A Study Protocol for an Online Intervention to Promote School Engagement
Condition: Cerebral Palsy
MeSH terms: Cerebral Palsy
Study type: Interventional

Summary: 
      Cerebral Palsy (CP) is a neurological, non-progressive, and permanent developmental disorder
      that mainly affects movement and posture, with a prevalence of 3 to 4 children per 1000 live
      births. CP's motor impairments are often accompanied by disturbances of sensation,
      perception, cognition, communication, and behavior. These impairments echo in the activities
      of daily life, as well as in the learning process. Importantly, children with CP are
      especially prone to display working memory and EFs deficits, as well as difficulties in
      self-regulation, which might help explain some of their social and learning problems.

      These children have a high risk of showing learning disabilities, which may arise before the
      schooling years. This risk is not exclusively determined by cognitive impairment, with
      children with a normative cognitive level still presenting specific learning difficulties
      (e.g., mathematics, reading).

      Due to their clinical picture, children with disabilities, including CP, struggle with their
      difficulties in school. Consequently, they are prone to develop a poor School Engagement (SE)
      - multidimensional and multifaceted construct involving three interrelated dimensions:
      students' behaviors, emotions, and cognition.

      In children with disabilities, one of the factors that contributes to lower SE is their high
      level of school absenteeism. These children miss, on average, 3 weeks of school in a school
      year due to health issues, which may hinder their academic performance. The promotion of SE
      in children with disabilities is, therefore, a priority.

      To promote SE, Gamification strategies can be used. Gamification is the use of game elements
      (e.g., points, rewards, feedback) in non-game contexts. The potential of using Gamification
      is high and constitutes a unique opportunity to engage participants in specific activities,
      such as in intervention or learning contexts.

      Therefore, through game mechanics, Gamification can be used as a tool to promote SE. This is
      because, it offers an attractive learning environment and converts difficult tasks into more
      appealing ones, motivating individuals to perform. Moreover, it enhances the degree and depth
      of participant engagement, rises behavior and lifestyle changes, promotes learning
      opportunities, motivates students, and improves intervention appeal, especially for
      youngsters. To conclude, this project aims to increase SE through Gamification in children
      with CP.

      Literature has highlighted the need to focus interventions on SE and self-regulated learning
      (SRL) on a specific domain. Because children with CP are at high risk of presenting learning
      difficulties, especially in mathematics, this project will focus on mathematics performance.
      Moreover, SE is multidimensional, including behaviors, emotions, and cognitions related to
      school. Specifically, behavioral SE can be conceptualized in three levels: 1) school
      attendance and fulfillment of school work, 2) participation in class, and 3) active
      participation (e.g., doing extra school-work). Emotional SE refers to students' affective
      reactions and sense of connectedness with school. Finally, cognitive SE is related to
      personal investment in academic tasks, self-regulation, and value of the learning process.
      Because SRL may be compromised in children with CP, mainly due to difficulties in planning
      and setting goals, this project will promote SE in mathematics by developing SRL strategies
      in these children. SRL processes are key for students to attain their self-set goals and
      include competences of planning, execution, evaluation, and monitoring of the learning
      process. SE and SRL will be promoted through Gamification strategies on the Canvas platform.

      Thus, the main purpose is to assess an intervention program with children with CP to increase
      SE, and enhance SRL, through Gamification Strategies in mathematics. Specifics aims:

        -  Embed Gamification Strategies (e.g., rewards, collaboration, competition) in the Canvas
           Platform using the tools already available (e.g., forum/chat);

        -  Develop and assess the efficacy and impact of the intervention in promoting SE, and SRL
           competences, through an integrated assessment approach (functional, educational,
           neurocognitive, and neuroimaging).
    

Detailed description: 
      Participants

      30 children with CP, age-range between 8 and 15 years (elementary and middle school - 3rd
      grade to 9th grade), without cognitive impairments, will be selected. Agreements in partaking
      in the study are already in place with CP rehabilitation centers on the north of Portugal.
      Participants have already been evaluated through cognitive and neuropsychological tools.
      Specifically, children should present a cognitive performance at least in Medium- Low level
      (WISC-III) and should have eventual epilepsy episodes under control. Participants need to be
      able to use a computer and have internet access, and are required to have a native level of
      writing and reading skills in the Portuguese language.

      Recruitment and selection

      Recruitment will take place in the Portuguese associations of cerebral palsy. A collaboration
      agreement was established with the Federation of Portuguese Cerebral Palsy Associations
      (FPCPA), which includes 15 Cerebral Palsy Associations in Portugal. The Associations will
      evaluate their children and identify those who fulfil the inclusion criteria. The first
      contact with the parents/caregivers will be made by the associations and only after they
      accept to participate will the research team contact them. When identified, children and
      their parents will be debriefed, the consents delivered, explained, and signed.

