A Computer Game Intervention for Improving Joint Attention in Children with Autism Spectrum Disorder: A Pre–Post Study

A Computer Game Intervention for Improving Joint Attention in Children with Autism Spectrum Disorder: A Pre–Post Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Computer Game Intervention for Improving Joint Attention in Children with Autism Spectrum Disorder: A Pre–Post Study Wenye Hu, Meng Huang, Yufeng Yuan, Rong Luo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9439864/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract This study used a pre-post design to assess the initial effects of a computer game intervention aimed at improving joint attention (JA) in children with autism spectrum disorder (ASD). Twenty-four ASD children (senior group, n = 14, age 62.8 ± 10.61 months; junior group, n = 10, age 35.5 ± 5.47 months) received routine rehabilitation training. Half of each age group was randomly assigned to an extra 20‑minute game intervention three times a week. The Early Social Communication Scales were used to evaluate JA both before and after the intervention. Baseline data showed routine training mostly enhanced responsive joint attention (RJA), while initiating joint attention (IJA) was still lacking. All indicators did not survive Bonferroni correction after the game intervention (α = .0042), although the senior game group showed improvement in gaze alternation (GA) compared to the senior control group (Δ = 14.00 vs. 0.00, p = .007). The low-cost, touchscreen-based computer game shows promise as a workable supplemental tool for fostering particular IJA abilities (especially GA) in ASD children. Future research should use larger samples, including active controls, and prolong the length of the intervention. autism joint attention computer game intervention social behavior Figures Figure 1 Figure 2 Introduction Children with Autism Spectrum Disorder (ASD) exhibit pronounced social communication deficits (Christensen et al., 2016 ), including impairments in joint attention (JA) (Adamson et al., 2019 ; Janson et al., 2022 ; Kaur et al., 2021 ; Liu et al., 2024 ; Meindl & Cannella-Malone, 2011 ). JA, the ability to directs others’ attention to a shared object/event via eye gaze, gestures, or language, or follows others’ direction (Mars et al., 1998 ; Osterling et al., 2002 ; Redcay et al., 2013 ), is foundational for language, social cognition, and adaptive functioning (Abdelaziz et al., 2024 ; Billeci et al., 2017 ; Delbruck et al., 2019 ; Iao et al., 2024 ; Mundy et al., 1994 ; Piatti et al., 2024 ). It is categorized into responsive joint attention (RJA) and initiative joint attention (IJA) (Jones & Carr, 2004 ; Whalen & Schreibman, 2003 ). RJA based on following others (e.g., gaze following, point following), with short-range cue following (< 5 cm) as low-level RJA (RJA-L) and long-range as high-level RJA (RJA-H) (Mundy et al., 1994 ). IJA involves self-initiated attention sharing, including eye contact (EC), gaze alternation (GA), Pointing, and Showing (Amat et al., 2021 ; Liu et al., 2024 ). IJA deficits are often more persistent and resistant to intervention than RJA deficits as RJA improve over time (Shih et al., 2021 ). Evidence-based interventions such as Applied Behavior Analysis (ABA) have been shown to improve JA in ASD children. Rooted in Skinner’s principles of operant conditioning, ABA strengthens the association between stimuli and responses, thereby establishing a functional relationship between behavior and the environment (Al-Dwaikat et al., 2026 ; Gitimoghaddam et al., 2022 ; Reichow & Wolery, 2009 ). Some ABA-based programs also incorporate two- or multi-player modes involving parents (Carlier et al., 2020 ; Jouen et al., 2017 ), caregivers (Nie et al., 2021 ) or therapists (Bono et al., 2016 ) to integrate real-world educational and communicative elements. Despite the efficacy of these approaches, they are resource-intensive, requiring substantial financial investment and highly trained personnel (Eldevik et al., 2010 ). Autism services are still developing, but accessible, low-cost, and culturally appropriate tools remain scarce. Serious games, a computer games with educational or therapeutic functions, have emerged as a promising alternative, offering standardized, repeatable, and engaging training environments at relatively low cost (Em et al., 2015 ; Grossard et al., 2017 ; Jyoti & Lahiri, 2020 ; Martins et al., 2024 ; Scherf et al., 2018 ; Talebi Azadboni et al., 2024 ). However, existing digital interventions for ASD primarily target emotion recognition or general social skills, with relatively few focusing specifically on JA, particularly in the Chinese context (Fan et al., 2025 ; Mundy, 1995 ; Tell et al., 2014 ). The present study developed a computer game designed to supplement routine rehabilitation training by targeting JA, especially IJA. The study found through the Early Social Communication Scales (ESCS) test that although RJA improves with age and training duration, routine rehabilitation training has limited effect on improving IJA in ASD children. This finding highlights a critical gap in routine rehabilitation. Subsequently, a preliminary pretest-posttest study was used to assess the initial feasibility and effectiveness of the game. Considering that the intervention dose in this study was relatively short (4 or 8 weeks) compared to the high-intensity ABA standard (Eldevik et al., 2010 ; Hustyi & Yingling, 2025 ), it was hypothesized that the game would demonstrate initial feasibility and a trend of improvement in specific JA behaviors, rather than large, clinically significant effects. Methods This study employed a between‑group, pre-post design. All participants received daily half-day routine rehabilitation training at the facility. Within each age group (senior and junior), children were randomly assigned to either the game group (routine training plus computer game intervention) or the control group (routine training only). JA was assessed at baseline and immediately post-intervention using the Early Social Communication Scales (ESCS). The study was approved by the relevant institutional review board. Informed consent was obtained from primary caregivers. Participants Twenty-seven children with a confirmed ASD diagnosis from a rehabilitation facility in Jiangxi, China, initially participated. All met the following criteria: (a) diagnosis of ASD by Jiangxi Provincial Children’s Hospital, (b) Childhood Autism Rating Scale (CARS) score ≥ 30 (Schopler et al., 1980 ), and (c) enrollment in the facility’s half-day routine rehabilitation program (consisting of core courses such as life skills, arts, writing, and cognitive training, as well as specialized educational sessions including music therapy, sensory integration play, situational imitation, social practice, and parent-child play workshops., etc.). Based on age and prior training duration, they were divided into a senior group (n = 14; mean age 62.79 ± 10.61 months; ≥12 months of training) and a junior group (n = 13; mean age 35.46 ± 5.47 months; ≤3 months of training). Within each age group, participants were randomly assigned (1:1 ratio, computer-generated sequence) to the game group or the control group. For the intervention phase, three junior group children were excluded because caregivers declined further participation due to concerns about screen-induced visual fatigue. Thus, 24 ASD children (senior: n = 14; junior: n = 10) completed the pre-post study. Material The computer game was developed using the Unity platform. Based on the hierarchical structure of JA (see Fig. 1 ), the game content was divided into five stages, each corresponding to a distinct game targeting RJA‑L (low‑level), RJA‑H (high‑level), eye contact (EC), gaze alternation (GA), Pointing, and Showing. The game featured animated characters with exaggerated eye and gesture cues, immersive storylines, goal‑oriented tasks, rewards, progress feedback, and progressive difficulty (Fan et al., 2025 ; Gao et al., 2025 ; Scherf et al., 2018 ). The game was delivered on a 14‑inch