with long
speed as the other clocks hands, but with a different muscular latent periods (i.e., the time elapsed between
phase. The clocks also have a red hand fixed at noon. the movement command and the muscle movement) by
To select an element the user has to find the associated helping them with indications of when to start preparing
clock and try to press the switch, as precisely as possible, themselves for pressing the switch.
when the black hand is crossing the red hand at noon. 2) Making the clocks more eye-catching. Game objects are
Then, for each clock, NOMON calculates the probability usually attractive, colorful and animated, hence they tend
of it being the intended selection, given the clicks thus to concentrate the attention of children. Moreover, as the
far. If the probability of a clock is sufficiently high but clocks are just the means for selecting game objects, it
not enough to declare it as the selection, because there is normal that the former are less striking than the latter.
are also other likely candidates, the clock faces of all However, the clocks appearance was redesigned to be
candidates turn yellow and a new round starts. Finally, as eye-catching as possible (while keeping its simplicity)
when the probability of one clock reaches a predefined to prevent the less attentive children from ignoring the
threshold, it turns green and the associated element gets clocks. In particular, the clocks were enlarged, the colors
selected. were made brighter and more contrasting, the lines were
thickened and the moving clock hand was made pointier.
In particular, GNomon provides functionalities for creating Figure 1 shows a comparison between the classical and
sets of selectable game objects with associated NOMON new appearances of the clocks.
clocks for enabling dynamic point-and-click game mechanics 3) Reducing the average speed of rotation of the moving
using a single switch. These sets can be resized at any clock hands and making it customizable. The rotation
time by adding or removing elements, which is necessary period of the clock hands ranges from 1 to 10 seconds, to
for supporting common dynamic game actions such as the allow children with long muscular latent periods to enjoy
creation of new items or the destruction of characters. More- GNomon based games. The rotation speed can be set and
over, the framework is also very useful to make static games changed easily by the children caregivers.
(e.g., scanning-based games) more challenging by allowing 4) Giving auditory and visual feedback when a clock is
selectable elements to be displayed without layout restrictions. selected. Besides the specific feedback and the actions
A participatory approach was adopted for eliciting the triggered in each game when a clock is selected, the clock
features and accessibility guidelines of GNomon, thus we itself changes color and a sound is played.
worked in close collaboration with a team of speech therapists,
physiotherapists and psychologists from one of the Local The final implementation of the GNomon framework in-
Health Agencies in Turin, Italy. They actively supported us corporates our custom extended C# versions of the original
NOMON Python libraries into a Unity2D6 plugin.
4 http://www.potoandcabenga.com/, last visited on April 30, 2015
5 http://ominousdev.com/strange-attractors/, last visited on April 30, 2015 6 http://unity3d.com/unity/2d-3d, last visited on April 30, 2015
 Fig. 3. The figure shows the red ladybug (top left) jumping while it is being
Fig. 2. The figure shows a red ladybug and its associated clock during a selected during a One Switch Ladybugs game.
One Switch Demo game.

IV. T HE G AMES
7
Three prototype games with different degrees of difficulty
which are fully playable with just one switch were designed
in collaboration with the Regional Health Agency. Here we
present them in order of difficulty: One Switch Demo, One
Switch Ladybugs and last One Switch Invaders.

A. One Switch Demo

The first game is One Switch Demo, a very simple ac-
tion/reaction video game that allows children to make a red
ladybug jump when they select the clock associated to it. When
the ladybug is selected correctly and it jumps, it also produces
an auditory feedback to increase the childrens reward. There
are no scores or time constraints of any kind because the
game has been designed mainly to explain how clock selection Fig. 4. The figure shows six aliens falling down the screen while the green
works. The aesthetics, as the objective of the game, are very one (at the left) is being selected during a game of One Switch Invaders.
