'e current paper presents the development and the evaluation of an Arabic application (app) for electronic stories (eStories) thatcan be used as an assistive tool in the rehabilitation of children with social communication difficulties. 'e development processinvolved engineers and researchers and speech and language pathologists (SLPs) from a rehabilitation hospital, who formulatedthe design methodology of the Arabic app. 'is process is critical when designing tools for children with communicationdifficulties since they have a wide range of differences in their abilities.'e evaluation of the app from the standpoint of the SLPs ata local school suggests that the app is easy to use, and the involvement of these SLPs helped in developing a better solution. 'eresults of the usability study on twenty-five students showed positive evaluation with an average score that signifies that the apphas above-average usability. 'is paper highlights the importance of the evaluation process in catering the app for successfuluser experience.
1. Introduction
Children with social communication difficulties show sig-nificant deficits in language with limited social interactionand verbal commenting. 'ese children frequently strugglein social settings due to deficits in initiating and respondingto communication. In the USA, the number of children withcommunication difficulties has increased [1]. 'is increasepresents new challenges for parents, caregivers, and speechand language pathologists (SLPs) of children with socialcommunication difficulties. Language skills develop quicklythroughout the preschool years. Assistive apps are flexibleand widespread for teaching children with communicationdifficulties [2, 3] and therefore promise innovative inter-ventions adaptable for various treatments.
Effective treatment and intervention will aid manychildren with communication difficulties to enhance theirlevel of functioning and subsequently their quality of life. Aneffective teaching method for children with communicationdifficulties is breaking down an activity into multiple smallersteps and replacing their representative words with pictures
[2]. Another technique, called Social Stories™ [4], uses asequence of images with words representing the steps ofdaily habits along with the script for expected behaviour forthe child. Literature shows that stories help improve chil-dren’s perception of social expectations [5].
We developed an application that contains four storiesbased on a request from the SLPs at Kuwait physical medicaland rehabilitation hospital (KPMRH). 'is request was valuedand encouraged by funding. 'e number of SLPs per childrenwith communication difficulties is relatively low at the hospital.'erefore, an assistive tool to enhance the work of these SLPs insupporting these children was needed because of the scarcity ofArabic story applications for children with communicationdifficulties. 'e assistive tool, developed with the assistance ofthe SLPs of KPMRH to accommodate the local culture, con-tains stories that help the children learn skills associated withactivities of daily living.We developed the app and evaluated itsusability, and the findings are reported hereinafter. It is theobjective of this work to validate the designmethodology whenproviding a solution for tablet application for children withsocial communication difficulties.
HindawiAdvances in Human-Computer InteractionVolume 2020, Article ID 9530218, 9 pageshttps://doi.org/10.1155/2020/9530218
Children with communication difficulties show a deficit innarrative comprehension, which negatively impacts theirsocial world. 'e usage of new technologies for people withcommunication difficulties mostly addresses communica-tion as well as behavioural analysis, self-stimulation, andsocial interactions. iOS and Android app stores currentlyprovide several inexpensive apps. Old-generation commu-nicators such as GoTalk, Tango, Dynavox, and Activity Padhave been lately substituted by mobile apps that are easy touse, flexible, scalable, adaptable, educational, and affordable.However, considerable efforts for configuration are requiredfor some apps, so usability is an important factor that guidesin developing learning tools.
Hirano [6] created a visual system for planning andorganizing children’s everyday activities and found im-provements in communication and increased efficiency fortherapists. Hailpern [7] explored the conduct of nonverbalchildren, using the computer for evaluating attention, en-gagement, and vocal behaviour. Monibi [8] installed on asmartphone a customizable library of virtual cards for theactivities of autistic children. Hetzroni [9] explored theeffects of an app on five children with autism, observingimproved communication and the possibility of transferringthe newly learned skills from the classroom to dailyactivities.
