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. 2018 Oct 4;8(9):e023682. doi: 10.1136/bmjopen-2018-023682

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© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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Schematic illustration of the intervention game structure. The game is designed to train learning about three functional uses of eye gaze cues including the use of gaze to reference locations and objects in the world via a single informant and in episodes of joint attention between multiple informants (A). The game is organised around three sequential phases. The tasks in phase 1 are structured to help participants learn that eye gaze is an important cue to solving problems in the game. The tasks in phase 2 help participants learn to estimate precise gaze trajectories by making target gazed-at objects closer together and to ignore salient objects that are not the target gazed-at object. Episodes of joint attention are also introduced in phase 2 in which participants have to determine the target object that two avatars are looking at together. This is difficult because the timing of the non-verbal cues to identify the object is not perfectly synchronous between the two avatars. In phase 3, the tasks are structured around helping participants learn the difference between a goal-directed gaze cue (eg, looking at a target object to solve a puzzle) and a non-goal-directed gaze cue (eg, looking around at all the objects before deciding which one to select). To complete a phase of the game, participants must finish all levels within a phase. Each phase has multiple levels (B). Levels are defined by the number of non-verbal cues avatars use to guide participants to solve puzzles in the game. Easy levels have multiple cues. Level progression increasingly focuses learning to use eye gaze cues exclusively by stripping away other cues. Within each level, there are six stages (C). Each stage represents the number of potential objects or locations that the participant has to discriminate between based on the cue from the avatar. In the easiest stage, the participant chooses between two objects or locations that the avatar is pointing, directing shoulders, head, and gaze to (as in level 1), whereas in stage 6, the participant chooses between six possible objects or locations that the avatar could be referring to with the non-verbal cue(s). Within each stage, participants have five trials. They must perform with 80% accuracy to advance to the next stage, and they must finish all stages within a level before they can progress to the next level within a phase. When they do not reach 80% accuracy within a stage, they are returned to the previous stage to reify the learning where they were recently successful. Sometimes that means they are returned to later stages of previous levels.