touchscreen laptop. Children responded via finger‑touch, eliminating the need for mouse operation. Measure The Early Social Communication Scales (ESCS) is a tool for assessing JA in ASD children (Mundy et al., 2003 ). The researchers were blind to group assignment. The researcher sat across from participants, with cartoon pictures affixed to the left, left rear, right, and right rear of participants’ seats. During assessment, six toys (wind-up, hand-held, squeeze toys, balloons) were used to elicit JA behaviors, and a video camera recorded the researcher-participant interactions throughout. Behaviors were later coded and scored via repeated video review to document indicators of ASD children’s JA behaviors. Specific details regarding the research instruments and data coding procedures are provided in the Online Resource. Indicators included: RJA‑L (success rate, %), RJA‑H (success rate, %), EC (times), GA (times), Pointing (times), and Showing (times). Procedure All participants completed the ESCS assessment at baseline (pre‑intervention). Then, the 4‑week (senior group) or 8‑week (junior group) intervention period began. The game group received an additional 20‑minute game session three times per week in a quiet classroom. A researcher provided initial instructions and demonstrated the game once. A caregiver sat nearby for accompaniment but provided no active guidance. The control group continued with routine training only. Post‑intervention, all children were reassessed with the ESCS under the same conditions. Statistical Analysis The data were not normally distributed (Shapiro‑Wilk test, p < .05), non‑parametric tests were used. Mann–Whitney U tests were used to compare pre‑intervention scores between the game and control groups within each age group to set baseline. For intervention effects, Mann–Whitney U tests were performed to compare the post‑intervention scores of the game group versus the control group within each age group, and Wilcoxon signed‑rank tests were conducted separately for the game group and the control group within each age group to examine whether significant changes occurred from pre‑ to post‑intervention. To control for Type I error due to multiple comparisons, a Bonferroni correction was applied to the between‑group post‑intervention comparisons (12 comparisons total), setting the significance threshold at α = .0042. Results Pre-intervention baseline Before the intervention (Table 1 ), senior group (n = 14) exhibited significantly higher success rates in RJA-L, RJA-H, and more frequent GA compared to junior group (n = 10), all surviving Bonferroni correction. EC showed a trend but did not survive correction ( p = .017). Pointing and Showing did not differ between groups, and almost no child demonstrated Showing behavior. Notably, RJA indicators showed ceiling effects in both groups (M = 100%). Spearman correlations revealed that RJA-L and RJA-H were strongly correlated with both age (r = .793, r = .761) and training duration (r = .859, r = .861; all p < .001) (Table 2 ). No significant correlations were found between IJA indicators (EC, GA, Pointing, Showing) and age or training duration after correction, except an uncorrected trend for GA (r = .480, p = .011). These baseline results confirmed that routine rehabilitation training primarily benefits RJA, while IJA remains largely deficient, justifying the need for a targeted intervention. Within the senior and junior groups separately, no significant differences were found between the game and control groups on any JA indicator at pre-intervention (all p > .05). Table 1 Comparison of the various indicators of JA between the two groups of ASD children [M (P25-P75)]. Indicators Senior ASD children Junior ASD children Z Sig RJA-L (%) 100.00 (100.00 ~ 100.00) 60.00 (10.00 ~ 88.00) -4.760 .000 *** RJA-H (%) 100.00 (100.00 ~ 100.00) 75.00 (25.00 ~ 79.00) -4.770 .000 *** EC (times) 14.00 (5.25 ~ 17.75) 6.00 (3.00 ~ 8.00) -2.384 .017 GA (times) 10.00 (5.00 ~ 13.50) 2.00 (1.00 ~ 5.00) -3.099 .002 ** Pointing (times) 4.50 (3.00 ~ 7.25) 0.00 (0.00 ~ 8.00) -1.463 .143 Showing (times) 0.00 (0.00 ~ 0.00) 0.00 (0.00 ~ 0.00) -1.389 .165 Note: M is the median and P25-P75 are the interquartile range. P-values were adjusted for multiple comparisons using the Bonferroni method (adjusted α = 0.0083). *** means p <.001. ** means p <.0083. Table 2 Spearman correlation analysis of JA in ASD children in relation to age and training duration. Variables RJA-L RJA-H EC GA Pointing Showing age r .793 *** .761 *** .268 .342 .160 .158 p .000 .000 .176 .081 .426 .431 training duration r .859 *** .861 *** .344 .480 .181 .127 p .000 .000 .079 .011 .365 .528 Note: r is the Spearman’s correlation coefficient. P-values were adjusted for multiple comparisons using the Bonferroni method, with an adjusted significance threshold of α = .0042. *** means p <.001. (Table ) Post-intervention between‑group comparisons (Table 3 ) Senior group (4‑week intervention). At post‑intervention, the game group (n = 7) showed significantly higher GA scores (M = 22.00, IQR = 21.00–27.00) compared to the control group (n = 7, M = 13.00, IQR = 9.00–16.00, Z = − 2.698, p = .007). However, after Bonferroni correction, this difference was not significant. No other significant between‑group differences were observed for any other JA indicator (all p > .05, uncorrected). Junior group (8‑week intervention). At post‑intervention, the game group (n = 5) showed numerical trends toward higher scores in EC (M = 10.00 vs. 4.00), GA (M = 11.00 vs. 2.00), and Pointing (M = 10.00 vs. 0.00) compared to the control group (n = 5). However, none of these differences reached statistical significance, and none survived Bonferroni correction. Table 3 Comparison of pre-test and post-test results, and pre-post delta, for each JA indicator among senior and junior ASD children in Group A and B [M (P25-P75)] . Indicators Senior ASD children Junior ASD children Group A (game group) Group B (control group) Z Sig Group A (game group) Group B (control group) Z Sig Pre-test RJA-L (%) 100.00 (100.00 ~ 100.00) 100.00 (100.00 ~ 100.00) .000 1.000 86.00 (53.00 ~ 91.00) 10.00 (5.00 ~ 83.00) -1.152 .249 RJA-H (%) 100.00 (100.00 ~ 100.00) 100.00 (100.00 ~ 100.00) .000 1.000 75.00 (69.00 ~ 86.00) 38.00 (19.00 ~ 82.00) -1.273 .203 EC (times) 13.00 (3.00 ~ 17.00) 15.00 (6.00 ~ 20.00) -0.320 .749 6.00 (2.00 ~ 8.50) 5.00 (4.00 ~ 7.00) -0.211 .833 GA (times) 8.00 (5.00 ~ 10.00) 13.00 (9.00 ~ 17.00) -1.606 .108 5.00 (1.50 ~ 10.50) 4.00 (1.50 ~ 5.00) -0.745 .456 Pointing (times) 5.00 (3.00 ~ 9.00) 4.00 (3.00 ~ 7.00) -0.453 .650 5.00 (0.00 ~ 11.50) 0.00 (0.00 ~ 8.50) -0.447 .655 Showing (times) 0.00 (0.00 ~ 1.00) 0.00 (0.00 ~ 0.00) -1.468 .142 0.00 (0.00 ~ 0.00) 0.00 (0.00 ~ 0.00) .000 1.000 Post-test RJA-L (%) 100.00 (100.00 ~ 100.00) 100.00 (100.00 ~ 100.00) .000 1.000 100.00 (96.00 ~ 100.00) 54.00 (14.00 ~ 93.00) -2.117 .034 RJA-H (%) 100.00 (100.00 ~ 100.00) 100.00 (100.00 ~ 100.00) .000 1.000 100.00 (88.00 ~ 100.00) 50.00 (26.00 ~ 100.00) -0.900 .368 EC (times) 14.00 (3.00 ~ 21.00) 13.00 (6.00 ~ 15.00) -0.385 .700 10.00 (3.50 ~ 21.50) 4.00 (3.50 ~ 7.00) -1.064 .287 GA (times) 22.00 (21.00 ~ 27.00) 13.00 (9.00 ~ 16.00) -2.698 .007 11.00 (6.50 ~ 19.00) 2.00 (1.50 ~ 7.50) -2.102 .036 Pointing (times) 10.00 (2.00 ~ 12.00) 5.00 (2.00 ~ 6.00) -1.878 .060 10.00 (4.00 ~ 15.00) 0.00 (0.00 ~ 6.00) -2.015 .044 Showing (times) 1.00 (0.00 ~ 2.00) 0.00 (0.00 ~ 0.00) -2.248 .025 1.00 (0.00–1.00) 0.00 (0.00-0.50) -1.315 .189 Note: Delta(Δ)= post-test score − pre-test score in ESCS. M is the median and P25-P75 are the interquartile spacing. P-values were adjusted for multiple comparisons using the Bonferroni method, with an adjusted significance threshold of α = .0042. Median differences of pre- and post-intervention scores for each joint attention indicator across different groups were showed in Fig. 2 . Within-group pre post comparisons Senior group. In the game group (n = 7), Wilcoxon signed-rank tests revealed a significant increase from pre- to post-intervention in GA (Z = − 2.388, p = .017, r = 0.90), Pointing (Z = − 