Nowadays, children’s daily lives are dominated by on-screen activities that include watching television and playingcomputer games on tablets and other devices [10]. Also,there is a considerable increase in the number and avail-ability of electronic storybooks. 'e mid-1990s witnessedthe appearance of the first picture storybook on CD (JustGrandma and Me) [11], and this format has become asubstitute for traditional paper books for children. 'eAssociation of American Publishers [12] has reported thatsales of children’s electronic books on phones, tablets, ande-readers increased from 7 million US dollars in 2011 to 19.3million the next year. 'is evolution from traditional paperbooks as the principal source of storybook reading toelectronic sources marks a change in the way young childrenare growing up [13]. Parents have been concerned about thepotential adverse effects of technological devices on youngchildren, and there is a need to understand how digitalstories can support or hinder the development of literacy inyoung children when most of them have not yet becomeconventional readers [14].
Electronic storybooks are mostly stimulating because,besides the involvement in reading or listening to a story,these books also provide technical enhancements that renderthe experience of reading different from that of traditionalpaper books. Electronic books typically provide a blend offeatures, such as animated scenarios and characters andbackground music and sounds that accompany the text. 'echild can activate these interactive hypermedia elements andanimations with a mouse click or screen touch. Hotspots arepictures with links to animation, sounds, or music. 'esehotspots may be for entertainment but could also be used toprovide useful on-demand help. A huge variety of such
digital elements can be incorporated into electronic picturestorybooks [15–17].
Stories presented on phones and tablets offer an excusenot to print books. 'e fundamental challenge is to specifywhen and how children recall information from electronicstorybooks. Research on children has shown different effectsof electronic stories, and the way the data in the stories isprocessed. Adding specific information to electronic sto-rybooks enables multimedia learning, especially in childrenthreatened with language or reading difficulties. 'e storiesthat contain animated pictures enriched with music andsound can help integrate nonverbal information and ex-pression and thus help store those elements in memory [18].Even though there are very few well-controlled studies in-vestigating the effectiveness of social stories, the interven-tions are frequently used as a treatment option for childrenwith communication difficulties, and most reviews reportfavourable results [19].
3. Proposed System
3.1. Development Process. An Arabic application for eStorieswas developed for children with communication difficulties.'e development process aimed at making the stakeholdersactive participants from the early stages of the design processto ensure the usefulness, usability, and accessibility of theproduct. 'is process is crucial when designing tools forchildren with communication difficulties since they have awide range of differences in their abilities. Interaction withchildren with communication difficulties is very intricatebecause of their deficiency in communication skills. Un-derstanding the needs of the children is furthermore achallenging task because of their difficulties in verballyexpressing their needs or in using gestures instead of words[20]. Augusto [21] preferred applying the user-centred in-telligent environments in the development process to thecreation of a system that includes individuals with specialneeds into society. 'is methodology requires stakeholderswho are willing to engage and developers who have thecapacity to listen.
Users can contribute to the development process in anumber of ways, such as interviews, prototype testing, andsystem evaluation [22]. 'ese approaches allow designersand users to quickly understand the potentials of the app[23]. In this design approach, stakeholders and users areactive contributors of ideas and decision-makers instead ofmerely a source of information or evaluator of the finalproduct [24, 25].
We formed an interdisciplinary workgroup: engineers,researchers, and SLPs who worked together on the appli-cation. 'e SLPs of the rehabilitation hospital provided themain requirements and requested that the application beeasy to use with no opportunities for children to makemistakes to avoid frustration. Several meetings were held,including the multidisciplinary team to identify the mainfunctionalities of the app, followed by developing the pro-totype. 'e SLPs, from the rehabilitation hospital, wereheavily involved in this development process, and their inputwas thoroughly reviewed and incorporated into the design.
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3.2. Design Guidelines. 'e literature has a set of proposedrecommendations and guidelines which were applied whendeveloping the app [21, 26–29]. 'e proposed solution takesinto consideration these guidelines:
(i) Story narration: 'e narration of the story wasadded to enhance accessibility for children who lackreading ability or children who prefer storytelling.'e narration sound files were recorded in a pro-fessional sound studio to ensure the sound’s quality.Although iOS supports text-to-speech, developerspreferred sound recording to ensure the correctpronunciation of Arabic words. Arabic text-to-speech in iOS is highly influenced by the iOS up-dates, and its quality does not always match users’acceptance. Only a limited number of sentences(Table 1) needed to be recorded for the narration ofboth Kuwaiti dialect and formal Arabic.