simple to help the children with visual and attention difficulties
to stay focused on the game mechanics. Figure 2 shows a
screenshot of the game. one-switch game that does not require accurate timing or
clicking precision to be played. This is a game without a fixed
layout, in which multiple selectable elements (aliens), moving
B. One Switch Ladybugs down across the screen, have to be selected with a time con-
The second game is One Switch Ladybugs, another simple straint (i.e., before they touch the ground). The implementation
mini game that allow children to make one of four ladybugs of One Switch Invaders is not feasible by applying scanning
jump. Each ladybug has a different color and provides a unique interfaces because the elements are not static in predefined
auditory and visual feedback when it is successfully selected. layouts and it is not possible to establish a scanning order
There are no scores or time constraints of any kind, but unlike without negatively affecting the game mechanics.
the first game the aesthetics are richer and there is background The game objective is to score points by eliminating the
music playing in loop. The objective of the game is the same aliens before three of them touch ground. There are aliens of
as in the previous game: to make a ladybug jump, with the five different colors which constantly fall down the screen at
difference that in this case, the children have to first choose the a bounded random speed. Each alien is associated to a clock
ladybug they want to make jump. Figure 3 shows a screenshot to enable its selection and is generated in a random position
of the game. at the top of the screen. Figure 4 shows a screenshot of the
game.
C. One Switch Invaders
The third game is definitely more complex than the first two D. Design Considerations
and is called One Switch Invaders. It is an engaging dynamic
The design of the mini games (specially One Switch
7 Downloadable at http://elite.polito.it/gnomon-games, last visited on April Ladybugs and One Switch Invaders) take into account some of
30, 2015 the valuable design recommendations from Hernandez et al. in
[5] for playable action-oriented video games for children with Different game objects have to produce different visual
cerebral palsy: and/or acoustical feedbacks when selected.
Although aliens can fall with different speeds, the max-
1) Simplify level flow, reducing the number of decisions imum falling speed has to be bounded by a maximum
players need to make and reducing the demands on visual- value set by the player or the caregiver. However, for
spatial reasoning. In One Switch Ladybugs, this is taken evaluation pourposes, in this version all aliens fall at the
into account by presenting only four ladybugs which can same constant speed.
perform just one action (jump). Although in One Switch In the One Switch Invaders game, the aliens wait until
Invaders the player has many aliens to eliminate, the the first click to start falling. In this way, the player
decision of which one to eliminate first is simple: the can observe the clocks and familiarize with the speed of
lowest one, because the goal is to keep them out of the rotation of the clock hands before trying to select one of
ground and all them fall with an equal and constant speed. them.
2) Reduce consequences of errors, ensuring that errors due
to difficulties completing rapid or time-sensitive actions V. E VALUATION
do not impair fun. While in One Switch ladybugs there
is no error penalty at all, in One Switch Invaders players Following the design and implementation phase of
have three lives before they lose. Moreover, if a player GNomon and the mini games, an evaluation of these was
misses the selection of an alien, she has more opportuni- conducted in collaboration with the group of experts of the
ties to kill it as the falling time of its associated clock is Regional Health Agency. The research question to answer was
enough for allowing several clock hand revolutions before whether it is possible to develop dynamic video games that are
the alien touches the ground. playable by children with severe motor disabilities using just
3) Limit available actions, reducing the number of decisions single switch as input device. In particular, we were interested
players need to make, and enabling a simpler control in determining if GNomon can be used for such a purpose.
scheme. The control scheme of GNomon-based games For this evaluation, we consider a game playable (suitable for
consists of just one action: to press the switch. The only being played) if it is usable and fun for the player (based
decisions that the players have to make, besides from on the concept and characteristics of playability presented in
when to press the switch for selecting the desired clock [18]). Hence, we assess the following properties of playability
are: which ladybug jumps next in One Switch Ladybugs of the GNomon-based mini games through a series of eight
and which alien is better to kill next in One Switch tests:
Invaders.
Learnability: How easy is for the children to understand
4) Remove the need for precise positioning and aiming,
and successfully start to use a GNomon-based interface
reducing the demands on manual ability and visual-motor
after it has been explained?
integration. This is part of the selection process itself. The
Effectiveness: Does a GNomon-based interface actually
player does not have to press the switch precisely when
support the children in achieving the various goals of the
the clock hands are together for the interface to work.
game?