2.060, p = .039, r = 0.78), and Showing (Z = − 2.000, p = .046, r = 0.76). No significant changes were found for RJA-L, RJA-H, or EC (all p > .05). In the control group (n = 7), no significant pre-post changes were observed for any indicator (all p > .05). Junior group. In the game group (n = 5), Wilcoxon tests showed a significant increase in EC (Z = − 2.041, p = .041, r = 0.91) and GA (Z = − 2.032, p = .042, r = 0.91). No significant changes were found for other indicators (all p > .05). In the control group (n = 5), no significant pre-post changes were observed for any indicator (all p > .05). Given the very small sample sizes in the junior group, these within-group findings should be interpreted with caution, as they are based on uncorrected p-values and have low statistical power. Discussion This study developed a low‑cost, touchscreen‑based computer game targeting JA in ASD children and evaluated its preliminary effects using a pre‑post design. In the baseline data, RJA showed a ceiling effect, meaning that in routine rehabilitation training, ASD children were able to achieve relatively good recovery in RJA, while almost all children exhibited no Showing behavior, indicating the persistent deficit in IJA (Paparella et al., 2011 ). This finding is consistent with previous literature (Shih et al., 2021 ) and reflects the necessity of targeted interventions for IJA. The post‑intervention between‑group comparisons did not yield statistically significant differences after correction for multiple comparisons. However, the exploratory within‑group pre‑post comparisons revealed that the game group showed significant improvements in GA (senior and junior), Pointing (senior), Showing (senior), and EC (junior). These patterns suggest that the game may have potential to promote specific IJA skills, particularly GA, although the lack of significant between‑group differences after correction indicates that the effect is not robust enough to withstand strict multiple comparison control in this small sample. The absence of significant between‑group effects after correction likely reflects the combined influence of small sample sizes (senior: n = 7 per group; junior: n = 5 per group), the brief intervention dose (4–8 hours total), and the greater developmental challenge of IJA for younger children. After Bonferroni correction for multiple comparisons, no significant between-group intervention effects were observed for any JA indicator, inconsistently with initial hypotheses. Unlike previous intervention studies reporting significant overall effect by assessing broad categories of responsive (gaze shifting) and initiating (sharing) joint attention (Amat et al., 2021 ; Billeci et al., 2017 ; Liu et al., 2024 ; Mundy et al., 1994 ; Whalen & Schreibman, 2003 ), the present study further divided JA into six specific indicators. Several limitations must be acknowledged. The total intervention dose was far below the recommended intensity for ABA‑based interventions (Eldevik et al., 2010 ). The lack of an active control group means it cannot rule out placebo or attention effects. Sample sizes were small, and participant attrition occurred. The use of a single outcome measure (ESCS) and the absence of follow‑up assessment limit conclusions about generalization and maintenance. Ceiling effects for RJA prevented any detection of improvement in that domain. Despite these limitations, this study has strengths. The game was theory‑driven, developmentally appropriate, and demonstrated high adherence based on caregiver reports. It represents one of the first such tools developed specifically for Chinese ASD children. The research team will subsequently update the computer game version and content based on interviews with ASD children, caregivers, rehabilitation therapists from institutions, and clinical psychologists, aiming to develop an intervention game that enhances the IJA abilities of ASD children. In conclusion, this computer game is a feasible, low‑cost supplementary tool that shows promise for improving specific IJA skills, particularly GA, but the current evidence is preliminary. Larger, well‑powered studies with longer intervention durations, active control conditions, and follow‑up assessments are needed to confirm efficacy. Declarations Clinical trial number not applicable. Disclosure of potential conflicts of interest : not applicable. Research involving Human Participants and/or Animals . Written informed consent was obtained from the rehabilitation facility involved in this study and the caregivers of the participants. Funding not applicable. Author Contribution Conceptualization: Yufeng Yuan, Rong Luo;Methodology: Rong Luo, Wenye Hu, Meng Huang;Formal analysis and investigation: Wenye Hu, Meng Huang;Resources: Yufeng Yuan; Software: Meng Huang;Supervision: Rong Luo, Wenye Hu;Writing - original draft preparation: Wenye Hu; Writing - review and editing: Rong Luo, Wenye Hu. Data Availability Included in the paper or Supplementary Information (for not summary data such as means and variances). Due to proprietary interests of the collaborating rehabilitation institution, the specific raw data will not be publicly available. References Abdelaziz, A., Wagner, M., & Naigles, L. R. (2024). 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IEEE REVISTA IBEROAMERICANA DE TECNOLOGIAS DEL APRENDIZAJE-IEEE RITA , 19 , 186–194. https://doi.org/10.1109/RITA.2024.3458859 Meindl, J. N., & Cannella-Malone, H. I. (2011). Initiating and responding to joint attention bids in children with autism: A review of the literature. Research in Developmental Disabilities , 32 (5), 1441–1454. https://doi.org/10.1016/j.ridd.2011.02.013 Mundy, P. (1995). Joint attention and social-emotional approach behavior in children with autism. Development and Psychopathology , 7 (1), 63–82. https://doi.org/10.1017/s0954579400006349 Mundy, P., Delgado, C., Block, J., Venezia, M., Hogan, A., & Seibert, J. (2003). Early social communication scales (escs) . Mundy, P., Sigman, M., & Kasari, C. (1994). Joint attention, developmental level, and symptom presentation in autism. Development and Psychopathology , 6 (3), 389–401. https://doi.org/10.1017/S0954579400006003 Nie, G., Ullal, A., Zheng, Z., Swanson, A. R., Weitlauf, A. S., Warren, Z. E., & Sarkar, N. (2021). An immersive computer-mediated caregiver-child interaction system for young children with autism spectrum disorder. IEEE Transactions on Neural Systems and Rehabilitation Engineering: A Publication of the IEEE Engineering in Medicine and Biology Society , 29 , 884–893. https://doi.org/10.1109/TNSRE.2021.3077480 Osterling, J. A., Dawson, G., & Munson, J. A. (2002). Early recognition of 1-year-old infants with autism spectrum disorder versus mental retardation. Development and Psychopathology , 14 (2), 239–251. https://doi.org/10.1017/S0954579402002031 Paparella, T., Goods, K. S., Freeman, S., & Kasari, C. (2011). The emergence of nonverbal joint attention and requesting skills in young children with autism. Journal of Communication Disorders , 44 (6), 569–583. https://doi.org/10.1016/j.jcomdis.2011.08.002 Piatti, A., Van der Paelt, S., Warreyn, P., & Roeyers, H. (2024). Neural correlates of response to joint attention in 2-to-5-year-olds in relation to ASD and social-communicative abilities: An fNIRS and behavioral study. Autism Research: Official Journal of the International Society for Autism Research , 17 (6), 1106–1125. https://doi.org/10.1002/aur.3149 Redcay, E., Dodell-Feder, D., Mavros, P. L., Kleiner, M., Pearrow, M. J., Triantafyllou, C., Gabrieli, J. D., & Saxe, R. (2013). Atypical brain activation patterns during a face-to-face joint attention game in adults with autism spectrum disorder. HUMAN BRAIN MAPPING , 34 (10), 2511–2523. https://doi.org/10.1002/hbm.22086 Reichow, B., & Wolery, M. (2009). Comprehensive synthesis of early intensive behavioral interventions for young children with autism based on the UCLA young autism project model. Journal of Autism and Developmental Disorders , 39 (1), 23–41. https://doi.org/10.1007/s10803-008-0596-0 