Interview – Elaine Biddiss

On Videogames, Assistive Devices, & Accessibility

Dr. Elaine Biddiss is a scientist with the Bloorview Research Institute at Holland Bloorview Kids Rehabilitation Hospital and an Assistant Professor with the Institute of Biomaterials and Biomedical Engineering at the University of Toronto.  Her research is oriented around the creation of assistive devices, including videogames, that can benefit children and youth with disabilities.


First Person Scholar editor-in-chief Steve Wilcox recently spoke with Elaine Biddiss about assistive devices, videogames, and rehabilitation. An audio version of the interview is available at the bottom of this post.  [The following text has been edited for clarity.]

First Person Scholar: One of your most recent projects involved re-designing a hospital waiting room with an interactive game system intended for children, many of whom have disabilities. So correct me if I describe this inaccurately, but for those who haven’t heard of it, the project is called “Screenplay” [see video below] and it uses touch sensitive floor tiles to translate movements into images projected on to a screen. In order to account for different mobilities, the software modifies the size of the image in inverse proportion to the movement of the child. So the longer you remain stationary, the larger the image you generate. The result is a digital mural of sorts that represents the presence of children as they play. But the objective here is not only to engage children but to reduce their anxiety as well.  So, can you tell us what led you to address anxiety and why you think it’s important?

Elaine Biddiss: So anxiety preoperatively or even pre-procedurally for children and for adults, it’s a concern because it actually affects the ability for the doctors to provide the treatments as well as postoperative recoveries. So that’s through the human immune response [which] is very much linked with the stress response. There has been studies indicating that recovery time is slower, wound healing is slower and when preoperative anxiety is high, particularly for our children when they are anticipating uncomfortable or painful procedures, the mitigating anxiety can lead to less resistance to the treatment, less nightmares, separation anxiety and things like that. So…mitigating pre-procedural anxiety is one of the main concerns in family and patient or child centered healthcare.

FPS: Okay, building on that but in a different direction, “Screenplay,” it’s sort of a custom built installation. It’s a rather sophisticated piece of technology too, so I’m wondering–I know that you’ve worked with systems such as Nintendo Wii before but–what excites you about the wider availability of low cost, motion capture systems such as the Wii or Xbox Kinect.

Biddiss: Well I think it opens up a whole load of possibilities for home based virtual reality therapies. So right in the moment there is more interest in virtual reality therapies but most of the systems are still very expensive like on an order of ten to twenty thousand dollars, and so they are centered mostly in the rehabilitation centers. So I guess our ideas are around the fact that kids love video games, they like to play video games, and so they spend quite a deal of time playing video games. So if we could even take half an hour of that daily playtime and turn in into something that is directed towards a physical therapy that they would be self motivated to do, and would enjoy doing, then that would be a huge win. And so commercial devices such as the Kinect and the Wii potentially open up the possibility for that.

FPS: I wonder if even these VR installations can produce their own sense of anxiety when you’re first entering into them and contrast that with the familiarity of your home, of your own living room and the systems there. Is there something to be said about you’re already [being] comfortable with this technology?

Biddiss: One of the reasons why we thought now is the good time for bringing in an installation like “Screenplay” is that kids are becoming more and more familiar with these sorts of technologies so it’s something that is within their realm of experience, while being sort of novel and interesting with aspects that they need to explore and the idea being that it will distract them and offer them a bit of an escape.

FPS: Absolutely. I was thinking of a different kind of virtual reality environment that’s sort of a darkened room with a projector screen and that sort of a thing. “Screenplay” for those who haven’t seen it seems very organically integrated with the waiting room. The colour scheme works there; the space is designed around it but it seems very organic and inviting for children to play with.

Biddiss: Yeah, it absolutely was. A lot of thought went into how we could create this installation so that it blends very much in with the environment because Holland Bloorview has a lovely, beautiful and welcoming architecture itself. So it was designed for that purpose.

FPS: I’m going to continue on the home motion capture, home electronic angle. In one of your articles you talked about the Wii as a rehabilitation tool and one of your observations is the potential for “unrealistic or adaptive movements to achieve success in the game, i.e., flicking the wrist to emulate a tennis swing rather than moving the entire arm.” For some learning these unrealistic movements is part of the game itself, so how do you navigate that tension in your designs between the intended form of interaction and the element of play that can and often does undermine those intentions.