Moreover, if there is ambiguity between two or more
Errors: How many times the element selected does not
elements, their associated clocks turn yellow to indicate
match with the element that the children had in mind to
it.
select?
5) Make the game state visible, reducing the need for at-
Satisfaction: Do children like to play video games with a
tention to gameplay, and reducing the need for visual
GNomon-based interface?
spatial reasoning to deduce game state. Only One Switch
Invaders has a state, displayed at the top bar, which The tests were conducted in Italian at the Regional Health
consists in the number of remaining lives and points Agency with children between 4 and 14 years old with severe
reached. motor disabilities, who already consistently use one-switch
interfaces. The sessions were carried out at the facilities of the
Finally, we also present the main recommendations made Health Agency, a known environment for the children, to avoid
by the Regional Health Agency experts regarding the prototype making some children anxious about being in an unfamiliar
games: place. An expert speech therapist (tester) held the sessions
and two observers carefully took notes during these. It was
The appearance of each game object (ladybugs or aliens) decided to have an expert speech therapist as the tester simply
must be unique. This helps the children to remember the because she knows how to communicate more effectively with
game object that they are trying to select if they lose track the children (in particular with non-verbal children) than HCI
of it. For the ladybugs, this was achieved by assigning researchers. Similarly, the reason for having just two observers
them four different colors and placing them in the four during the tests, (one expert from the Health Agency and one
quadrants of the screen. However, in the case of the aliens HCI researcher) was to prevent some children from distracting
this is not possible because there is not a predefined and being uncomfortable in the presence of many people.
number of aliens that can be on the screen at the same
time. Therefore, the solution adopted in the second game A. Set-up and Materials
was choosing five colors to be sequentially assigned to
each new alien. In this way, children that lose track of All the tests were video recorded, with the authorization of
their game object can retrieve it without being confused the childrens parents and hiding the children faces, in order
with another near object that looks the same. to allow researchers to observe simultaneously the mini games
 TABLE I. M ATERIALES USED FOR CARRYING OUT THE TESTS
The sessions were held in Italian and lasted between 7 and
Materials 18 minutes, depending on various factors such as the cognitive
Intel i7 laptop with 8GB of RAM running 64-bit Windows 7
or visual difficulties of the children taking the test, their fatigue
One Switch Demo game
and how much they wanted to play each game. The sessions,
One Switch Ladybugs game
although in a flexible way, were structured in three parts. In
One Switch Invaders game
the first part, the tester explained the scope of the first game
Helpibox 16 interface
(i.e., to make the single ladybug jump) and how to accomplish
Big Red 5-inch switch
it. The tester demonstrated two times the selection mechanism
Logitech Orbit webcam
by making the ladybug jump. Then, the child tried to make the
Adjustable school table
ladybug jump and could play for 2 minutes maximum. In the
Alternative and Augmentative Communication (AAC) tables
second part, the speech therapist presented the One Switch
21 VGA monitor
Ladybugs game to the child by saying that it was played
in the same way as before, but explaining that this time it
was necessary to identify which of the four ladybugs make to
being played in a 21 screen and the children while they were jump and to concentrate on the clock next to it. As before,
pressing the switch, for later analysis. The switch utilized for the tester exemplified twice. Then, he asked the children to
playing was a Big Red 5-inch mechanical switch activated with make a different ladybug jump following a standard sequence
the hand or with the head, depending on the capabilities of 1) green, 2) red, 3) yellow, 4) blue. Finally, the child was asked
each child. The switch was connected to a Intel i7 laptop with to choose a ladybug to make it jump and to say it out loud
8GB of RAM running Windows 7. The interface between the (the non-verbal participants used an AAC table for this task)
switch and the computer was a Helpibox 16. In the case of non before selecting it. At the end of this part of the test, the child
verbal children, it was also necessary to use Alternative and could play freely for 3 minutes maximum. The last part of the
Augmentative Communication (AAC) tables to allow them to evaluation consisted in playing the One Switch Invaders game
answer the tester questions, in particular these tables contained but it was carried out only with participants P5, P6 and P8.