Scherf, K. S., Griffin, J. W., Judy, B., Whyte, E. M., Geier, C. F., Elbich, D., & Smyth, J. M. (2018). Improving sensitivity to eye gaze cues in autism using serious game technology: Study protocol for a phase I randomised controlled trial. BMJ OPEN , 8 (9), e023682. https://doi.org/10.1136/bmjopen-2018-023682 Schopler, E., Reichler, R. J., DeVellis, R. F., & Daly, K. (1980). Toward objective classification of childhood autism: Childhood autism rating scale (CARS). Journal of Autism and Developmental Disorders , 10 (1), 91–103. https://doi.org/10.1007/BF02408436 Shih, W., Shire, S., Chang, Y. C., & Kasari, C. (2021). Joint engagement is a potential mechanism leading to increased initiations of joint attention and downstream effects on language: JASPER early intervention for children with ASD. Journal of Child Psychology and Psychiatry , 62 (10), 1228–1235. https://doi.org/10.1111/jcpp.13405 Talebi Azadboni, T., Nasiri, S., Khenarinezhad, S., & Sadoughi, F. (2024). Effectiveness of serious games in social skills training to autistic individuals: A systematic review. Neuroscience & Biobehavioral Reviews , 161 , 105634. https://doi.org/10.1016/j.neubiorev.2024.105634 Tell, D., Davidson, D., & Camras, L. A. (2014). Recognition of emotion from facial expressions with direct or averted eye gaze and varying expression intensities in children with autism disorder and typically developing children. Autism Research and Treatment , 2014 , 1–11. https://doi.org/10.1155/2014/816137 Whalen, C., & Schreibman, L. (2003). Joint attention training for children with autism using behavior modification procedures. Journal of Child Psychology and Psychiatry and Allied Disciplines , 44 (3), 456–468. https://doi.org/10.1111/1469-7610.00135 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9439864","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":636381182,"identity":"40d37367-ef8f-4024-b9ef-85a800d6d76e","order_by":0,"name":"Wenye Hu","email":"","orcid":"","institution":"Jiangxi Normal University","correspondingAuthor":false,"prefix":"","firstName":"Wenye","middleName":"","lastName":"Hu","suffix":""},{"id":636381183,"identity":"0f686c0f-d7f6-4292-97bb-262ccbea679d","order_by":1,"name":"Meng Huang","email":"","orcid":"","institution":"Jinggangshan University","correspondingAuthor":false,"prefix":"","firstName":"Meng","middleName":"","lastName":"Huang","suffix":""},{"id":636381184,"identity":"93ae54b3-17d4-4e5c-ab0b-c947f23f05e8","order_by":2,"name":"Yufeng Yuan","email":"","orcid":"","institution":"Jiangxi Provincial Children’ s Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yufeng","middleName":"","lastName":"Yuan","suffix":""},{"id":636381185,"identity":"e6ec4932-1060-4813-8912-1b4189890d66","order_by":3,"name":"Rong Luo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAvElEQVRIiWNgGAWjYBACNmb2AwYfeCTs7NsbiNTCx86TUDhDxibZgOcAkVrk+BkMPnPYpDFukEgg2mEMiZsZcg4zm0s+3niDocYmmggtjIeNC84c5rOcnVZswXAsLbeBCFvSjGf2HGZmuJ1jJsHYcJgoLea/ef8dZmy4eYZ4LQbGPDxA79/gIVoLT4LhDB6bZMkeoF8SiPGLfP9xSFTysx/eeONDjQ1hLcjAgOioQdJCqo5RMApGwSgYGQAAGEg526c+t9kAAAAASUVORK5CYII=","orcid":"","institution":"Jiangxi Normal University","correspondingAuthor":true,"prefix":"","firstName":"Rong","middleName":"","lastName":"Luo","suffix":""}],"badges":[],"createdAt":"2026-04-16 15:08:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9439864/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9439864/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":109216653,"identity":"5fcb7996-80a5-4dfd-8e1c-8c92a6923a27","added_by":"auto","created_at":"2026-05-13 18:07:09","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1751654,"visible":true,"origin":"","legend":"\u003cp\u003eGame content classification and partial screenshots of the computer game\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9439864/v1/5fa3d3b439586fde49ff49c2.png"},{"id":109249105,"identity":"f71e3c00-67bb-405e-80e3-58f6ded8c155","added_by":"auto","created_at":"2026-05-14 08:42:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":40898,"visible":true,"origin":"","legend":"\u003cp\u003eMedian differences of pre- and post-intervention scores for each joint attention indicator across different groups\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9439864/v1/cf29ee891c81ae0de3df0791.png"},{"id":109296646,"identity":"5d362e84-2770-422d-8fd4-6a6eaf379127","added_by":"auto","created_at":"2026-05-15 08:48:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2532580,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9439864/v1/53673fe1-a274-47de-93bb-35fa234f359d.pdf"},{"id":109216652,"identity":"50619046-b8fd-4586-8e8b-e319d21d226d","added_by":"auto","created_at":"2026-05-13 18:07:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":740532,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryInformation.docx","url":"https://assets-eu.researchsquare.com/files/rs-9439864/v1/4fff087058ad375eb84c7558.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Computer Game Intervention for Improving Joint Attention in Children with Autism Spectrum Disorder: A Pre–Post Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChildren with Autism Spectrum Disorder (ASD) exhibit pronounced social communication deficits (Christensen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), including impairments in joint attention (JA) (Adamson et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Janson et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Kaur et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Liu et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Meindl \u0026amp; Cannella-Malone, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). JA, the ability to directs others\u0026rsquo; attention to a shared object/event via eye gaze, gestures, or language, or follows others\u0026rsquo; direction (Mars et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e1998\u003c/span\u003e; Osterling et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; Redcay et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), is foundational for language, social cognition, and adaptive functioning (Abdelaziz et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Billeci et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Delbruck et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Iao et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Mundy et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Piatti et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). It is categorized into responsive joint attention (RJA) and initiative joint attention (IJA) (Jones \u0026amp; Carr, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2004\u003c/span\u003e; Whalen \u0026amp; Schreibman, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). RJA based on following others (e.g., gaze following, point following), with short-range cue following (\u0026lt;\u0026thinsp;5 cm) as low-level RJA (RJA-L) and long-range as high-level RJA (RJA-H) (Mundy et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1994\u003c/span\u003e). IJA involves self-initiated attention sharing, including eye contact (EC), gaze alternation (GA), Pointing, and Showing (Amat et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Liu et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). IJA deficits are often more persistent and resistant to intervention than RJA deficits as RJA improve over time (Shih et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEvidence-based interventions such as Applied Behavior Analysis (ABA) have been shown to improve JA in ASD children. Rooted in Skinner\u0026rsquo;s principles of operant conditioning, ABA strengthens the association between stimuli and responses, thereby establishing a functional relationship between behavior and the environment (Al-Dwaikat et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2026\u003c/span\u003e; Gitimoghaddam et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Reichow \u0026amp; Wolery, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Some ABA-based programs also incorporate two- or multi-player modes involving parents (Carlier et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Jouen et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), caregivers (Nie et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) or therapists (Bono et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) to integrate real-world educational and communicative elements. Despite the efficacy of these approaches, they are resource-intensive, requiring substantial financial investment and highly trained personnel (Eldevik et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Autism services are still developing, but accessible, low-cost, and culturally appropriate tools remain scarce.