Exploring the Feasibility of an Innovative Inter-Generational Computer Game for Sexual Health Education in Youth with Autism Spectrum Disorder and Other Neurodevelopmental Disabilities: A Mixed-Method Case Study

Background: Although youth with Autism Spectrum Disorder (ASD) and other Neurodevelopmental Disabilities (NDD) experience deficits in communication and social skills, the onset of puberty and sexual development is not equally delayed. Yet, their sexual and relationship needs are often neglected. Moreover, barriers to effective peer and parental communication experienced by these individuals, limit the educational impact of traditional sexual health interventions. As the individuals with ASD/NDD are often visual learners, technology based serious intergenerational games represent a salient strategy to fulfil this gap. Hence, this study aims to explore the potential of an innovative, home-based intergenerational computer game, The Secret of Seven Stones (SSS),to promote sexual education and parent-youth communication in this population.

 Objectives:

1. To explore the usability of SSS for sexual health education in ASD/NDD youth. 
2. To explore the feasibility of using SSS in the home setting.
3. To explore the feasibility of SSS to promote parent-youth communication. 

Methods: This study is a mixed methods multiple case study of six parent-youth dyads (11-14 years) in a large metropolitan area in Texas. This study is a subset of a larger, randomized control efficacy trial, to evaluate the 18-level home-based SSS computer game and parent website (Figure 1). A stepped development framework, Intervention Mapping, informed the theoretical and empirical foundation of SSS. Parent and youth self-reported data were collected via Questionnaire Development System (QDS^TM) survey assessing pre-sexual and sexual behaviors, intentions towards sex and parent-youth communication about sex, and gaming behaviors at baseline and 3-month follow-up. Game progress and time-on-task data were collected from the SSS data base. Usability rating surveys and in-depth semi-structured exit interviews were conducted with parents and youth at 3-month follow-up.  

Results: The youth sample (n=6) was male (50%), Caucasian, of mean age 13.04 ± 1.49 years, and with diagnosis of Autism Spectrum Disorder (ASD) (33%) and/or had  other Neurodevelopmental Disabilities (NDD) (67%). Youth were sexually inexperienced (100%) but engaged in some pre-sexual behavior (50%) and intending to have sex in next year (33%). Some had ever talked to their parent about sexual topics such as birth control (50%), condoms (33%), HIV/AIDS (50%), and STIs (33%). Parents were female, 46.1 ± 2.43 years old, and Caucasian. By 3-month follow-up most youth had either completed SSS (57%) or completed over half of SSS (14%). Youth and parents rated the game as captivating (67-100%), easy to use (67-83%), understandable (50-100%), credible (67-100%), and helpful for making future healthy choices (83-100%) (Figure 2). SSS rated lower on uniqueness, attractiveness, and motivational appeal (33-67%). Youth reported length and technical difficulties as barriers to game play. Qualitative findings highlighted higher acceptability of the game and website among parent-youth dyads, particularly for ease of navigation, website resources, and parental involvement. Parents indicated benefits of SSS in mediating parent-youth communication regarding sexual health.

Conclusions: Our exploratory analysis indicated that an intergenerational game offers an acceptable and feasible strategy to address the socio-sexual needs of youth with ASD/NDD. These exploratory results suggest that further research with larger samples is indicated.