the colors of ladybugs, the yes/no answers and the faces to This part of the test was not proposed to the other participants
indicate like or dislike. Table I summarizes the materials because during the preparation of the evaluation phase, the
used for carrying out the tests. experts considered that it would be above the cognitive or
visual-attentive capabilities of children P1, P2, P3, P4 and P7,
B. Participants thus no reliable results could be expected from them. However,
when the third part of test was conducted, it followed a similar
The participants of this study are 8 children, 7 boys and 1 scheme than the one adopted for the other parts of the test:
girl, with severe motor disabilities. All of them are between 4 the objective of the game was explained to the children, then
and 14 years old and rely on the use of single switch interfaces the tester demonstrated twice how to kill the aliens and finally
to access electronic devices. The severe motor impairments of the children could play freely for 5 minutes maximum.
the children have different causes, which in some cases entail
cognitive disabilities as well (as in the case of some children At the end of each game, three questions were asked to the
with Cerebral Palsy). See Table II for a detailed summary of participants:
the participants. 1) Did you like the game?
Given the fact that the participants are children which have 2) What did you like the most?
special communication needs due to their disabilities, it was 3) What did you not like?
not possible for the tester to conduct the test in the exact same Likewise, at the end of the entire session, the children were
way for every child. Inevitably, for some children the therapist also asked the following questions:
had to explain the requested tasks in more detail and avoided
to ask open questions at the final questionnaire. Nevertheless, 1) Did you remember how to select the elements while you
the results are acceptable as the contents of the information were playing?
provided (and requested) by the therapist to (and from) the 2) Was it difficult to select the elements?
participants was essentially the same. Only its presentation was 3) Did you have fun?
adapted to suit better each child capabilities. At the end of all the tests, the recordings were carefully
transcribed for further analysis, as well as the observation notes
C. Procedures taken by the observers. Moreover, we also logged data from
As mentioned before, each session was conducted and each test; in particular, we collected information about: the
video recorded at the Regional Health Agency facilities, in rotation speed of the clocks, the falling speed of the aliens
Turin, by an expert speech therapist with two observers: (in the One Switch Invaders game), the number of clicks
another therapist and a HCI researcher. The recruitment of performed and the time of each one of them, the selection
the participants was straightforward since the Health Agency of a ladybug in the One Switch Ladybugs game and the final
proposed and gathered the children and helped us to fix score in the One Switch Invaders game.
the appointments for the tests. The criteria for selecting the
D. Observations
participants was that they had to be children between 4 and
14 years old, which use a single switch for accessing electronic Before discussing the obtained data, some general observa-
devices or that will do it in the near future due to degenerative tions are presented, in order to provide contextual information
conditions. useful for understanding the following sections of this paper.
 TABLE II. PARTICIPANTS WITH DETAILS ABOUT AGE , IMPAIRMENTS , DIAGNOSIS AND BODY PART USED FOR OPERATING THE SWITCH
Participant Age (years) Gender Impairments Diagnosis Switch activation
P1 4 Male Non-verbal with spastic quadriplegia with dystonia Cerebral Palsy Head
P2 4 Female Postural hypotonia Aicardi-Gouti`eres syndrome (AGS) Head
P3 4 Male Spastic quadriplegia, cognitive and communication difficulties Cerebral Palsy Hand
P4 6 Male Spastic quadriplegia, strabismus and cognitive difficulties Cerebral Palsy Hand
P5 7 Male Muscular dystrophy Spinal Muscular Atrophy (SMA) Hand
P6 7 Male Moderate cognitive difficulties Down syndrome with right-side hemiparesis Hand
P7 8 Male Cognitive, visual and coordination difficulties. Spastic quadriplegia. Cerebral Palsy Hand
P8 14 Male Muscular dystrophy Spinal Muscular Atrophy (SMA) Hand

There were minor difficulties while testing the games with P4 were facilitated by hiding two of the four ladybugs from
the children at the Regional Health Agency mainly related to them in an initial phase. In such a way, the tester limited the
the childrens mood. In general, the youngest children with visible options at the beginning of the free selection phase
cognitive or attention difficulties (P1 and P3) became tired by during the One Switch Ladybugs game, to help the children to
the end of the first game (i.e., the one with a single ladybug) concentrate in the ladybug they wanted to select. By contrast,
and faced the rest of the test with unfavorable attitude. In P5 and P8 had no errors when they tested all the three mini
particular, P1 (which is a non-verbal child) started to stare games, moreover they asked to play One Switch Invaders again
at the door when the tester asked him for the fourth time but with a faster falling speed (i.e., the falling speed is the
to select a ladybug during the second game, indicating that speed at which the aliens fall down the screen).
