The Effect of Usability of Mobile Applications on the Attention-Span of Children with ADHD

44 Pages·2014·1.07 MB·English

The Effect of Usability of Mobile Applications on
the Attention-Span of Children with ADHD

Roos van den Kieboom
anr 727419

Bachelor’s Thesis
Communication and Information Sciences
Specialization Human Aspects of Information Technology

Faculty of Humanities
Tilburg University, Tilburg

Supervisor: C.S. Shahid
Second reader: R.J.H. Mattheij
July 2014
Abstract
The aim of this study is to investigate and identify the influence of the usability of mobile
applications on the attention-span of children with ADHD. This study also explores how the
implementation of different game elements in applications or games affect the effectiveness
and efficiency of these applications. With an upcoming trend of using mobile applications in
everyday lives, the focus is on whether or not mobile applications can be used for children
with ADHD for improving their attention span. The study is conducted within a regular
primary school in Bergen op Zoom and a special primary school in Cuijk. To control for
biases, the study used a control group of children from the regular primary school in Bergen
op Zoom. For both the test group and the control group the usability score of three existing
applications was measured as well as the attention-span of the children. Based on the results it
can be suggested that usability of mobile applications does influence the attention-span of
children with ADHD. Furthermore, the results show that the control group (regular children)
and the test group (children with ADHD) appreciate different (design) elements of
applications in very different ways and that there is a need of designing more customized
applications for children with ADHD
Table of Contents