(ii) Simple and colourful images: As directed by theguidelines of the World Wide Web Consortium(W3C), soft and mild colours were used to create theimages.'e images were appealing, as an artist createdthem. No bright colours were used. Images composedof a limited number of items were utilized not todistract users but to ensure focus. In addition, anyelements that might stand out toomuch were avoided.
(iii) Easy to flip-navigate through pages: 'e user caneasily navigate between the pages. Simple and clearnavigation was utilized.
(iv) Animation: a limited number of animations wereincorporated in the app, and all animations weresimple. 'e use of pop-up elements and distractionswas eliminated.
(v) Caption: Caption was set in navy colour on whitebackground. A contrast between font and back-ground was respected. 'e caption was not set onpicture background since this can make reading textdifficult [30]. 'e text box was clearly separatedfrom the rest of the picture with no overlappingtransparent images and text. 'e iOS system fontbold 46 was selected by the developers, as the fonttypeface and size should be clear and easy to readon-screen [31]. 'e SLPs at the rehabilitationhospital recommended the use of only Arabiccaption in text. Kuwaiti dialect is somewhat dif-ferent from formal Arabic and difficult to write.
(vi) Characters: Friendly characters were used, reflectingthe local culture. 'e main characters of the storiesare two young children: a girl (Lulu) and a boy(Hamad). 'e Kuwait Institute for Scientific Re-search (KISR) has the copyright of these twocharacters as they are used to promote science in theyoung population.
'e following recommendations were also concludedfrom the SLPs at the rehabilitation hospital during thedevelopment process:
(i) Animation to be activated when the user taps theitem to keep the user focused on the narration
(ii) Caption to be set on/off from the settings to ac-commodate the user’s abilities. Personalizing theapp is highly valued, as personalization is a crucialelement for successful user experience for childrenwith communication difficulties [29]
(iii) Narration to support Kuwaiti dialect as well asformal Arabic
(iv) Background sound to be set on/off to accommodatethe user’s needs
(v) Images of displayed items per page to be fully shownand not partially illustrated
3.3. Stories Setup. Four stories were drafted by the SLPs ofKPMRH covering daily routines and reflecting the localculture lifestyle. 'ese stories were simple, colourful, andeasy to comprehend. Electronic versions of these stories(eStories) were implemented in Xcode swift programminglanguage to develop the Arabic iPad application. 'e appwas built based on the requirements and recommendationsof the SLPs at the rehabilitation hospital and consisted of thefollowing:
(i) An introductory page with the proposed four stories(Figure 1).
(ii) A settings page for the selection of narration,caption, background sound, and the dialect (Ar-abic or Kuwaiti). 'e settings page can be accessedfrom the introductory page using a small settingbutton kept on the upper left corner of the page, asthis page will only be used by SLPs, parents, orcaregivers.
'e primary objective of the eStories app is to enhancethe vocabulary and to encourage the integration of childrenwith communication difficulties in their surroundings. Fourstories were created (Figure 1), and the characteristics ofthese stories are listed in Table 1. 'e eStories were devel-oped to accommodate the local culture and activities, such asvisiting the Kuwait towers and celebrating Kuwait nationalday, as illustrated in Figure 2.
Application developers are tempted to rely on multi-media elements to replace text-based information. However,stories enhanced with a rich multimedia interface, such ashotspots, may result in poor user experience and readingcomprehension problems [29]. Grynszpan [32] showed thatASD children had poorer performance on richer multimediainterfaces. In such children, using these features requirestask switching, which seems to cause cognitive overload, asin the case of multitasking in general. Modalities thatsimulate typical children could be confusing for ASD.'erefore, the eStories incorporated a limited number ofanimations to attract the interest of the child as in dressingup for school (Figures 3) where the animation is playable,upon request, to divert the child’s attention.
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4. Evaluation
'e development of the app significantly affects perfor-mance. 'e basis of a lot of existing applications has noresearch evidence; therefore, these applications might havelimited usability. We approached a local school for childrenwith communication difficulties to conduct the evaluationstudy on eStories. 'e support of the school managementand the perseverance of the staff was an encouraging factorto conduct the study.
