One day in the spring of 2017, at the department of clinical psychology at Babes-Bolyai University, Romania, a robot stood on a table facing a child. The robot was a half-metre tall humanoid in brightly coloured plastic, like a toy. Its round eyes lit up as it spoke, its voice childlike. Across the table sat a young boy in a Pokémon T-shirt, playing a game where he had to figure out which object the lit-up eyes are looking at.
Over the table-top between the pair was a horizontal display, showing two digital items, a flower and a tree. Sitting directly across from the robot, the little boy intently followed its mechanical gaze, giggling with pleasure when he correctly discerned that the robot was focused on the digital tulip on the right side of the table-top display. It's a simple game, but despite the laughter it's not only for fun — it's teaching a skill called joint attention that children with autism spectrum disorder are taught as part of their behavioural therapy.
The robot tracked the child's gaze, watching to see if the boy got it right, giving positive feedback. "Very good!" it said.
Silviu Matu, assistant professor in clinical psychology at Babes-Bolyai University, explains that most children react positively to the robot in the room. "They are curious about the robot and want to see and play with it," he says. "That's the vast majority of children. But there are some who are a bit afraid of the robot." He notes that's not unexpected; children react differently to new toys or people, too.
Matu is part of a major EU-funded study that's testing whether such robot-assisted therapies work any better than human-only sessions. Robots are already being used in autism therapy, but whether they work any better than human-only sessions remains in question. Another study suggests they may be no more helpful than standard therapies, even if this robot-child interaction looks so positive.
Previous research suggests robots are well received by children with autism spectrum disorders, and there's plenty of anecdotal stories of children showing progress with interaction and communication after working with robots. In the UK, researchers based at the University of Hertfordshire have had plenty of positive attention around Kaspar, a child-like robot that helps teach children social skills.
The Development of Robot Enhanced Therapy for children With Autism Spectrum Disorders, or DREAM, is a long-running study of robot-assisted therapies, funded by the European Commission and run across seven European universities, including the universities of De Montfort, Portsmouth and Plymouth, as well as Skövde in Sweden. The first stage of the research tests the use of robots for common autism treatments, mostly using NAO, a half-metre tall programmable, humanoid robot made by French firm Aldebaran Robotics. The researchers are also using a "huggable" robot called Probo, developed by Vrije Universiteit Brussel, which was designed to teach communication skills, showing facial expressions using 20 motors in its head. Both robots have been used in previous autism spectrum disorder research.
The robots are used to assist with common treatments, cognitive-behaviour theory (CBT) and applied behavioural analysis (ABA), and target three skills: joint attention, imitation, and turn taking. Children are judged on how well they share and follow instructions before and after the sessions, which are set up as a series of games to play. For example, a robot will be used to show physical actions for the child to mimic, such as miming drinking from a cup or waving their hand. Imitation is one way young children learn, and the idea is that such actions will teach the child to model the skill, which may not come naturally to them. With turn taking, children play a game with the robot, learning how to wait their turn and interact with each other, while joint-attention measures how the child initiates contact with the play partner, human or robot.
These robots aren't designed to replace human therapists, but to be used as a tool by them. The therapist might use the robot as a focal point for the child, as some find it easier or more engaging to interact with a robot than an adult, or the therapist may use it to show a movement the child should mimic, a key aspect of behaviour-based therapies. A robot can do the movements to mimic, saving human therapists' time and energy.
The DREAM research is ongoing and results haven't yet been fully published, stresses Billing and his co-researcher Silviu Matu. Early results from the first phase were reported last fall, halfway through the study, saying there were "no significant differences" on the primary outcomes, the turn-taking, imitation and joint attention skills measured by the therapists. While the robots offered "small advantages" in secondary outcomes, such as how the children interacted in the sessions, there wasn't improvement in the three specific skills being measured, the two researchers note. "There are of course lots of variation for individual children."
Erik Billing, at the University of Skövde, says the results so far suggest that some children benefit from robot-assisted therapy, but others may do better without robots in the room. He also notes that the effects appear to wear off after time — like any new tech, robots are intriguing to anyone when they first see them, but less so after the tenth time. Matu adds that most children react positively to the robot in the room. "They are curious about the robot and want to see the robot and play with him," he says.
