**1. Introduction**

Children and youths with complex needs, here indicating having severe physical disabilities and complex communication needs [1] such as cerebral palsy with severe motor impairments and Rett syndrome, encounter difficulties using speech for everyday communication and may be at great risk of participation restrictions in daily activities [2,3]. Without adaptations, the dysfunction of movement of children/youths with complex needs and the interplay between the impairments in cognition, motor, or other domains might

**Citation:** Hsieh, Y.-H.; Borgestig, M.; Gopalarao, D.; McGowan, J.; Granlund, M.; Hwang, A.-W.; Hemmingsson, H. Communicative Interaction with and without Eye-Gaze Technology between Children and Youths with Complex Needs and Their Communication Partners. *Int. J. Environ. Res. Public Health* **2021**, *18*, 5134. https:// doi.org/10.3390/ijerph18105134

Academic Editor: Eunil Park

Received: 13 April 2021 Accepted: 5 May 2021 Published: 12 May 2021

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hinder their communicative interaction with the environment [2–4]. Most often, these children use vocalization, eye pointing, facial expressions, or body movements to express needs or socialize; however, their idiosyncratic behaviors or communicative intentions may be subtle and difficult to be recognized or interpreted appropriately by those around them [5,6]. The lack of appropriate responses from communication partners and lack of communication access adapted to their motor impairments and speech difficulties could impede the children's motivation to communicate, hinder their communication development, and restrict participation in social life [7–9]. Therefore, their fundamental human right of communication should be addressed [10,11].

Assistive technology (AT) as a means to enhance participation has been highlighted for children with complex needs [12]. Augmentative and alternative communication (AAC), which is one type of AT designed to facilitate communicative interactions, includes unaided methods (e.g., gestures, vocalization or speech) and aided methods (e.g., low-tech communication boards or high-tech communication devices) to supplement or compensate for the impairments of verbal communication for children with complex communication needs [13]. However, previous studies found that when aided AAC resources such as communication boards were provided, most children with complex needs required considerable assistance in using the communication interfaces and preferred the use of gesture or vocalization, with which they can communicate with familiar partners quickly and easily [5,14,15]. They occasionally used aided AAC systems via eye pointing or partnerassisted scanning when they were requested to provide information or clarification in complex conversations.

In recent years, eye-gaze assistive technology (EGAT) has been demonstrated as an opportunity for children/youths with complex needs to communicate and participate in various daily activities [16–18]. This innovative technology can detect eye movements using a specialized infrared video camera mounted on a tablet/computer. This calculates the direction of eye movements within a few millimeters when a child is gazing at a screen [19]. In combination with AAC software, EGAT could help children/youths with complex needs express their opinions by using their eyes to operate an AAC interface on a tablet/computer (Figure 1). It has been shown to be a feasible and relatively intuitive way to aid their communication in school or home contexts with ongoing support from communication partners and healthcare professionals [16,20,21]. Although many research studies have demonstrated communication benefits in the adult population with severe physical disabilities, there is a need for more research to support the positive effects of using EGAT in natural contexts in the children population. Some studies indicate that children with complex needs might need long-term practice to master eye-gaze control skills [22] and to develop the communicative competency to become an efficient user of communication aids [23]. Long-term practice includes both use for extended time periods and frequent use every day. Hemmingsson and Borgestig [17] reported that these children used EGAT for only a few hours per day. Besides low exposure to technology, other factors might reduce the effectiveness of EGAT, for instance, multiple impairments (e.g., visual or cognitive impairments), eye-gaze performance [22], communication abilities, learning opportunities [24], accessibility of the devices across environments [17], and attitude, knowledge and strategies of communication partners [25]. However, one recent multicenter intervention study indicated positive effects of EGAT intervention on expressive communication skills for children/youths with complex needs [26]. The stakeholders from previous studies also revealed positive experiences as the use of EGAT gave the children an opportunity to express things on their own initiative, which could lead to more opportunities to engage in communicative interaction and participate in social life [16,24].

**Figure 1.** Example of EGAT with adapted communication page.

Communicative interaction, including interactional sequences of communicative behaviors in the persons interacting (e.g., initiation of a conversation or response), communicative functions during interaction (e.g., requesting an object or answering a question), and the means of communication (e.g., using speech or eye pointing) [27], is one of the building blocks of cognitive and social development [28]. Nevertheless, research has indicated that children/youths with complex needs show a limited range of communicative interaction as they tend to play nondirective or non-initiating roles, give more adopting responses as yes–no answers, and provide less information [5,15,27]. The communication partners usually occupy more conversational space, initiate most of the interactions and request specific responses to encourage the communicative exchanges. EGAT, which requires less physical effort and assistance from communication partners than other interfaces, could provide children/youths with complex needs with opportunities to take initiative, express opinions, and interact with others [16,24]. However, few studies have provided knowledge about how use of EGAT by the children/youths influences the communicative interaction with their communication partners.

Therefore, the central aim of this study is to investigate the impacts of employing EGAT, compared to the Non-EGAT (NEGAT) condition on communicative interaction, in terms of interactional structure and communicative functions used by children/youths with complex needs and their communication partners. The research questions posed are: Which interactional structure are shown by children/youths with complex needs and their communication partners when EGAT is or is not used? Which communicative functions are used by the dyads when EGAT is or is not used? The hypotheses are: when the children/youths use EGAT in communicative interaction, (1) children/youths initiate more frequently, in contrast to the NEGAT condition; (2) communication partners take fewer communicative turns; (3) communication partners make fewer requests or demands.

The structure of this article is organized as follows. Section 2 first describes the study design, using a systematic video-coding approach to research questions and the procedure of film clip collection. Secondly, participants and the selection of film clips based on criteria are addressed. Thirdly, a coding scheme as the outcome measure for communicative interaction is detailed. Lastly, data analysis, including video analysis and the three-tiered method of analysis, is described. Section 3 presents results based on the structure of the three-tiered method. In Section 4, study findings on communicative interaction between dyads are discussed. Section 5 concludes this study.