'e proposed app was tested and verified by six SLPs ofAl-Nibras School based on the input of the students withcommunication difficulties. 'e field evaluation was carriedout in April–May 2019 with twenty-five students. 'e SLPsof the school were heavily involved in the evaluation processto assess the feedback of students with communicationdifficulties on the usability study. 'e participatory designadopted in the development process is optimized with theusability study reflecting the users’ behaviours.
4.1. Participants. Twenty-five students aged 5–12 participatedin the evaluation. 'e attributes of the students are listed inTable 2, and Figure 4 shows the ages of the students. 'esestudents included six females and nineteen males. 'e SLPswere positive towards trying new technologies to support theirwork practices due to the individualized needs of each student.
5. Methods
5.1. Reading Session. For this study, each student completeda 15-minute reading session involving a single electronicstory. 'e sessions were held in a quiet, air-conditionedroom with suitable lighting within the school and performedby the SLPs. 'e readings were of the same title, and thestory chosen for the reading session was “'eWeekend” as itinvolved both characters. A brief informal training was givento the SLPs on the use of the app before the start of the study.'e students experienced the eStories app in an interactivemode with the guidance of the SLPs. 'e eStories readingsession provided the students with the opportunity to ex-plore the features of the app. After reading each pageelectronically, the student was given the option to play withhotspots on the page. But the SLPs did not encourage orextend conversations beyond the script to ensure thecompletion of the story within the time frame.
5.2. User Response. 'e student’s experience was evaluatedto measure the subjective user’s experience based on a 7-point Likert scale that ranged from 1 to 7. Table 3 is thequestionnaire used to measure the student’s response to
eStories as to whether the experience is easy, fun, andenjoyable.
Table 4 is the output of the questionnaire presented inthe previous table for the 25 students.'e answers reflect thedifficulty of the app, the fun in reading the story, and theliking of the experience. A high average value indicates thatthe story was challenging, the story was fun to read, and theexperience was enjoyable. Based on Table 4, it was noted thatthe story was relatively easy and comprehensible. 'e storywas also somewhat fun to read and, to a better extent, likable.
5.3. Usability Test. 'e System Usability Scale (SUS) test isan established tool and one of the most widely used in theliterature. It helps determine the usability of a system [33].SUS is free, very simple, and short and has been foundcuriously robust in numerous studies [34–36]. 'e partic-ipants have to answer ten questions on a scale ranging from1, “Strongly disagree,” to 5, “Strongly agree,” and the result isa score between 0 and 100. A score above 68 signifies that theusability of the application is above average [37]. It ispossible to assess the usability of software and determine itsquality through the result of the SUS questionnaire, wherelearning facility is based on four questions out of the tenquestions of the SUS test, efficiency on three questions,storage facility on one question, error minimization on onequestion, and satisfaction on three questions out of the totalten questions [38].
'e Arabic version of the SUS translated by AlGhannam[39] was used in the usability study in addition to the Englishversion. Most SLPs are Arabic speakers and felt morecomfortable with the Arabic translation than the originalEnglish version of SUS. Figure 5 shows the output of the SUStest for all the participants.
'e results of the usability study helped draw interestingconclusions about the proposed system.'ese results showed apositive evaluation for most of the students. 'e SUS scoresaveraging 74 were above 68 signifying that overall the usabilityof the app is considered above average [37].
5.4. Qualitative Observations. We generated two-wordclouds for the responses given for the two open-endedquestions regarding the features that were most preferred(question 1) and those that needed improvement (question2) in the app. 'e results for question 1 (Figure 6) showedthat the most favoured features of the app were the attractivecolours and beautiful drawings, followed by the charactersthat reflect the local culture. 'e Arabic/Kuwaiti dialect wasalso another favoured feature. 'e results for question 2(Figure 7) showed that the primary suggested improvementswere to introduce caption and narration on demand on each
Table 1: Characteristics of stories.
Book Number of pages Total words in the text Total number of sentencesHamad Daily Routine 15 73 16Lulu Daily Routine 15 73 16'e Weekend 12 104 12Hamad and Lulu Educational Daily Routine 11 129 11
4 Advances in Human-Computer Interaction
page, followed by adding more hotspots to be also used ondemand.
6. Results and Discussion
A prototype of the eStories application was developed andevaluated in the current study to identify its usability andadequacy for children with communication difficulties.