1. Introduction ............................................................................................................................ 1
2. ADHD and ADD explained ................................................................................................... 3
2.1 ADHD within the field of education ................................................................................ 3
3. Mobile applications ................................................................................................................ 5
4. Usability testing of mobile applications ................................................................................. 5
4.1 Usability testing for children ............................................................................................ 6
4.2 Usability testing of mobile applications for children with ADHD ................................... 7
5. State of the art of mobile applications within education ........................................................ 8
5.1 Mobile applications for educational purposes for children .............................................. 8
6. Charsky’s framework for game elements ............................................................................. 10
7. Game elements linked to usability of mobile applications .................................................. 12
8. Current study ........................................................................................................................ 14
9. Methodology ........................................................................................................................ 15
9.1 Type of research ............................................................................................................. 15
9.2 Variables ......................................................................................................................... 15
9.3 Sample ............................................................................................................................ 16
9.4 Research design and test method .................................................................................... 16
10. Results ................................................................................................................................ 20
10.1 Questionnaire and attention-span measurements ......................................................... 20
10.2 Observations and interviews ......................................................................................... 22
11. Conclusion and discussion ................................................................................................. 27
11.1 In summary ................................................................................................................... 27
11.2 Conclusion .................................................................................................................... 29
12. References .......................................................................................................................... 31
Appendix 1 ............................................................................................................................... 36
Appendix 2 ............................................................................................................................... 41
1. Introduction
ADHD (attention-deficit/hyperactivity disorder) is a common disorder. ADHD is a diagnosis
that is given to children, adolescents, and adults, which is characterized by very high levels of
inattention, over-activity, and impulsivity (Sowerby & Tripp, 2009). In the past few years,
ADHD diagnosis has received quite some attention in the scientific community and a good
amount of research has been conducted on ADHD in general (Rief, 1998; LeFever,
Butterfoss, & Vislocky, 1999; Klingberg, T., Forssberg, H., & Westerberg, H., 2002; Ota &
DuPaul, 2002; Sowerby & Tripp, 2009). Overall these studies indicate that ADHD is a
growing problem and affects children in multiple ways. These children suffer in different
situations of everyday lives and one important context is educational or school environment
(Ota & DuPaul, 2002).
Several studies indicate that ADHD negatively affects educational outcomes, because
of the high levels of inattentiveness (LeFever et al., 1999; LeFever, Villers, Morrow and
Vaughn, 2002; Ota & DuPaul, 2002; Loe & Feldman, 2007). Because of these high levels of
inattentiveness, it is even argued that children with ADHD are substantially more limited in
their daily functioning than children without ADHD (Ota & DuPaul, 2002). This high level of
inattentiveness in children demands for extra care by teachers or caretakers in the school
environment but unfortunately, this demand is not always possible to fulfill, especially in
regular educational environment. It is therefore interesting and of great importance to look
further into possible alternatives to support the children with ADHD in their daily activities
and in educational settings as well.
In the past decade, use of computer technology within educational (Dickey, 2006), not
only for skill development but for personality development as well, has dramatically
increased. A more recent development is the increasing use of mobile applications (Li & Liao,
2002) for similar purposes. Mobile applications have become an important part of children’s
lives. Most of the mobile applications designed for children are designed for serious aims i.e.
playful games with a serious purpose. These applications are not only restricted to regular
children. Children with special needs e.g. children with ADD or with ADHD are also
benefiting from this new wave. In the case of children with ADHD, these applications can
help them in numerous ways, from increasing attention-span to reducing hyperactivity.
Although it is a recent trend to design special applications for children with ADHD, it is not
an easy task. It becomes even more difficult when children are required to use these
applications in a more independent manner i.e. without the supervision of teachers for easing
out their workload.
1
Children with ADHD differ from regular children in many ways and it is not clear
which criteria of designing a good application for them are needed. Are all the design
principles valid for regular children, suitable for children with ADHD as well? If not, what
changes do we need to make for designing a more customized application for children with
ADHD?
The focus of this study is on the attention-span of children with ADHD. This study
particularly explores how different mobile solution should be designed in a usable manner for
assisting children with ADHD in everyday routine i.e. in school as well as in home
environment. Although a number of mobile applications are available as off-the-shelf
solutions for improving the attention span of children with ADHD, it is not clear which
features or design elements make one application a good one and another one a bad one.
Furthermore, the core purpose of such applications is either to increase the attention span of
children or keeping them involved and motivated. It is therefore important to know how
different design elements and the usability of the application affect the overall attention span
and task performance. This is what we try to explore in this study.
A decent criteria to evaluate a mobile application is to measure the usability and
engagement of the application using standard methods and frameworks. It is argued that when
the mobile application scores high on usability and engagement, the aim of the application