\u003c/p\u003e \u003cp\u003eSerious games, a computer games with educational or therapeutic functions, have emerged as a promising alternative, offering standardized, repeatable, and engaging training environments at relatively low cost (Em et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Grossard et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Jyoti \u0026amp; Lahiri, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Martins et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Scherf et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Talebi Azadboni et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, existing digital interventions for ASD primarily target emotion recognition or general social skills, with relatively few focusing specifically on JA, particularly in the Chinese context (Fan et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Mundy, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e1995\u003c/span\u003e; Tell et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe present study developed a computer game designed to supplement routine rehabilitation training by targeting JA, especially IJA. The study found through the Early Social Communication Scales (ESCS) test that although RJA improves with age and training duration, routine rehabilitation training has limited effect on improving IJA in ASD children. This finding highlights a critical gap in routine rehabilitation. Subsequently, a preliminary pretest-posttest study was used to assess the initial feasibility and effectiveness of the game. Considering that the intervention dose in this study was relatively short (4 or 8 weeks) compared to the high-intensity ABA standard (Eldevik et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Hustyi \u0026amp; Yingling, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2025\u003c/span\u003e), it was hypothesized that the game would demonstrate initial feasibility and a trend of improvement in specific JA behaviors, rather than large, clinically significant effects.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study employed a between‑group, pre-post design. All participants received daily half-day routine rehabilitation training at the facility. Within each age group (senior and junior), children were randomly assigned to either the game group (routine training plus computer game intervention) or the control group (routine training only). JA was assessed at baseline and immediately post-intervention using the Early Social Communication Scales (ESCS). The study was approved by the relevant institutional review board. Informed consent was obtained from primary caregivers.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eTwenty-seven children with a confirmed ASD diagnosis from a rehabilitation facility in Jiangxi, China, initially participated. All met the following criteria: (a) diagnosis of ASD by Jiangxi Provincial Children\u0026rsquo;s Hospital, (b) Childhood Autism Rating Scale (CARS) score\u0026thinsp;\u0026ge;\u0026thinsp;30 (Schopler et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e1980\u003c/span\u003e), and (c) enrollment in the facility\u0026rsquo;s half-day routine rehabilitation program (consisting of core courses such as life skills, arts, writing, and cognitive training, as well as specialized educational sessions including music therapy, sensory integration play, situational imitation, social practice, and parent-child play workshops., etc.). Based on age and prior training duration, they were divided into a senior group (n\u0026thinsp;=\u0026thinsp;14; mean age 62.79\u0026thinsp;\u0026plusmn;\u0026thinsp;10.61 months; \u0026ge;12 months of training) and a junior group (n\u0026thinsp;=\u0026thinsp;13; mean age 35.46\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47 months; \u0026le;3 months of training). Within each age group, participants were randomly assigned (1:1 ratio, computer-generated sequence) to the game group or the control group. For the intervention phase, three junior group children were excluded because caregivers declined further participation due to concerns about screen-induced visual fatigue. Thus, 24 ASD children (senior: n\u0026thinsp;=\u0026thinsp;14; junior: n\u0026thinsp;=\u0026thinsp;10) completed the pre-post study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMaterial\u003c/h3\u003e\n\u003cp\u003eThe computer game was developed using the Unity platform. Based on the hierarchical structure of JA (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), the game content was divided into five stages, each corresponding to a distinct game targeting RJA‑L (low‑level), RJA‑H (high‑level), eye contact (EC), gaze alternation (GA), Pointing, and Showing. The game featured animated characters with exaggerated eye and gesture cues, immersive storylines, goal‑oriented tasks, rewards, progress feedback, and progressive difficulty (Fan et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Gao et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Scherf et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The game was delivered on a 14‑inch touchscreen laptop. Children responded via finger‑touch, eliminating the need for mouse operation.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eMeasure\u003c/h3\u003e\n\u003cp\u003eThe Early Social Communication Scales (ESCS) is a tool for assessing JA in ASD children (Mundy et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). The researchers were blind to group assignment. The researcher sat across from participants, with cartoon pictures affixed to the left, left rear, right, and right rear of participants\u0026rsquo; seats. During assessment, six toys (wind-up, hand-held, squeeze toys, balloons) were used to elicit JA behaviors, and a video camera recorded the researcher-participant interactions throughout. Behaviors were later coded and scored via repeated video review to document indicators of ASD children\u0026rsquo;s JA behaviors. Specific details regarding the research instruments and data coding procedures are provided in the \u003cem\u003eOnline Resource.\u003c/em\u003e Indicators included: RJA‑L (success rate, %), RJA‑H (success rate, %), EC (times), GA (times), Pointing (times), and Showing (times).\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eAll participants completed the ESCS assessment at baseline (pre‑intervention). Then, the 4‑week (senior group) or 8‑week (junior group) intervention period began. The game group received an additional 20‑minute game session three times per week in a quiet classroom. A researcher provided initial instructions and demonstrated the game once. A caregiver sat nearby for accompaniment but provided no active guidance. The control group continued with routine training only. Post‑intervention, all children were reassessed with the ESCS under the same conditions.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were not normally distributed (Shapiro‑Wilk test, \u003cem\u003ep\u003c/em\u003e \u0026lt; .05), non‑parametric tests were used. Mann\u0026ndash;Whitney U tests were used to compare pre‑intervention scores between the game and control groups within each age group to set baseline. For intervention effects, Mann\u0026ndash;Whitney U tests were performed to compare the post‑intervention scores of the game group versus the control group within each age group, and Wilcoxon signed‑rank tests were conducted separately for the game group and the control group within each age group to examine whether significant changes occurred from pre‑ to post‑intervention. To control for Type I error due to multiple comparisons, a Bonferroni correction was applied to the between‑group post‑intervention comparisons (12 comparisons total), setting the significance threshold at α\u0026thinsp;=\u0026thinsp;.0042.