What’s really going on in those Boston Dynamics robot videos?
Even if the robots are no better than a human therapist, they may still be better than nothing. The robots could be sent home with a programme of movements or other games for the child to practise on, helpful for those who live too far away from psychology clinics for frequent visits. "It opens up a new way to conduct therapy in completely different forms," Billing says.
Plus, these robots are only being tested with the CBT and ABA therapies — and the robots can only be as good as they treatment they're programmed to deliver, and a different therapy style may do better with robots. "The application is as important as the tech itself," says Ben Robins, who works on the Kaspar project at the University of Hertfordshire.
Kathleen Richardson, professor of ethics of robots at De Montfort University, who organised a recent conference on robot therapy and ethics, explains that because it's based on the idea of behaviour changing cognition, ABA is often criticised for being repetitive and mechanical – in other words, too robotic even when robots are not involved. "A robot can become just another extension of behaviourism," she says.
DREAM aside, there are plenty of smaller studies suggesting robots can encourage social interactions. At the conference, Robins showed remarkable videos of children speaking when they were previously entirely silent or walking right up to a robot and interacting when they normally hide in the corner of a room. There's no question to him that robots can be useful for some children with autism, but they don't necessarily need to be real robots.
While Kaspar is a fully functioning piece of tech — there are cameras behind its eyes and it tells children it's sad if they smack it — the robot is in many ways a puppet, and can be controlled by therapists. Indeed, Robins' early "robots" were remotely controlled, making them more akin to puppets than actual robots. They worked just as well, he says, suggesting that there may be something in the reduced facial detail and expressions that appeals to autistic children, making interaction easier. To test that theory, he went to Covent Garden in London and found a street performer whose gig was to pretend to be a robot. Robins hired the actor to do his routine with autistic children; just like with the real robot, it worked.
Even when working with a robot, he argues it shouldn't run an automated script and that it's necessary to allow the human therapist into the feedback loop. "If we take a cue from a child, we can achieve so much more than following the script," he says. The Kaspar project is currently running a small scale pilot with the NHS; if successful, a larger study will follow.
One aspect of the DREAM project is focusing on the ethics of using robots for treatment. And there's plenty to consider, above and beyond the usual quandaries raised by the use of AI and robotics elsewhere in healthcare, such as building in bias and data privacy.
Robots may help treat children with autism, but we need to be wary of treating them like robots in return. Are machines the best way to teach social interaction? Do we risk further entrenching flawed assumptions that people with autism are machine-like? Could we be ignoring known successful therapies in favour of high-tech wizardry?
Given we don't understand the causes of autism, it's difficult to know how to treat it, and even though we don't yet know if robots help in therapy, they're already becoming a focus for research. Why spend so much money developing robots that can track eye movements, interact using AI and the like if all we need is a doll or street performer? Are we putting too much focus — and too much R&D funding — into robotics for children with autism?
Autism research, like anything else, ebbs and flows in trends, attracting new ideas because it's such a central concept to child development, says Bonnie Evans, a historical researcher into autism and the author of The Metamorphosis of Autism.
For instance, the last R&D trend was around the idea that autism could be associated with an unique genetic code, not because of any specific discoveries around autism, but because genetic research became easier after the Human Genome Project.
"This was a superficial idea given the complexity of gene-environment interaction in any condition, let alone one that is primarily psychological," she says." What everyone discovered — yet which many practicing psychological specialists knew — is that there is no unique genetic code attached to the diagnosis of autism and the picture is hugely complex. Yet the scientific community could not give up on the idea that the autism diagnosis is a useful way to categorise and class human difference."
That's happening again with robots, she says. "The burgeoning scientific field of AI and robotics in the present day has again latched onto autism diagnosis as a way to make claims that what is happening with interactions between robots and children who need developmental support is 100 per cent legitimate science and not just an experiment."