Information technology can enhance rehabilitation therapyfor these children with improvement in socialization,communication, and behaviour [40]. 'e developmentprocess followed the design guidelines presented in theliterature and the recommendations of the design team. 'eevaluation process, on the other hand, was performed on 25students with communication difficulties accompanied bytheir SLPs at a local school for special needs.
Figure 1: eStories.
(a) (b)
Figure 2: eStories reflecting local culture.
(a) (b)
Figure 3: eStories with minor animation.
Advances in Human-Computer Interaction 5
Both Arabic and English versions of the SUS test wereused in the usability study. Each SLP had a preference forusing the Arabic or the English version. For future studies,however, the SLPs recommended using a SUS sample testwith questions supplied in both English and Arabic con-comitantly and not on separate sample tests.
Based on the scores of the SUS test presented in Figure 5,it was noted that a positive evaluation was obtained with aSUS score above average for most of the students. S11 scoredhighest (92.5) on the SUS test. S11 is a nine-year-and-seven-month-old male. His high score at the SUS test is attributedto the questions related to ease of learning. S11, as can beseen in Figure 8, scored highest (100) on the ease of leaningquestions. Most of the students scored relatively high on theease of learning questions which corroborate the observa-tions of the users’ responses (Table 4) and the first-wordcloud (Figure 6).'e students found the story to be relativelyeasy and comprehensible, and one of the app’s preferredfeatures is the fact that it is easy to use. When developingtechnological apps for people with disabilities, measuringthe ease of use is one of the most important aspects [41]. 'estudents, however, averaged 74 on the questions related tosatisfaction (Figure 9). 'is is in line with the responses tothe questionnaire to measure the users’ responses (Table 4).'e story was somewhat fun to read and, to a better extent,likable.
'e SUS scores presented in Figure 5 were correlatedwith the ages of the students found in Figure 4. As can beseen in Figure 10, there is a moderate positive correlationbetween the age of the student and its SUS score whichmeans that there is a tendency for older students to scorehigher on the SUS test and vice versa. According to thePearson correlation coefficient, the value of R was 0.6078,
Table 2: Attributes of students with communication difficulties.
Table 3: Questionnaire to measure users’ responses to eStories.How did you find the story?Super easy Super hard1 2 3 4 5 6 7How was your experience with the story?Not fun Lots of fun1 2 3 4 5 6 7How did you feel about the story?Don’t like the story Best story1 2 3 4 5 6 7
Table 4: Response of a questionnaire tomeasure users’ responses toeStories.
Difficult Fun LikeAverage� 1.85 Average� 3.81 Average� 4.04Standarddeviation� 1.85
Standarddeviation� 1.02
Standarddeviation� 1.25
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Figure 5: SUS of eStories.
Figure 6: Word cloud representation of responses indicating themost preferred features of the app.
Figure 7: Word cloud representation of responses indicating el-ements in need of improvement in the app.
6 Advances in Human-Computer Interaction
and the coefficient of determination valued 0.3694. Youngerstudents below six years old, such as S3, S18, and S19, scoredbelow average on the SUS test. Several SLPs commented thatthe story is suitable for a specific age group, and thiscomment is confirmed by the SUS results of studentsyounger than six years old.
It was also noted that the SUS scores were somewhatreflective of the skillsets of the students in using the iPad.S11, who scored highest on the SUS test and the ease oflearning questions, has decent communication skills, areasonable ability to memorize, dependency in self-care, andexcellent skills in using the iPad and its settings. He can alsomake friends and interact with his classmates. S19, on theother hand, who scored lowest on the SUS test (50) and haddifficulty in learning (56), is a six-year-old male who per-forms the activities entrusted to him by verbal guidance. S22
also scored low on the ease of learning questions (56) and onthe SUS overall test (57.5). S22 is an eight-year-old femalewho performs the activities entrusted to her and abides bythe rules of the class. She knows how to use the iPad, but shegets distracted upon using it, which explains her low SUSscore (57.5).
Overall, the SLPs gave positive feedback on the eStories.'e app is reportedly easy to use, and its settings are simpleto set with the possibility of showing/hiding caption andnarration, turning the background sound on/off, and theavailability of dialect selection. 'e SLPs recommended theintroduction of narration on demand for each page. In thesettings page, narration can be excluded or included inreading sessions. But it was noted that it was best if narrationcan be introduced on demand on each page to accommodatethe pace of the reading session.