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePre-intervention baseline\u003c/h2\u003e \u003cp\u003eBefore the intervention (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), senior group (n\u0026thinsp;=\u0026thinsp;14) exhibited significantly higher success rates in RJA-L, RJA-H, and more frequent GA compared to junior group (n\u0026thinsp;=\u0026thinsp;10), all surviving Bonferroni correction. EC showed a trend but did not survive correction (\u003cem\u003ep\u003c/em\u003e = .017). Pointing and Showing did not differ between groups, and almost no child demonstrated Showing behavior. Notably, RJA indicators showed ceiling effects in both groups (M\u0026thinsp;=\u0026thinsp;100%). Spearman correlations revealed that RJA-L and RJA-H were strongly correlated with both age (r = .793, r = .761) and training duration (r = .859, r = .861; all \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). No significant correlations were found between IJA indicators (EC, GA, Pointing, Showing) and age or training duration after correction, except an uncorrected trend for GA (r = .480, \u003cem\u003ep\u003c/em\u003e = .011). These baseline results confirmed that routine rehabilitation training primarily benefits RJA, while IJA remains largely deficient, justifying the need for a targeted intervention. Within the senior and junior groups separately, no significant differences were found between the game and control groups on any JA indicator at pre-intervention (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the various indicators of JA between the two groups of ASD children [M (P25-P75)].\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSenior ASD children\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eJunior ASD children\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eSig\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRJA-L (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.00 (10.00\u0026thinsp;~\u0026thinsp;88.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.760\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRJA-H (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.00 (25.00\u0026thinsp;~\u0026thinsp;79.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-4.770\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEC (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.00 (5.25\u0026thinsp;~\u0026thinsp;17.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.00 (3.00\u0026thinsp;~\u0026thinsp;8.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-2.384\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.017\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGA (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.00 (5.00\u0026thinsp;~\u0026thinsp;13.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.00 (1.00\u0026thinsp;~\u0026thinsp;5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.002\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePointing (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.50 (3.00\u0026thinsp;~\u0026thinsp;7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;8.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.463\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShowing (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.389\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: \u003cem\u003eM\u003c/em\u003e is the median and \u003cem\u003eP25-P75\u003c/em\u003e are the interquartile range. P-values were adjusted for multiple comparisons using the Bonferroni method (adjusted α\u0026thinsp;=\u0026thinsp;0.0083). \u003csup\u003e***\u003c/sup\u003e means \u003cem\u003ep\u003c/em\u003e\u0026lt;.001. \u003csup\u003e**\u003c/sup\u003e means \u003cem\u003ep\u003c/em\u003e\u0026lt;.0083.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSpearman correlation analysis of JA in ASD children in relation to age and training duration.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRJA-L\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRJA-H\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEC\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePointing\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eShowing\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.793\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.761\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.426\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.431\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etraining duration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003er\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.859\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.861\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.344\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e.365\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNote: \u003cem\u003er\u003c/em\u003e is the Spearman\u0026rsquo;s correlation coefficient. P-values were adjusted for multiple comparisons using the Bonferroni method, with an adjusted significance threshold of α\u0026thinsp;=\u0026thinsp;.0042. \u003csup\u003e***\u003c/sup\u003e means \u003cem\u003ep\u003c/em\u003e\u0026lt;.001.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e (Table )\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cem\u003ePost-intervention between‑group comparisons\u003c/em\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e)\u003c/div\u003e \u003cp\u003eSenior group (4‑week intervention). At post‑intervention, the game group (n\u0026thinsp;=\u0026thinsp;7) showed significantly higher GA scores (M\u0026thinsp;=\u0026thinsp;22.00, IQR\u0026thinsp;=\u0026thinsp;21.00\u0026ndash;27.00) compared to the control group (n\u0026thinsp;=\u0026thinsp;7, M\u0026thinsp;=\u0026thinsp;13.00, IQR\u0026thinsp;=\u0026thinsp;9.00\u0026ndash;16.00, Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.698, \u003cem\u003ep\u003c/em\u003e = .007). However, after Bonferroni correction, this difference was not significant. No other significant between‑group differences were observed for any other JA indicator (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05, uncorrected).\u003c/p\u003e \u003cp\u003eJunior group (8‑week intervention). At post‑intervention, the game group (n\u0026thinsp;=\u0026thinsp;5) showed numerical trends toward higher scores in EC (M\u0026thinsp;=\u0026thinsp;10.00 vs. 4.00), GA (M\u0026thinsp;=\u0026thinsp;11.00 vs. 2.00), and Pointing (M\u0026thinsp;=\u0026thinsp;10.00 vs. 0.00) compared to the control group (n\u0026thinsp;=\u0026thinsp;5). However, none of these differences reached statistical significance, and none survived Bonferroni correction.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of pre-test and post-test results, and pre-post delta, for each JA indicator among senior and junior ASD children in Group A and B \u003cem\u003e[M (P25-P75)]\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eSenior ASD children\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eJunior ASD children\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(game group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(control group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eSig\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003cp\u003e(game group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003cp\u003e(control group)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003eSig\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRJA-L (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e86.00\u003c/p\u003e \u003cp\u003e(53.00\u0026thinsp;~\u0026thinsp;91.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.00\u003c/p\u003e \u003cp\u003e(5.00\u0026thinsp;~\u0026thinsp;83.