he wanted to leave the room. Similarly, P3 at the end of the
second game, did not want to freely play as he wanted at the All participants but one (P1) answered that they enjoyed
end of the first game. Nevertheless, the experts that regularly and had fun playing the mini games. However, the negative
assist these children agreed that it was normal that they were answer of P1 to the question Did you have fun? is not reliable
tired after trying new experiences that require them attention because it was asked at the end of the test when he was very
and concentration. tired, moreover it is in contrast with what he expressed at the
end of the first game when he said he liked the game. It is also
Another slightly problematic situation happened with P2, a in contrast with the notes taken by one of the observers which
4-years-old girl , as she was not being cooperative because she reported that the child was continuously smiling while he
wanted her mother in the room. The tester and the observers was playing.
decided to call in the mother in order to calm the child.
However, although the child calmed down, she was very The rotation speed of the clock hands was initially deter-
distracted by continuously looking at her mother and she was mined by the tester on the basis of the previous knowledge
not able to perform at her best in the test. that she had about each participant. However, when necessary,
the rotation speed was modified after the first mini game. The
rotation speed is expressed as an integer between 1 and 20,
VI. R ESULTS AND D ISCUSSION where 1 represents a rotation period of 10 seconds and 20
In this section we present the data and information col- represents a rotation period of 1 second. Setting the right
lected during the playability tests, along with their analysis and rotation speed was not an easy task, especially when the
the derived research findings. First, we present the observations participants had attention difficulties because setting a fast
made during the tests along with Table III, which summarizes speed increases the difficulty of successfully selecting the
them. Secondly, we asses the learnability, effectiveness, er- intended ladybug, while a slow speed gave some participants
rors and satisfaction of the mini games stemming from the enough time to be distracted and forget about the selection
aforementioned table and from the careful analysis of the task.
video recordings of each test. Lastly we attempt to answer the In Table III we summarize information regarding the
research question of whether it is possible to develop dynamic following aspects: the number of games actually played by
video games playable by children with severe motor disabilities each participant, the error ratio in the One Switch Ladybugs
using just a single switch as input device. game (i.e., the number of selections that were not the intended
The tests lasted in average 13 minutes and all participants, selection by the participant), clock hand rotation speed, overall
except P7, played at least the first two games (One Switch duration of the test, the answer of each participant to the final
Demo and One Switch Ladybugs). What happened with P7 is question Did you have fun? and the most relevant observers
that he could not make the single ladybug jump in the One notes.
Switch Demo. He was not even trying to make the ladybug
jump as he was distracted by watching the clock hand rotating A. Playability assessment
or looking at the table, hence the tester decided to stop the
test. On the other hand, P5, P6 and P8 were able to play From the data reported above we now assess the learnabil-
satisfactorily One Switch Invaders. ity, effectiveness, errors and satisfaction of the GNomon-based
mini games in order to determine their playability.
The errors were higher in the case of children with cog-
nitive or attention impairments than in the case of children 1) Learnability: In order to asses the learnability of these
with just motor disabilities, as expected. In particular, P3 and GNomon-based games we have to determine how easy is for
 TABLE III. T EST OBSERVATIONS
Participant Games played Test duration Error ratio Rotation speed Was fun? Observers notes
P1 2 14 min 55% 5 NO The observers noted that the children understood the game as well as
the selection mechanism. However for activating the switch he had to
turn the head left, thus loosing the screen out of sight and dropping
the attention. He was smiling while playing at the beginning, but then
he was tired and wanted to leave.