Biddiss: So we switched technologies, we [now] use the Microsoft Kinect. Well, you know that for play purposes it’s great that kids figure these things out and they explore and they discover new ways of doing things but when you’re trying to design something for a specific therapeutic purpose, you want to make sure that the kids are actually doing the movements that are going to be helping them. So that’s one of the limitations with accelerometer based technologies like the Wii is that the sensor simply can’t tell if you’re making a small movement or a large movement. It’s much more so based on the acceleration of that movement, whereas with the Kinect it’s much harder to cheat because the algorithms are built to look for the intended movement. So from that perspective I see a little bit more potential for the camera based systems, in rehab based devices and applications.

FPS: Have you had a chance to work with the Kinect SDK at all in terms of the software environment and how have you found that?

Biddiss: Yeah. It’s pretty good; it’s quite good at capturing gross body movements but not so good at capturing finer motor movements. So that’s the movement of the hands and the wrist, which we are also very much interested in. So from that perspective, it’s not so much a problem with the hardware but the software and the algorithms that are picking up those motions that need development. So we do some work in developing better algorithms. I believe that there is a new version of Kinect coming out in December that’s supposed to have better hand tracking potential. Then there is other technologies as well, similar to the Kinect like the Leap Motion that is more focused in on the hand. So we explore all of those different technologies.

FPS: I recently watched a documentary on technology and accessibility, it’s called “Login to Life,” and in one of the narratives they tell is about a woman who has mobility issues and she spends most of her time on Second Life where she runs a course for other people that also have mobility issues and are working to get back into the workforce. So they have this whole community that they have built in Second Life, which is really remarkable, and part of what they are trying to do is make the game more receptive to these different forms of embodiment, so in the documentary they hire someone to come up with some dance moves because you can dance in Second Life with your avatars, but what they wanted to do is that you could have two people in wheelchairs dancing, you could have two people that are ‘able bodied’ dancing but they wanted dance animations between someone that can walk and someone that is in a wheelchair. And I thought that was a really interesting pairing because as the woman points out, there are dance competitions all across America that cater to this form of dance. And so I’m wondering if Microsoft or if somebody in a research position is going to need to develop algorithms that can detect specifically these different kinds of mobility’s, these different forms of embodied interactions or if the machines themselves already sophisticated enough to pick up on that.

Biddiss: Well I think it definitely requires some programming. I know that when the Kinect first came out, for instance, people in wheelchairs, it had a hard time picking up people in wheelchairs because it needed to find the feet in order to build the skeleton and it would get confused by the surrounding wheelchair and feet of the person. So I know that Microsoft has made advances with regards to that so now it is possible to use the Kinect in the wheelchair. But certainly if you were trying to do specific interaction, say having a dance between a person in a wheelchair and on foot, then there might be challenges that you could run into, so inclusion of limbs by the wheelchair and things like that, which would make it difficult for the current algorithms to pick up the skeleton of the user. So there always needs to be work done to make sure that these technologies are actually accessible to everyone. But certainly Microsoft is working towards that, and we work towards that too trying to pick up smaller movements where the kids may not have as large of a range of motion with their body, particularly their fingers and their wrists as typically developing children.

FPS: That’s interesting that they are very much involved in making that more sophisticated and open to different body types essentially and different mobilities. I am a games studies guy and I believe that a lot of professionals, especially those designing tools and spaces in general, they could really benefit from thinking about their work from a game design perspective. Mainly because games force us to think about the experience of the player, even the idea of usability testing has this implied objective to design an interface that will be used in the right way. Game design, at least in my mind, really asks us to consider what the player wants to do in that space. Has working with games changed how you view design?