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.152\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.249\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRJA-H (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e75.00\u003c/p\u003e \u003cp\u003e(69.00\u0026thinsp;~\u0026thinsp;86.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e38.00\u003c/p\u003e \u003cp\u003e(19.00\u0026thinsp;~\u0026thinsp;82.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.203\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEC (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.00 (3.00\u0026thinsp;~\u0026thinsp;17.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15.00 (6.00\u0026thinsp;~\u0026thinsp;20.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.749\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.00 (2.00\u0026thinsp;~\u0026thinsp;8.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.00 (4.00\u0026thinsp;~\u0026thinsp;7.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.833\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGA (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.00 (5.00\u0026thinsp;~\u0026thinsp;10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.00 (9.00\u0026thinsp;~\u0026thinsp;17.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.606\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.00 (1.50\u0026thinsp;~\u0026thinsp;10.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.00 (1.50\u0026thinsp;~\u0026thinsp;5.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.745\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.456\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePointing (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.00 (3.00\u0026thinsp;~\u0026thinsp;9.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.00 (3.00\u0026thinsp;~\u0026thinsp;7.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.453\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.650\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.00 (0.00\u0026thinsp;~\u0026thinsp;11.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;8.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.447\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.655\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShowing (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.142\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRJA-L (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100.00\u003c/p\u003e \u003cp\u003e(96.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e54.00\u003c/p\u003e \u003cp\u003e(14.00\u0026thinsp;~\u0026thinsp;93.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRJA-H (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100.00 (100.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e100.00\u003c/p\u003e \u003cp\u003e(88.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003cp\u003e(26.00\u0026thinsp;~\u0026thinsp;100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEC (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.00 (3.00\u0026thinsp;~\u0026thinsp;21.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.00 (6.00\u0026thinsp;~\u0026thinsp;15.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.700\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.00 (3.50\u0026thinsp;~\u0026thinsp;21.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e4.00 (3.50\u0026thinsp;~\u0026thinsp;7.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGA (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.00 (21.00\u0026thinsp;~\u0026thinsp;27.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.00 (9.00\u0026thinsp;~\u0026thinsp;16.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.698\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e11.00 (6.50\u0026thinsp;~\u0026thinsp;19.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.00 (1.50\u0026thinsp;~\u0026thinsp;7.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.102\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.036\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePointing (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00 (2.00\u0026thinsp;~\u0026thinsp;12.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.00 (2.00\u0026thinsp;~\u0026thinsp;6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-1.878\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.060\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.00 (4.00\u0026thinsp;~\u0026thinsp;15.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;6.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-2.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.044\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eShowing (times)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00 (0.00\u0026thinsp;~\u0026thinsp;2.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.00 (0.00\u0026thinsp;~\u0026thinsp;0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-2.248\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.00 (0.00\u0026ndash;1.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.00 (0.00-0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e-1.315\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e.189\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eNote: Delta(Δ)= post-test score\u0026thinsp;\u0026minus;\u0026thinsp;pre-test score in ESCS. M is the median and P25-P75 are the interquartile spacing. P-values were adjusted for multiple comparisons using the Bonferroni method, with an adjusted significance threshold of α\u0026thinsp;=\u0026thinsp;.0042.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMedian differences of pre- and post-intervention scores for each joint attention indicator across different groups were showed in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eWithin-group pre post comparisons\u003c/h2\u003e \u003cp\u003eSenior group. In the game group (n\u0026thinsp;=\u0026thinsp;7), Wilcoxon signed-rank tests revealed a significant increase from pre- to post-intervention in GA (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.388, \u003cem\u003ep\u003c/em\u003e = .017, r\u0026thinsp;=\u0026thinsp;0.90), Pointing (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.060, \u003cem\u003ep\u003c/em\u003e = .039, r\u0026thinsp;=\u0026thinsp;0.78), and Showing (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.000, \u003cem\u003ep\u003c/em\u003e = .046, r\u0026thinsp;=\u0026thinsp;0.76). No significant changes were found for RJA-L, RJA-H, or EC (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05). In the control group (n\u0026thinsp;=\u0026thinsp;7), no significant pre-post changes were observed for any indicator (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05).\u003c/p\u003e \u003cp\u003eJunior group. In the game group (n\u0026thinsp;=\u0026thinsp;5), Wilcoxon tests showed a significant increase in EC (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.041, \u003cem\u003ep\u003c/em\u003e = .041, r\u0026thinsp;=\u0026thinsp;0.91) and GA (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.032, \u003cem\u003ep\u003c/em\u003e = .042, r\u0026thinsp;=\u0026thinsp;0.91). No significant changes were found for other indicators (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05). In the control group (n\u0026thinsp;=\u0026thinsp;5), no significant pre-post changes were observed for any indicator (all \u003cem\u003ep\u003c/em\u003e \u0026gt; .05). Given the very small sample sizes in the junior group, these within-group findings should be interpreted with caution, as they are based on uncorrected p-values and have low statistical power.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study developed a low‑cost, touchscreen‑based computer game targeting JA in ASD children and evaluated its preliminary effects using a pre‑post design. In the baseline data, RJA showed a ceiling effect, meaning that in routine rehabilitation training, ASD children were able to achieve relatively good recovery in RJA, while almost all children exhibited no Showing behavior, indicating the persistent deficit in IJA (Paparella et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). This finding is consistent with previous literature (Shih et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and reflects the necessity of targeted interventions for IJA.