P2 2 15 min 50% 7 YES She understood the mechanism and was able to wait for the clock hand
to select the ladybug she wanted, however her emotional instability and
her dependency on the her mother hindered a better performance.
P3 2 18 min 53% 8 YES He had difficulties concentrating on the tasks proposed by the tester,
so he was facilitated by limiting the ladybugs to two at the time. In
this way, the child learned to first decide which ladybug he wanted to
make jump and then to select it. When the time for freely playing the
second game was over, he yelled More twice, thus he was allowed
to play more after the test.
P4 2 11 min 62% 6 YES The child did well when there was only one ladybug (i.e., during the
first game), however he had the worst performance of the group in the
second game. He had difficulties locating and staring the ladybug he
was asked (or that he freely wanted) to make jump. He expressed it
in these words: It was difficult whit four (ladybugs) to make jump
the one I wanted. I liked more the first game with just one (ladybug)
P5 3 10 min 0% 10 YES He did not have any error during the test. He played One Switch
Invaders for the first time with a clock hand rotation speed of 10 and
a falling speed of aliens of 8. He decided to stop playing at 40 points
and asked to play again but with a rotation speed of 12 and a falling
speed of 10. Then he lost after making 17 points.
P6 3 15 min 29% 8 YES Even if he started activating the switch at random during the first
game, in the One Switch ladybugs game he did well. He presented
good hand-eye coordination and he was very attentive at the indications
of the tester. When he did not want to play more the second game he
tapped repeatedly the switch. He played the third game initially with
rotation and falling speeds of 8 and 2, respectively. Then the tester
increased the falling speed to 5, as he wiped the screen of aliens
and started to be bored. Finally, the tester increased even more the
falling speed up to 10. The game was over when he tapped repeatedly
the switch again, indicating that it was enough for him.
P7 1 7 min - 6 YES For this participant we have no error rate relative to the One Switch
Ladybugs game, as he did not play it. The tester stopped the test with
him as he was totally distracted (e.g., he was looking at table or the
button) and was not trying to perform the tasks for the test. He only
activated the switch 5 times in 6 minutes, making the ladybug jump
just 2 times during the One Switch demo Game.
P8 3 15 min 0% 10 YES He had no errors at all during the test. He is the child with the most
severe motor disabilities which took the test, yet he has no cognitive
difficulties at all (just as participant P5). He enjoyed really much
playing the games, specially the third game and said that he had never
played a similar game. When the test finished, he asked if he could
play again One Switch Invaders, but faster (he passed from 10 to 15
and a from 8 to 10, of rotation and falling speeds respectively). He
played for one minute before loosing and scored 17 points. One of the
observers noticed him tense when many aliens were near the ground
and he could not avoid loosing one life.

the children to understand and successfully start to use the P4 said that it was easy to select the single ladybug, but he
GNomon-based interface after it has been explained. emphasized that selecting one of four ladybugs was not an
easy task. Moreover, the observers agreed that the children
It took, in average, 2 activations of the switch for the understood how the selection mechanism works, even though
children to understand the mechanism and to be able to some of them had trouble to operate it by themselves.
consistently make the single ladybug jump. There were cases
(P5 and P8) in which the participants understood and were The results presented here suggest that a game with a
able to use the GNomon selection mechanism immediately, GNomon-based interface is learnable by children with severe
but in other cases (P7) it could not even be determined if the motor disabilities, especially if they do not have additional
mechanism was comprehended. cognitive or visual impairments.
