O artigo Preliminary impressions: Using a humanoid robot in the neuropsychological assessment of children with selective mutism foi publicado no http://International Journal of Advanced Robotic Systems
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Godoi DH, Azevedo H, Rodrigues CL, et al. Preliminary impressions: Using a humanoid robot in the neuropsychological assessment of children with selective mutism. International Journal of Advanced Robotic Systems. 2024;21(5). doi:10.1177/17298806241278174
Abstract
In the scope of anxiety disorders in childhood and adolescence, selective mutism is characterized by a consistent failure to speak, interfering with social communication and academic performance which invariably requires clinical interventions. Since children and adolescents with this condition may present cognitive difficulties, there is a need for further investigation, with the aim of identifying a neuropsychological profile. Traditionally, the most used interventions in the literature involve drug treatment as well as cognitive behavioral therapy. In support of traditional treatment, new and sophisticated technologies are being explored to improve the results already achieved. Examples of these technologies involve software systems and augmented reality used to support cognitive behavioral therapy. In line with new technologies, this article presents an unprecedented clinical trial, in the context of neuropsychological assessment, involving the use of a humanoid robot as a verbal communication tool between the psychologist and the child. The pilot study involved four children with selective mutism, where in two cases the approach showed very promising results. In the other two cases, the children remained mute and chose not to interact with the robot. The results of this initial clinical trial motivated the team to evolve the experiment by including new cases of selective mutism.
Introduction
Selective mutism (SM) is a rare disorder linked to anxiety. It is defined by the inability to speak in specific social situations, even when the person shows normal language skills. SM is commonly associated with extreme shyness, fear of social embarrassment, obsessive-compulsive tendencies, isolation, clingy behavior, and temper tantrums. Additionally, individuals with SM often receive diagnoses of other anxiety disorders such as social anxiety disorder and separation anxiety disorder.1
SM is categorized as an anxiety disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).2 This categorization reinforces approaches that emphasize the treatment of SM in conjunction with the treatment of underlying anxieties. Symptoms generally manifest in children aged between 2 and 5 years3 but are often only clinically recognized once children start attending school.4,5
Children diagnosed with SM may have difficulty in certain situations, such as school, restaurants, shopping malls, and parks.6 SM is a rare condition, with a prevalence of < 1% in the population.4 Typically, the disorder follows a natural course of remission after 6 months. However, persistent symptoms lasting longer than 6 months or the presence of symptoms after the age of 10 are considered unfavorable prognostic indicators.7
The most extensively researched cognitive ability in children with SM is language, as per the findings of McInnes et al.8 Besides Language deficit, motor challenges, and social difficulties have also been related to SM, as reported by Kristensen and Oerbeck.9 In clinical practice, individuals with this disorder show inhibition, shyness, and a tendency to remain silent. They may exhibit signs, such as avoiding eye contact, feel embarrassed, and showing reluctance in separating from their parents.10 The result of these symptoms is a communication barrier that makes it difficult to properly assess and treat the disorder. Consequently, the strategy for evaluating and following up on the individual’s progress primarily involves their parents and teachers.
In this process, neuropsychological assessment is used as a way of obtaining cognitive and behavioral mapping that makes it possible to describe aspects of cognition, personality characteristics, social behavior, emotional state, and adjustment conditions. This information is essential for understanding functionality and conditions for adapting to practical life.
The objective of the pilot study presented here is to evaluate the use of a humanoid robot as an aid tool in verbal tests for the neuropsychological assessment of children with SM.
We consider that humanoid robots have the potential to interact naturally with patients, creating a more comfortable and less intimidating environment than interacting with a human. Additionally, they can be programmed to provide positive and encouraging feedback, which can help reduce children’s anxiety during the assessment.
To the best of our knowledge, this proposal is unprecedented in SM neuropsychological assessment, where interaction is traditionally carried out through writing by the child or through the intermediation of parents or guardians.
It is important to highlight that a complete analysis of this proposal considering statistical analysis and control groups is unfeasible due to the rarity of the disorder. In fact, in a period of 10 years of work in the psychiatric outpatient clinic, the neuropsychologist involved in this work identified only 14 cases of the disorder. In this scenario, this article reports a pilot study involving just four research subjects.
This article is organized as follows. In the “Related work” section, some studies related to the use of computational or robotic agents in SM treatment are presented. In the “Methods” section, we describe the methodology adopted to use a humanoid robot as an intermediary agent in the interaction with the child as well as a comparison with other methodologies. In the “Case study” section, the implementation environment, the characteristics of the research subjects and the experiments carried out are presented. Furthermore, the results achieved in the neuropsychological assessment stage are also discussed. Finally, in the “Conclusion and future work” section, we present the conclusion and future perspectives for use in the proposed system.
Conclusion and future work
In this work, we propose a computational system that uses a humanoid robot to mediate between a psychologist and a child diagnosed with Selective Mutism during the neuropsychological assessment process.
The interaction with the robot enables direct communication with the child in verbal activities. It’s worth remembering that traditional interaction normally takes place by adapting the tasks, such as asking the child to write down the answers (if they are literate) or guide the child to give the answers to their parents. Both strategies increase the application time and the child’s fatigue, as well as taking care to avoid interference by the parents in the answers, since the professional would not be present in the room.
This pilot study showed that using a robot to assess a child’s verbal communication could be a viable alternative, however, due to the rarity of the disorder, the limited number of cases prevented consistent validation of the strategy. The arrival of new cases of SM at the Institute of Psychiatry will enable a deeper analysis of the issue. We also believe that with the dissemination of this study other research groups can replicate and refine the research with a larger group of local subjects.
In addition to the inclusion of more subjects, new challenges must be overcome, such as adapting assessment protocols to explicitly include interaction with the robot. Despite this, under the careful supervision of psychologists, research in this area continues to advance and offers new perspectives for the diagnosis and treatment of SM in children.
However, more research is needed, and based on this pilot study, some new lines of research should also guide our future work:
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Confident: So far a guardian remains in the interview room. Removing this guardian can increase the child’s confidence and stimulate a richer dialog with the humanoid robot. This dialog can be directed towards determining the causes of the underlying anxiety that often accompanies SM.
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Progressive: The humanoid robot can encourage the child to interact with human beings invited to take part in the experiment. In this process, the robot reduces its speech to the detriment of the new persons taking part in the interaction. Note that the ultimate goal is to evolve the process towards removing the robot from the environment.
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Community: Instead of using individualized interactions, other research subjects who have already interacted with the robot are invited to take part in group sessions.
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Reverse: The child with mutism is trained to operate the robot remotely. The aim is to use the robot as an instrument to insert the child into environments where they traditionally remain silent. The strategy uses the advantages of the Wizard of Oz to motivate the child to overcome their anxiety.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Msc. Diogo H Godoi is funded by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brasil (CAPES) – Finance Code 001, the Brazilian National Research Council (CNPq), the São Paulo Research Foundation (FAPESP) 2017/01687-0 and FAPESP 2018/25782-5, and the National Institute of Science and Technology (INCT-CAPES-CNPq-FAPESP) under the grants #88887.136349/2017-00, CNPq 465755/2014-3 and 2014/50851-0.
ORCID iD
Helio Azeved