Biddiss: Well, I don’t know if it’s changed that. I think I have always thought of it like a kid sort of thing. So I think I have always been very focused on the experience that they have when they are engaged in a therapy or an activity, but it certainly has reinforced that. So some research that I have done in the area of neuroplasticity for instance, it gives a very scientific basis for the importance of designing for motivation and for fun. And I think it’s the sort of thing where you can design the best rehab system in the world, you can show that it’s functional if it’s used but it still all hinges on the child wanting to participate in that activity repetitively sort of thing. So I think that is actually where a lot of the systems fall down that they have looked a lot at the functionality of the system without considering the user experience and the user motivation. For instance, a lot of systems give the child maybe one or two games to play, well after a week the child is tired of those two games, they are ready to move on. So I think that it’s really important to consider that but it’s also really challenging because these games, it’s not like in mainstream games, there is a very large market, so billions of dollars or millions of dollars can be spent in the development of these games. So I think it’s not so much that researchers and designers of sort of more rehab specific games don’t know that their games should be more fun or more visually appealing or that. It’s just the challenge of actually being able to accomplish it with limited resources. But it’s absolutely essential if virtual realities therapies are going to be effective for kids.

FPS: I guess what I’m angling at here is that a part of game play is subverting intentions. I wonder if there are ways of incorporating that into rehabilitation games, they obviously have a very logical reason for why they want this intended motion. But a lot of our joy we get in games is finding that short cut, that faster way of performing that action.

Biddiss: I see. I see what you mean. I don’t know. That’s a tough one. Well it’s…number one it’s tough because kids are so creative, so you never know exactly how they are going to adapt or find a different way of doing something. So, if you can’t predict that, then it’s hard to know what their actual behaviour is going to be. I suppose there is the opportunity to, in a rehab game; it doesn’t have to be all about the rehab aspect. There could be other fun aspects that keep them playing, so not every movement that’s done has to be therapy targeted sort of thing. So there is that opportunity, but I haven’t really thought about it that way because usually I’m trying to think of the way to get the child to actually do the movement that’s difficult for them because if they can find a way to do it easier, they usually do. Usually we are addressing that challenge as oppose to thinking about opportunities for them to find shortcuts and things like that. So yeah, it’s an interesting idea. I think the thing is finding that balance between the rehab goals and the child’s goals, which is basically to have fun. So I think it’s striking a good balance there is probably the answer.

FPS: I guess your point about the difference between the accelerometer and the camera is already implicit, but in this technology there are less shortcuts you can take since the camera is taking your full body into account. And that’s one way of definitely mitigating that. Do you have any advice for scholars and game designers that are looking to contribute to health related initiatives like this?

Biddiss: Yeah, absolutely. Don’t embark on anything without first consulting clinicians and therapists and kids and parents. I mean, the designs that are early on that I’ve worked on that we didn’t involve the end users and the people who really understand those clinical problems right from the onset are nowhere near as effective as later on when we realize that we really need to start these conversations very early on, so I mean that would probably be my main advice if you’re looking to design for health applications.

FPS: Great. Yeah I was talking to somebody from SSHRC [Social Sciences and Humanities Research Council] recently and we were discussing whether game studies should have their own department and then my answer was ‘I like it  the way it is’ because it really fosters this interdisciplinary activity and if you created its own department that might undermine that a little bit. Have you found that there’s that component when working with games?

Biddiss: Well it’s such an interdisciplinary area you know you need the engineers to do the motion capture business but you are looking at health change and behavior change and that’s really sort of a focus in psychology, you’re looking at therapeutic relevance so that’s the expertise of clinicians, you know we should also be looking at things like narratives and plotlines which is sort of in the area of literature, there’s the design and artistic side of things to make it look visually beautiful and interesting, there’s the audio component, so I mean it’s such a multifaceted area simply because you’re trying to create fantasy worlds or you’re trying to create a real life experience of immersion…you know our lives are so multifaceted, we may go to work and be an engineer but when we go home we have a whole lot of different facets to ourselves and so I think that game environments reflect that as well.

FPS: There’s a staple of game studies, this idea of homo ludens, which is that the human is inherently driven by play and I think that common denominator really provides a foundation for this sort of interdisciplinary work because you’re right you can leave the office but there’s still that, if you follow the philosophy, you’re still defined by play. [Then there’s] this idea of gamification which is often associated with the workplace and trying to get more out of an employee, but as Neil Randall has pointed out, the director of The Games Institute, you can gamify your education; the education system is geared towards that and that is kind of what I was getting at a little bit earlier with how children interacted with these systems because the games encourage you to find those little exploits and the little shortcuts and that’s how you build a little bit of mastery, out of that idea of developing those shortcuts.