will be reached easier than when these scores are low (Zhang & Adipat, 2005). This statement
suggests that the usability and associated engagement elicited by the application affects the
achievement of the goal of the mobile application.
The rest of the thesis is structured as follows. In chapter 2, ADHD and ADD will be
further explained and defined. Furthermore, the link between ADHD and its role in the
educational context will be discussed. In chapter 3, mobile applications will be discussed. In
chapter 4, usability testing of mobile applications will be explained. In this chapter, usability
testing for mobile applications for children and for children with ADHD will be specified as
well. After that, in chapter 5 the state of the art of mobile applications within education will
be discussed. Within this chapter, there will be looked further into mobile applications for
educational purposes for children and after that, into mobile applications for educational
purposes for children with ADHD. In chapter 6, a framework of game elements will be
shown. Chapter 7 is about those game elements linked to this study. Chapter 8 links the
theoretical framework as a whole to the research conducted for the current study. In chapter 9,
the methodological aspects of the study will be discussed and chapter 10 shows the results.
Finally, in chapter 11, a conclusion and discussion will be presented.
2
2. ADHD and ADD explained
Attention-deficit/hyperactivity disorder (ADHD) is a well-known disorder. Sowerby and
Tripp (2009) define ADHD as “The diagnosis given to children, adolescents, and adults who
display developmentally inappropriate levels of inattention, over-activity, and impulsivity”
(Sowerby & Tripp, 2009, p.210). Ota and DuPaul (2002) complement this definition and state
that children with ADHD exhibit developmentally deviant levels of inattention or have
hyperactivity-impulsivity that significantly impair functioning in different areas. Therefore,
Ota and DuPaul (2002) suggest that ADHD is considered one of the most common childhood
behavior problems in western societies. Given this information, it becomes clear that ADHD
has become a major public health issue (LeFever et al., 1999).
To narrow down the type of ADHD, which will be focused in this study, it is
important to explain the current and official types of ADHD. The term ADHD is seen as an
umbrella for three types of the disorder: the predominantly inattentive type (ADHD-I), the
predominantly hyperactive and impulsive type (ADHD-HI), and the combined type (ADHD-
C) (Rief, 1998). According to the American Psychiatric Association (Sowerby & Tripp,
2009), the predominantly inattentive type (ADHD-I) is characterized by six or more
symptoms of inattention, but fewer than six symptoms of hyperactivity/impulsivity. The
predominantly hyperactive and impulsive type (ADHD-HI) is distinguished by six or more
symptoms of hyperactivity and impulsivity, but fewer than six symptoms of inattention.
Finally, the third type of ADHD, the combined type (ADHD-C), is known for six or more
symptoms of inattention and six or more symptoms of hyperactivity and impulsivity.
Because all three of the types of ADHD include inattentiveness, even ADHD-HI
includes few symptoms of inattention, they will all be used for our study. Furthermore,
attention-deficit disorder (ADD) is most compatible with type ADHD-I, since this type lacks
hyperactivity, but is still characterized with inattentiveness (Rief, 1998). In this review, the
term ADHD will be used as an overarching concept for all types of ADHD and ADD as well.
2.1 ADHD within the field of education
A good amount of research already has been conducted within the field of ADHD (Barkley,
1997, LeFever, et al., 1999, Klingberg et al., 2002). In this previous research on ADHD,
researchers focused on the effect of ADHD on children and most importantly how ADHD
affects children in the educational environment. Loe and Feldman (2007) state that
longitudinal studies show that the academic underachievement and poor outcomes associated
with ADHD are persistent. Ota and DuPaul (2002) agree with this statement and argue that
3
children with ADHD experience more difficulties with academic achievement in comparison
to average children. Also, Loe and Feldman (2007) acknowledge these facts and state that
ADHD is associated with bad results at school, increased grade detention, expulsion and low
rates of graduation. Furthermore, LeFever et al. (2002) state that children with ADHD are
four to five times more likely to use special educational services than children without
ADHD. They also argue that children diagnosed with ADHD often suffer from low self-
esteem and poor academic self-image.
LeFever et al. (2002) acknowledge that children with ADHD must be treated looking
at the consequences the disorder may cause in especially educational fields. In their study,
they divide treatments for children with ADHD into “medical management” and “behavioral
treatment”. According to LeFever et al. (2002), the parents of the children with ADHD that
were examined for their research, reported negative results from medical management.
Pelham et al. (1999) support this result and even argue that 30% of treated children respond
negatively to medication. These facts show that the benefits of medical management are not
always encouraging and attention should be also be paid to the behavioral treatment. In this
study, the focus will only be on behavioral treatment because it has been shown that this
treatment cannot be underestimated.
Since ADHD can have major consequences in educational systems (Loe & Feldman,
2007; Ota & DuPaul, 2002; LeFever et al., 1999; LeFever et al., 2002), behavioral treatment
is not only offered at special institutions, but in regular schools as well. LeFever, et al. (2002)
argue that effective and efficient use of school-based interventions will contribute to the
child’s development in primary school. Also, children with ADHD are characterized by
inattention (Luman, Oosterlaan & Sergeant, 2005; Ota and DuPaul 2002; Prins, Dovis,
Ponsioen, ten Brink & van der Oord 2011; Rief, 1998) and it is therefore important that the
children are stimulated to focus on the available resources which can help them.
Especially when tasks are extremely boring, or need to be performed without
supervision, the attention-span of children with ADHD tends to be very limited (Luman et al.,
2005). Prins et al. (2011) support these facts and therefore argue that by making tasks less
boring, the motivational state of the child will be optimized, which results in better
performances. Nevertheless Prins et al. (2011) argue that helping children with ADHD
throughout school-based interventions takes much time and effort from the facilitators within
the school. It is therefore important to look at alternatives that can provide a helping hand, but
merely on the effects of the usability of mobile applications on the attention-span of children
with ADHD.
4
3. Mobile applications
With the continuous advances and developments in the widespread use of mobile devices,
such as smartphones and tablets, many innovative mobile applications are emerging (Li &
Liao, 2002). Mobile applications, referred to as software systems operating on mobile
devices, are therefore evolving rapidly according to Zhang and Adipat (2005). They also
argue that, because of the fast growth of mobile applications, this market has attracted
extensive interest of research (Zhang & Adipat, 2005).
Mobile applications evolve over time and, as traditional software systems, are required