While any research that could lead to happier lives for children with autism is welcome, it's frustrating for those doing the day-to-day therapeutical work who can't get the funding for already successful treatments. "It does concern me because millions and millions go into these projects," Richardson says. "The arts, for example, have an extraordinarily positive proven effects with people with alzheimer's and autism and they just don't get any money. It just goes into the tech. That does concern me."
While art or therapy dogs — Richardson is a big fan of therapy dogs — help bring those with autism into social contact, there's a risk robots could be socially isolating. While Robins' research videos show multiple people in the room with the child subject and the robot, including researchers, therapists, and parents, Richardson says it's easy to imagine robots over time becoming digital babysitters, much as TV is for some. "Then you've created a technology that might have an unintended consequence of isolating someone further, whereas the arts are about bringing people together, and creative expression and using emotions. They found puppets to be effective — they're very cheap, but no-one is interested in puppets. Everything is about the tech these days."
What's most useful for those with autism is person-centred, intensive interaction, argues Damian Milton, lecturer in intellectual and developmental disability at the University of Kent. But that isn't the most "sellable product", he says. "In the autism market, not many people want to hear that what people [with autism] need is basic standards of care and humanity."
Inside the bitter war to bring Tupac and Michael Jackson back to life
Aside from costs and the most responsible way to spend research funding, there are other ethical questions raised by the use of robots for treatment, and much of it centres on how people with autism are viewed. There's a long-running — and false — assumption that everyone with autism is methodical and machine-like, lacking emotion and empathy.
"The idea that it's like a computer brain is dehumanising," Milton says. "Due to popular understanding — or misunderstanding — of what constitutes autism, it's often incorrectly seen in such terms that autistic people are somehow less than human, animalistic or machine like, only capable of compiling and broadcasting strings of information."
Richardson argues that the machine-like metaphor is one reason robotics are a popular research angle for autism therapy. "If you look into the underlying theory behind the use of robots, you find this idea of people with autism preferring things over other persons," she says. That idea suggests that autism is a version of the "extreme male brain" — which Richardson says is "nonsense" and "sexist". While people picture Sheldon Cooper from The Big Bang Theory — genius, abrupt, bad at social interactions — the reality is some people with autism can't speak, are withdrawn and beset by anxiety and obsessive compulsive issues. It just doesn't make for good TV. "I think this idea that children with autism are mechanical, they prefer systems, and they lack empathy is what really provided the basis for the thinking about autism and robots," she says.
And that's led robotics researchers to hope to build systems using autism models, such as theory of mind, a model that describes the idea that people with autism don't understand that other people have their own point of view, thoughts or even visual perspectives, making it difficult for them to relate socially. Roboticists at Richardson's conference showed off their systems developed with autism in mind, such as teaching their machines to have the ability to consider different perspectives, understanding that one person may see an object another may be blocked from viewing, for example.
Such borrowing from people with disabilities can be problematic, Richardson says, pointing to robotics developers creating vision systems using human blindness as a model. "They were borrowing lots of things from people with disabilities for their robots, as though people with disabilities weren't quite human," she explains. "If you're going to develop a technology around a group of people, they should be involved in it, otherwise you just end up with an echo chamber." That's why she's so eager to praise Billings DREAM work, as it incorporated ethical considerations early on in the project's development.
Including children with autism into research presents different challenges – but it's certainly possible to ask adults with autism for their thoughts. As plenty pointed out at the conference, we don't know what causes autism or even really what it is. But if we want to know what people with autism think about robot treatment, we need only ask.
Milton describes himself as on the spectrum, and he's not convinced robots are what's needed by people like him and his son, who also has autism spectrum disorder. "Why machines? Are machines the best things to teach social interaction to people?" he says. "I'm not so sure." He suggests that instead of robots being designed to fix how people with autism behave, perhaps such research can be used to help everyone else understand better what it's like to be autistic, building empathy in both directions.
Such ideas are worth exploring, and therapy robots are worth investigating, so long as they're about bettering the lives of affected children — and not merely about making clever, headline-grabbing robots. "Let's diversify what therapies are available and what support is available to parents," says Richardson. And that's true whether it's empathy building, low-tech puppets, or high-tech robots.