\u003c/p\u003e \u003cp\u003eThe post‑intervention between‑group comparisons did not yield statistically significant differences after correction for multiple comparisons. However, the exploratory within‑group pre‑post comparisons revealed that the game group showed significant improvements in GA (senior and junior), Pointing (senior), Showing (senior), and EC (junior). These patterns suggest that the game may have potential to promote specific IJA skills, particularly GA, although the lack of significant between‑group differences after correction indicates that the effect is not robust enough to withstand strict multiple comparison control in this small sample. The absence of significant between‑group effects after correction likely reflects the combined influence of small sample sizes (senior: n\u0026thinsp;=\u0026thinsp;7 per group; junior: n\u0026thinsp;=\u0026thinsp;5 per group), the brief intervention dose (4\u0026ndash;8 hours total), and the greater developmental challenge of IJA for younger children.\u003c/p\u003e \u003cp\u003eAfter Bonferroni correction for multiple comparisons, no significant between-group intervention effects were observed for any JA indicator, inconsistently with initial hypotheses. Unlike previous intervention studies reporting significant overall effect by assessing broad categories of responsive (gaze shifting) and initiating (sharing) joint attention (Amat et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Billeci et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Liu et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Mundy et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e1994\u003c/span\u003e; Whalen \u0026amp; Schreibman, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2003\u003c/span\u003e), the present study further divided JA into six specific indicators.\u003c/p\u003e \u003cp\u003eSeveral limitations must be acknowledged. The total intervention dose was far below the recommended intensity for ABA‑based interventions (Eldevik et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The lack of an active control group means it cannot rule out placebo or attention effects. Sample sizes were small, and participant attrition occurred. The use of a single outcome measure (ESCS) and the absence of follow‑up assessment limit conclusions about generalization and maintenance. Ceiling effects for RJA prevented any detection of improvement in that domain.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study has strengths. The game was theory‑driven, developmentally appropriate, and demonstrated high adherence based on caregiver reports. It represents one of the first such tools developed specifically for Chinese ASD children. The research team will subsequently update the computer game version and content based on interviews with ASD children, caregivers, rehabilitation therapists from institutions, and clinical psychologists, aiming to develop an intervention game that enhances the IJA abilities of ASD children.\u003c/p\u003e \u003cp\u003eIn conclusion, this computer game is a feasible, low‑cost supplementary tool that shows promise for improving specific IJA skills, particularly GA, but the current evidence is preliminary. Larger, well‑powered studies with longer intervention durations, active control conditions, and follow‑up assessments are needed to confirm efficacy.\u003c/p\u003e "},{"header":"Declarations","content":"\u003ch3\u003eClinical trial number\u003c/h3\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eDisclosure of potential conflicts of interest\u003c/strong\u003e: not applicable.\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eResearch involving Human Participants and/or Animals\u003c/strong\u003e. Written informed consent was obtained from the rehabilitation facility involved in this study and the caregivers of the participants.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003enot applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: Yufeng Yuan, Rong Luo;Methodology: Rong Luo, Wenye Hu, Meng Huang;Formal analysis and investigation: Wenye Hu, Meng Huang;Resources: Yufeng Yuan; Software: Meng Huang;Supervision: Rong Luo, Wenye Hu;Writing - original draft preparation: Wenye Hu; Writing - review and editing: Rong Luo, Wenye Hu.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eIncluded in the paper or Supplementary Information (for not summary data such as means and variances). 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Recognition of emotion from facial expressions with direct or averted eye gaze and varying expression intensities in children with autism disorder and typically developing children. \u003cem\u003eAutism Research and Treatment\u003c/em\u003e, \u003cem\u003e2014\u003c/em\u003e, 1\u0026ndash;11. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/2014/816137\u003c/span\u003e\u003cspan address=\"10.1155/2014/816137\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhalen, C., \u0026amp; Schreibman, L. (2003). Joint attention training for children with autism using behavior modification procedures. \u003cem\u003eJournal of Child Psychology and Psychiatry and Allied Disciplines\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(3), 456\u0026ndash;468. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/1469-7610.00135\u003c/span\u003e\u003cspan address=\"10.1111/1469-7610.00135\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"autism, joint attention, computer game, intervention, social behavior","lastPublishedDoi":"10.21203/rs.3.rs-9439864/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9439864/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThis study used a pre-post design to assess the initial effects of a computer game intervention aimed at improving joint attention (JA) in children with autism spectrum disorder (ASD). Twenty-four ASD children (senior group, n\u0026thinsp;=\u0026thinsp;14, age 62.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.61 months; junior group, n\u0026thinsp;=\u0026thinsp;10, age 35.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.47 months) received routine rehabilitation training. Half of each age group was randomly assigned to an extra 20‑minute game intervention three times a week. The Early Social Communication Scales were used to evaluate JA both before and after the intervention. Baseline data showed routine training mostly enhanced responsive joint attention (RJA), while initiating joint attention (IJA) was still lacking. All indicators did not survive Bonferroni correction after the game intervention (α\u0026thinsp;=\u0026thinsp;.0042), although the senior game group showed improvement in gaze alternation (GA) compared to the senior control group (Δ\u0026thinsp;=\u0026thinsp;14.00 vs. 0.00, \u003cem\u003ep\u003c/em\u003e =\u0026thinsp;.007). The low-cost, touchscreen-based computer game shows promise as a workable supplemental tool for fostering particular IJA abilities (especially GA) in ASD children. Future research should use larger samples, including active controls, and prolong the length of the intervention.\u003c/p\u003e","manuscriptTitle":"A Computer Game Intervention for Improving Joint Attention in Children with Autism Spectrum Disorder: A Pre–Post Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-13 18:07:05","doi":"10.21203/rs.3.rs-9439864/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a0ebf9a-be31-497c-b38a-82d9b2f1ca3e","owner":[],"postedDate":"May 13th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewersInvited","content":"7","date":"2026-05-05T12:17:04+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T18:07:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-13 18:07:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9439864","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9439864","identity":"rs-9439864","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}