to be maintained (Minelli & Lanza, 2013). According to Minelli and Lanza (2013) it is
unclear whether or not the program comprehension used for software systems can be ported to
applications. It is therefore interesting to examine what is needed for designing mobile
applications in general.
According to Harrison, Flood and Duce (2013), it is important to consider several
aspects in designing mobile applications. They argue that the limited screen sizes, the limited
connectivity and limited input modalities are issues which need to be evaluated in the
designing process (Harrison et al., 2013). Moreover, they stress out the importance of the
context in which the application will be used (Harrison et al., 2013).
Adams (2007) acknowledges the importance of the context in designing mobile
applications. Furthermore, he states that the usability is determinative for the application’s
success. Harrison et al. (2013) demonstrate that cognitive overload influences usability.
Linking this to the most important characteristic of ADHD, inattentiveness, it is of great
importance that mobile applications developed for children with ADHD do not cause
cognitive overload which results in an increase in distractors. Hence, usability can affect the
outcome of mobile applications in general (Zhang & Adipat, 2005). Especially for children
with ADHD, the usability can affect outcomes in a more negative way than for children
without ADHD.
4. Usability testing of mobile applications
The usability of a mobile application, sometimes also referred to as appropriateness of a
mobile application, can differ based on context factors and personal preferences (Gong &
Tarasewich, 2004). Usability testing is a well-known method that is used to evaluate the
usability of a mobile application during the design- and developmental process (Kaikkonen,
Kekålåinen, Cankar, Kallio, & Kankainen, 2005). Zhang and Adipat (2005) argue that
usability testing of mobile applications is a mandatory process, because it can ensure that the
5
application is practical, effective and easy in use. Nevertheless, usability testing of mobile
applications faces various challenges due to unique features of mobile devices, unreliable
networks, limited bandwidth and changing contexts (Zhang & Adipat, 2005).
Ideally, usability testing is conducted in usability test laboratories with a monitoring
area and a one-way mirror (Kaikkonen et al., 2005). Kaikkonen et al. (2005) argue that the
laboratory environment should be a peaceful space where a test user can concentrate on their
performance. However, with the increase in mobile application usability testing, researchers
and practitioners are concerned that the ideally looking test laboratories do not comply
enough with realistic user environments (Tamminen, Oulasvirta, Toiskallio, & Kankainen,
2004). Kaikkonen et al. (2005) share this opinion, because they too argue that the laboratory
environment does not simulate the context in which mobile devices are used. Therefore, it is
seen more useful when participants are observed within an actual environment or the one that
does not look like laboratories (Kaikkonen et al., 2005; Tamminen et al., 2004).
Looking at the information mentioned above, one can argue that usability testing of
mobile devices brings challenges for researchers in general. However, for this study, the
usability testing of mobile applications will be performed by children, which is an even more
challenging task.
4.1 Usability testing for children
When thinking about usability testing of mobile applications for children, it is necessary to
consider the goal of the application. Moreover, it is of great importance to take the age of
specific target group of the application into account (Carusi & Mont’Alvão 2012).
As mentioned before, usability testing of mobile applications for children involves
numerous challenging situations (Markopoulos and Bekker, 2003).The children are required
to do much more than just evaluate the use of the technology. Kaikkonen et al. (2005) and
Tamminen et al. (2004) argue that children have to step out of their comfort zone when testing
mobile applications, because they have to test and evaluate the applications within an
unknown environment. Druin (2002) support these findings and state that testing with
children is multifaceted activity. It is not only complex for researchers to perform the test but
also very complicated for children to follow the process. The children need to adapt to the
testing environment, follow several processes and guidelines, report their experiences, and
they have to interact with the facilitator.
Although the above mentioned information suggests that usability testing with
children may be too challenging, it is also found that children are useful and active
6
participants in usability testing (Markopoulos & Bekker, 2003) and we should not ignore
them while designing products for them. Furthermore, children are known for their creativity,
which can provide major advantages for designers while designing innovative products for
them (Markopoulos & Bekker, 2003). Another advantage of usability testing with children is
that children do not tend to provide desirable answers which results in honest views (Druin,
2002; Khanum & Trivedi, 2012). Finally, previous research has consistently shown that
testing applications should be performed by the target group itself, because they know exactly
what is needed in a successful application (Carusi & Mont’Alvão 2012).
Elaborating on performing usability testing for mobile applications by the users itself,
the user can fulfill different roles. Druin (2002) describes four main roles that the children in
usability testing can fulfill: “user”, “tester”, “informant”, and “design partner”. The roles have
been defined according to the relationship to adults, the relationship to the technology and to
the goals for the research with children. For this study, only the role of user will be used, since
this study will not focus on the actual development of mobile applications, but merely on the
effects of the usability of mobile applications on the attention-span of children with ADHD.
In order to involve children in the usability testing process, it is essential to create a
clear and structured testing plan (Khanum & Trivedi, 2012). Firstly, it must be clear what the
aim and the objectives of the test are (Khanum & Trivedi, 2012). Secondly, the children must
know which role they are going to fulfill on forehand (Druin, 2002). Thirdly, there are
guidelines concerning the testing environment, which should feel natural for the children
(Hanna, Risden, & Alexander, 1997). For younger children (up to 7- or 8- years old) there
should be a tester in the room (Khanum & Trivedi, 2012). Hanna et al. (1997) also emphasize
the importance of discretely placed testing tools like cameras. Finally, the testing sessions
should not take any longer than 30-40 minutes per day. In this way, the sessions are said to be
more effective (Druin, 2002).
4.2 Usability testing of mobile applications for children with ADHD
Usability testing with children is challenging at itself, but when taking the information about
children with ADHD into account, usability testing with children diagnosed with ADHD
becomes even more challenging. Children with ADHD are said to be inattentive, overactive,
and impulsive (Sowerby & Tripp, 2009). Ota and DuPaul (2002) even state that these
characteristics cause impairment in functioning in different areas. This suggests that it will be
difficult to test usability of mobile applications with ADHD children, because of their limited
attention-span.
7