Biddiss: Yeah, absolutely. And I mean kids even more so than adults are motivated by fun. If you take a similar adult who’s involved in some kind of physical therapy they may be able to say ‘ah, I hate doing this task but this is good for me so I’m going to continue doing this because you know two years from now I want to be able to do this,’ where as children don’t necessarily, especially young children, don’t necessarily have that long term vision particularly if they have a congenital condition because they are so adaptive and they do tend to adapt very well to their disability so they may not have that same sort of logical reasoning behind participating in a therapy so it’s really important that it be fun and motivating and rewarding for them to do in order for them to adhere or to participate in therapy.

FPS: Do you think perception of play might change now that consoles are becoming more and more popular and used on a more daily basis.We have these people that grew up with game systems in the 70’s and 80’s that are now, they’re developing their own games and they’re getting a more mainstream appeal, do you think that has a ‘knock-on’ effect for how adults might approach rehabilitation through game design?

Biddiss: Well it definitely has, just even at our own hospital there’s increasing interest in looking at and using virtual reality therapy as an induct to traditional therapy and it’s simply because the kids like them sort of thing, they enjoy participating in them, and the therapists already know that therapy works better when the kids are engaged in them. So they are definitely looking at these things as an up and coming tool. A bit of a challenge at the moment is making them as therapeutic as possible while maintaining that fun factor so I think that that’s the major challenge.

FPS: That must be a difficult balance to strike.

Biddiss: It is; it is a difficult balance to strike. We’ve done studies comparing a couple of games with therapists and kids and the games the kids like is not as therapeutically relevant but more fun and the games that the therapists like is very therapeutically relevant but less fun; they have very different design criteria and goals and so balancing those goals and finding ways of meeting everybody’s needs is a big challenge.

FPS: We just talked about how games can change the perception of play even into adulthood, but can games developed for rehabilitative purposes challenge traditional understandings of disability?

Biddiss: I think so. To tell you the truth I would like to see the system the kids are playing where they don’t even realize that they’re doing a rehabilitation activity and I would like to see the system that is so much fun that their typically developing peers want to play it as well. I mean I think it’s really interesting some of the work that’s being done in terms of the skills matching so that kids with disabilities can play with kids that don’t have disabilities on an even playing field in the virtual world increasing that sort of social interaction component because that’s another big issue for kids with disabilities is the social interaction so I think there’s loads of potential in that area definitely.

FPS: Yes, I really like that specifically about “Screenplay” that when you took that inverted approach where the absence of movement created this bigger display, it didn’t hit kids on the head with this idea that these are two different body types, it was just a different form of representation that seemed to–in a weird way even though it’s sort of an inverse relationship–it kind of balanced the playing field in certain respects.

Biddiss: Absolutely because it meant that a kid who maybe has less mobility who’s in a wheelchair can participate maximally in the experience the same as a typically developing child where as in most experiences the more you can run around and things like that the more you can impact your environment so it was a very sort of subtle quality of the interaction I suppose but it did take us a lot of time to come up with it. It’s a simple solution but it did take us a while to figure it out. FPS: I think it’s very insightful and it’s very subtle but also it’s so crucial, I think, to the design.

Biddiss: It absolutely is;  it’s what makes the system accessible to a large range of kids.

FPS: Absolutely. Wrapping up here, what do you think the upper limit is on the role that video games can play in the lives of children with disabilities? Do games fundamentally change how we approach disability in healthcare?

Biddiss: I mean that’s a tough question. To me I think that everything should be in balance. I wouldn’t want to see virtual reality therapy replace traditional therapy. There are kids that tend to really actually enjoy traditional therapies; they have great interactions with therapists, so I don’t think that I’d look at virtual reality therapies and games as a solution to everything, I think I’d just look at it as ‘here’s a fun activity that could potentially be used to improve quality of life or quality of function.’ And I mean I wouldn’t want to see a child spend their whole day in front of a videogame console even if it did have components of social interaction and online gaming and things like that; there is still something to be said for those face-to-face real world interactions. I don’t really know, I guess I haven’t really given a lot of thought in terms of the upper limits of what games can do. I still look at them more as of a tool and as an enjoyable past time as opposed to something that’s going to solve all of the problems.