Two of the questions at the end of each test helped us to 2) Effectiveness: Here we determine whether making
determine if the selection mechanism was difficult to grasp: games based on a GNomon-based interface is effective. For
Did you remember how to select the elements while you were this, we assessed qualitatively (i.e., by analysing the notes
playing? and Was it difficult to select the elements?. Not all taken by the observers and the video recordings) if the partici-
the children were able to answer the first question because it pants were able to play and to achieve the goals of the diverse
was very difficult for their cognitive and communicative skills, games, utilizing the interface. Since the purpose of playing
but all of them (of those who played at least two games) the presented mini games is to entertain, their effectiveness is
agreed that it was not difficult to select the elements. Even highly related to the players satisfaction. Similarly, it is also
heavily dependant on how much it is possible for a player case of the last game, was really appreciated by the players as
to make progress and interact with the games, considered his something new that they were able to try.
impairments and the errors derived from these. In fact, the
evidence suggests that games and the interaction modality were Other children expressed their satisfaction while playing
effective, since it was certainly possible for 7 out of the 8 the games in diverse ways that were noticed and written down
participants to play and have fun while achieving the games by the observers. This is the case of the participant P3, which
goals, despite of the errors. Even participant P7, who could yelled More, more when the tester announced him that
just play One Switch Demo, was able to interact with the game the time for freely playing One Switch Ladybugs was over.
and the single ladybug through the GNomon-based interface Similarly, participant P2 indicated through an AAC table that
while having fun. The reason for him not being able to play the she wanted to continue playing the second game when the
second game is due to the fact that GNomon was not designed tester gave her the chance to stop due to her apparent lack
for making games for children with also visual and cognitive of interest. P5 and P8 also asked, on their own initiative, if
impairments. they could play more at the One Switch Invaders game after
finishing the test, which clearly indicates that they enjoyed
3) Errors: The error ratio was measured during the second playing the game.
game by counting the number of actual selections that were
not the intended selection by the participant. The error ratio Consequently, it is evident that engaging in the GNomon-
was around 50%, in average and without considering the based games was not only considered satisfactory but also fun
outstanding cases of P5 and P8. Although this significant error by the children during the tests. Moreover, the children that
ratio contrast with the fact that the participants had already had the cognitive and visual capabilities to play a dynamic
learned the selection mechanism by this phase of the test, it game such as One Switch Invaders indicated that was the one
is explained by the difficulties that some participants have to they liked the most.
plan the movement and by the long latent periods (i.e., the
time elapsed between the movement command and the muscle B. Addressing the Research Question
movement) they have.
The results indicate that GNomon-based interfaces are use-
However, considering that this was the first time for the ful to make playable one-switch video games. The playability,
participants to play these games and also that they did it for assessed through the properties of learnability, effectiveness,
just 13 minutes (in average), it is very likely that after some errors and satisfaction of the GNomon-based mini games
training and prolonged exposure to GNomon-based interfaces tested in this study was adequate and very promising. In
the error ratio reduces considerably. In fact, the 29% error particular, 7 out of 8 participants learned and were able to
ratio of P6 (lower than the average) is given almost exclusively use the GNomon-based interface to play the games. All of
by the first third of the One Switch Ladybugs game since he them had fun.
dramatically improved during the test when he concentrated.
Moreover, the evidence suggests that GNomon is not only
On the other hand, the performances of P5 and P8 are useful as an alternative to classic scanning one-switch video
remarkable, not only because their error ratio during the second games, but that it might allow the development of new types
game were null, but also because they performed as well in the of one-switch games, dynamic and time-dependent, such as
One Switch Invaders game. They even asked to play it again One Switch Invaders, that are playable and very enjoyable by
with faster settings, which indicates that dynamic games maybe one-switch users, especially in the case of those which do not
very enjoyable by children with severe motor disabilities such have cognitive impairments. All the participants who tried One
as spinal muscular atrophy (SMA). Switch Invaders (3 out of 8) indicated that it was the funniest of
4) Satisfaction: Since the players satisfaction is a very the 3 mini games, and also that they had never played anything
important property for a game to be playable, we assessed similar. Participant P8 asked if he could have the One Switch
the satisfaction experienced by the participants as the result of Invaders game for playing it again at home.