'e drawings are simple and colourful. 'e short storydoes not cause boredom and reflects the local Kuwaiti/Arabicculture, and its events and characters are familiar to the child.'e SLPs suggested adding more hotspots, to be used ondemand, to attract the attention of the child when needed eventhough it was recommended during the design stage of the appto minimize distraction by minimizing hotspots.
According to the SLPs at the local school, the assessmentof eStories inspires to think that eStories has the potential toenrich the narration comprehension of children withcommunication difficulties. 'e differentiated effects ofpaper and computer-assisted social stories were studied byMancil [42] on inappropriate behaviour in children withautism, and the outcomes were slightly better for thecomputer format than for the paper format. 'e teachersreported that the computer format was quickly imple-mented, and the students indicated that they liked thecomputer-assisted format. Vandermeer [43] concluded thatsocial stories on the iPad proved to be an effective inter-vention for one of the three children and confirmed that theresponse might be useful with some children, but not others.Several studies were built on research that supports socialstories as a promising practice, and children displayedhigher levels of persistence for the electronic story incomparison to the paperback storybook; however, childrenproduced more communicative initiations with a traditionalpaperback storybook.
7. Conclusions
'is paper defines the development and the evaluation of theeStories application for children with social communicationdifficulties, as assistive computing tools are useful in theeducation of these children. 'e eStories app follows thedesign guidelines recommended by the literature [21, 26–29]and the recommendations of the design team. Yet, duringthe evaluation process, few points were raised that were notobvious in the design process or were planned differently,such as the following:
(i) 'e introduction of narration on demand on eachpage, to accommodate the pace of the readingsession
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Figure 8: Ease of learning.
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Figure 9: Satisfaction.
y = 3.9808x + 38.84R2 = 0.3694
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Figure 10: Effect of age on SUS.
Advances in Human-Computer Interaction 7
(ii) 'e addition of more hotspots, to be used on de-mand to attract the attention of the child during thereading session when he or she loses focus or interestor gets distracted
'e evaluation process refined the development proce-dure by catering the design of the app to accommodate theindividualized needs of its users. Personalization is key tosuccessful user experience.
'e results of the application evaluation indicate that theapp has good acceptability and usability for children withcommunication difficulties, and there is a real potential forthe app to have a positive impact on society by improvinginterventions and education. eStories represent a way topresent a social story to the children and would providebetter accessibility to therapy and language stimulationmaterials for parents to use on the go. Further investigationis recommended into the effect of eStories on readingcomprehension, particularly for children of varying ages,abilities, and learning styles. Future collaboration andstudies are envisioned where the involvement of otherstakeholders, such as psychologists, would be considered forlongitudinal studies. 'e need for collaboration betweenresearch bodies and rehabilitation centres or schools shouldbe followed through to support research and developmentactivities and ensure the successful implementation of ad-vanced technologies that enhance the integration of childrenwith social communication difficulties into their society.
Data Availability
'e data used to support the findings of this study are in-cluded within the article.
Ethical Approval
A full explanation was provided to the SLPs involved in theusability study about the details of the research and the rolesof the students.
Conflicts of Interest
'e authors declare that there are no conflicts of interestregarding the publication of this paper.
Acknowledgments
'e authors gratefully acknowledge the SLPs of KuwaitPhysical Medicine and Rehabilitation Hospital (KPMRH)for supporting the development of the app. 'e authorswould also like to thank and acknowledge the managementand SLPs of Al-Nibras School for Special Needs for their helpand enormous support in conducting the usability study.'eir feedback and input were highly appreciated. 'eauthors salute the SLPs at the Al-Nibras School for theirteamwork, commitment, professionalism, and dedication. Itwas only because of their help that the authors were able torefine the applications to the actual needs of children withcommunication difficulties. 'e authors would like to ex-press their sincere gratitude to the Kuwait Foundation for
the Advancement of Sciences (KFAS) project number P116-13MC-12 for their financial support and the support of theKuwait Institute for Scientific Research (KISR) on theimplementation of this study under the project SD002C.
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