FPS: Absolutely. Again, I guess I’m circling back, but I did like your inverted approach with “Screenplay” and I was wondering if we could invert your approach to game design. I’m thinking of a game called “Auti-Sim”, have you heard of that?

Biddiss: No.

FPS: It was developed in a hacking conference, Hacking Health out in Vancouver…

Biddiss: Yeah I’ve heard that.

FPS: So what it does is it simulates a playground and you play as an autistic child and you start on the periphery of the playground and there are a bunch of kids in the middle playing and as you approach the game is intentionally trying to simulate auditory hyper-sensitivity so the screen kind of blurs, the voices get really, really loud as you get closer and closer and eventually you realize that it’s really uncomfortable to be with those other children and you’d rather be on the periphery, or there’s actually a wooded area that surrounds the playground and you can find a gap in the fence and escape and play. And that really communicates to what we might think of as neuro-typical people what that experience is like and I’m wondering if with your work if you’ve come across anything, or if you’ve seen any potential to address, not necessarily the needs of  kids with disabilities but kids that have what I call an able body and making them more aware of different mobilities.

Biddiss: Absolutely. I mean I think that is so important. You know one of the main challenges that people with disabilities face is just that lack of understanding and the lack of accessible and universal design in their everyday lives but on the other hand its really difficult for a child without a disability to necessarily understand the experiences of the child with disabilities just the same as it can be very difficult for an adult without a disability to understand the daily challenges and as well as the daily joys of a person with disabilities. So I definitely think that those sorts of approaches as long as they’re constructed with the input of people with autism to make sure that they are an accurate reflection, and a sensitive reflection, are extremely beneficial because I think understanding is half of the battle. I mean when you have a better understanding of someone else’s experiences then you better understand how to form relationships, how to interact and things like that in a way that can enrich both individuals lives and interactions. So I definitely think that that’s a really interesting angle for the technology to take.

FPS: I think that’s really important to keep in mind too. One of the staples of disabilities studies is that we’re only ever temporarily able, right? And that we’re approaching these different forms of mobility, these different levels of hearing and sight and it’s worth keeping in mind that at some point we’re going to occupy that position that’s marked us as disabled and that it’s worth keeping that in mind in our designs and in what we value too in terms of design.

Biddiss: Absolutely. I have an anecdote, it’s one of my favorite anecdotes. It’s [about] a little boy at Holland Bloorview, it was in a workshop,  and this little boy was in a power wheel chair and he had a ventilator and a gastric tube, and someone asked him ‘Well if you could have anything, or if you could have a superpower, anything you wanted, what would you want? ‘And he said that he would like a powered wheel chair for his little brother so he could keep up with him. And so I think that’s really interesting because this little guy in his power wheelchair could go faster than most of us, and faster for longer so in that case who has the disability, is it the little boy in the wheelchair, I mean he gets from point A to point B faster and quicker than I would, so I think that disabilities and barriers are very much in the eyes of both holders and is very much a matter of what is typical versus what is unique sort of thing, and I mean it’s important and interesting to understand the different perspectives to really put things into perspective.

FPS: That reminds me of, I think it’s Diderot, he has a story in which these characters talk to another blind character and at one point they ask him, ‘if you could, would you have your sight back’ and he thought about it and he goes ‘you know, I’d just as soon have longer arms than have eyes’ and he pointed out that when you look up at the moon you can see it but you can’t really feel it and that ‘if I had longer arms I could put my hands on it, I could touch it’ and he also made the point that vision degrades faster than touch does so ‘why would I not want to enhance the way I already experience the world rather than get something that isn’t really familiar to me at all.’

Biddiss: Absolutely. I mean I think that being able to understand that there’s lots of different ways to experience the world and to live well and happily in the world is a very important understanding.

FPS: Absolutely. Great, thanks for talking to us!