playing the GNomon-based mini games. For this purpose, we
asked the participants at the end of each game three questions: VII. C ONCLUSION
Did you like the game?, What did you like the most? and What This paper proposes GNomon, a framework that enables
did you not like?. Moreover, the tester asked them at the end the creation of one-switch video games for children with severe
of the test if they had had fun. motor disabilities. It also presents the design and implementa-
Although not every child was able to answer the questions tion of three mini video games with different characteristics,
What did you like the most? and What did you not like? based on GNomon. The design of the framework and the
due to cognitive or communicative impairments, 7 out of 8 mini games was carried out in collaboration with a team of
participants answered affirmatively to the last question of Did experts from one of the Local Health Agencies in Turin, Italy.
you have fun?. However, the negative answer from participant Moreover, we report the playability evaluation of the three
(P1) is not reliable, as explained before. mini games with 8 children with severe motor disabilities
from which we assessed the learnability, efficiency, errors and
The children that were able to answer the question What satisfaction of GNomon based games.
did you like the most? (P5, P6 and P8) said that they liked how
the ladybugs jump and also the ladybug moving around. For The results of this work are encouraging and demonstrate
the One Switch Invaders game, they answered that they liked that it is possible to develop dynamic one-switch games
the falling aliens and to be able to kill them. These answers playable by children with severe motor disabilities. From a
suggest that the dynamism of the games, in particular in the group of 8 participants, all of them expressed that they had fun
playing the GNomon-based mini games, and 7 of them were [13] T. Broderick and D. J. MacKay, Fast and flexible selection with a
able to play One Switch Demo and One Switch Ladybugs single switch, PloS one, vol. 4, no. 10, p. e7481, 2009.
autonomously. Three of the participant children played also [14] M. Belatar and F. Poirier, Text entry for mobile devices and users
One Switch Invaders and expressed that was the game they with severe motor impairments: Handiglyph, a primitive shapes based
onscreen keyboard, in Proceedings of the 10th International ACM
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after the test. 08, 2008, pp. 209216.
Currently, a second round of tests is already being carried [15] S. Harada, J. O. Wobbrock, J. Malkin, J. A. Bilmes, and J. A. Landay,
Longitudinal study of people learning to use continuous voice-based
out with the same group of children to also determine the cursor control, in Proceedings of the SIGCHI Conference on Human
memorability of GNomon-based mini games. Additionally, Factors in Computing Systems, ser. CHI 09, 2009, pp. 347356.
future works will consist in improving the framework and [16] R. Ron-Angevin, F. Velasco-lvarez, and S. Sancha-Ros, Brain-
in the development of engaging games based on GNomon computer interfaces: Proposal of a paradigm to increase output com-
that can be played by children with disabilities and by able- mands, in Intelligent Technologies for Interactive Entertainment, ser.
Lecture Notes of the Institute for Computer Sciences, Social Informatics
body children at the same time. Future developments will also and Telecommunications Engineering, 2012, vol. 78, pp. 1827.
consist in a better tuning of the rotation speed of the clock
[17] S. Aced Lopez, F. Corno, and L. De Russis, Gnomon: Enabling
hands and in extending the NOMON algorithm to support dynamic one-switch games for children with severe motor disabilities,
better a dynamically variable number of selectable elements. in Proceedings of the 33rd Annual ACM Conference Extended
Lastly, it should also be considered to run long-term studies Abstracts on Human Factors in Computing Systems, ser. CHI EA 15.
with larger groups of children with motor disabilities, without New York, NY, USA: ACM, 2015, pp. 9951000. [Online]. Available:
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[18] J. L. Gonzalez Sanchez, N. Padilla Zea, and F. L. Gutierrez, From
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ACKNOWLEDGMENT velopment process, in Proceedings of the 1st International Conference
on Human Centered Design: Held As Part of HCI International 2009,
The authors would like to thank all the experts of the 2009, pp. 6574.
Regional Health Agency (ASL TO1) that were involved during
the development of GNomon and its evaluation. In particular
we thank Sara Scotto, Silvana Crivellin and Elisabetta Cane for
their time, effort and shared knowledge. Likewise, the authors
thank all the children that participated in the study as well as
their families.

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