      Procedure

      The FCPA (Federation Associations of Cerebral Palsy) will identified the needs to promote
      self-regulation skills and school involvement of children with CP. Researchers will
      established contact and held formal meetings with therapists to identify key difficulties and
      needs.

      a) Two questions guided the meetings:

      i. "What are the main difficulties you have while intervening with children with CP?" ii.
      "What do you think we could help with?" For study 4 a randomized controlled trial will be
      developed with three groups. After obtaining informed consent from parents/caregivers,
      participants meeting criteria will be randomly assigned to one condition. The control group
      (CG) will not have access to the online platform, i.e. no intervention. The intervention
      group 1 (IG1) will receive on a weekly basis tasks and activities on the online platform to
      promote SR and SE, as well as chapters of the narrative. The intervention group 2 (IG2) will
      receive the same tasks and materials as IG1 but embedded with Gamification Strategies.

      Phase 1 - Selection of Gamification Strategies

      Reeves and Read (2009) identify the "Ten Ingredients of Great Games" as good examples of
      elements of Gamification: i) self-representation with avatars, ii) three-dimensional
      environments, iii) narrative context, iv) feedback, v) reputations, ranks and levels, vi)
      marketplaces and economies, vii) competition under rules that are explicit and enforced,
      viii) teams, ix) parallel communication systems that can be easily configured, x) time
      pressure. Specifically, in the school context, a number of game elements have been identified
      as promoters of SE, contributing to learning success of students: collaboration and
      competition, feedback and reputations, ranks and levels, and reinforcement. Accordingly,
      through Canvas® Platform tools, these elements will be applied to the IG2. The project will
      be presented to FCPA, who will be involved in all stages.

      Phase 2 - Implementation

      The project will be presented at the rehabilitation centers, to technicians and
      parents/caregivers; and to children who accept to participate. The intervention will take
      place at the rehabilitation centers, and the collaboration of all stakeholders is imperative.
      Parents/caregivers will be asked to stimulate their child to engage with, and talk about, the
      intervention, and to contact the research team whenever is necessary. Secondly,
      parents/caregivers and children will fill-in the informed consents and the socio-demographic
      questionnaires. Each child will have a login through e-mail into the platform.

      This intervention will take place during the weekly occupational therapy (OT) sessions at the
      rehabilitation centers to guarantee implementation of the research protocol (e.g., internet
      access).

      Phase 3 - Program evaluation

      To capture the procedural dimension of the phenomenon and evaluate the impact of the
      intervention on the promotion of SE, SRL, and EF in children with CP, several elements will
      be considered: aptitude (i.e. questionnaires), event (i.e. checklist, observations), and
      neuroplasticity, as suggested by the literature of SRL processes (Núñez, Rosário, Vallejo &
      González-Pienda, 2013; Zimmerman, 2008). The hypothesis is that the intervention will promote
      statistically significant improvements in the IG1 and IG2 in all measures - SE, SRL, EF
      evaluation, compared to the CG.

      The evaluation protocol described refers to assessment that will be conducted with the
      children participating in the study. Children were assessed on their intellectual ability
      using the Wechsler Intelligence Scale for Children - Third Edition (WISC-III) (Wechsler,
      2003). Medical and therapists' records were reviewed to collect information about the
      topographic motor type and quality of tonus, as well as the child's level on the Gross Motor
      Function Classification System (GMFCS) (Andrada, 2012; Palisano et al., 2015). Other
      variables were gathered: gender, date of birth, school grades from the last year, types of
      therapies each child is attending, extracurricular activities, internet access at home,
      computer access, story reading frequency, curricular adaptations.

      The following measures will be collected before the start of the intervention, at the end,
      and 3 months after the intervention completion.

        1. Neuropsychological assessment

             1. This investigation follows the Miyake model of EF. This model postulates that EF is
                comprised of three latent variables with different roles (Inhibition, Shifting, and
                Updating) that can be learned through the individual's performance (Miyake,
                Emerson, & Palisano et al., 2015). The CANTAB application was selected for the pre-
                post assessment. From the set of the CANTAB, 6 tests were selected: i. Multitasking
                Test (MTT) - To manage conflicting information provided by the direction of an
                arrow and its location on the screen and to ignore task- irrelevant information
                (Shifting).

           ii. One Touch Stockings of Cambridge (OTS) - To assess both the spatial planning and the
           working memory subdomains (Updating/Planning). Based upon the Tower of Hanoi test.

           iii. Stop Signal Task (SST) - To measure response inhibition and impulse control
           (Inhibition Control).

           iv. Spatial Working Memory (SWM) - To provide a measure of strategy and of working
           memory errors.

           v. Motor Screening Task (MOT) - To provide a general assessment of whether sensorimotor
           deficits or lack of comprehension will limit the collection of valid data from the
           participant.

           vi. Emotion Recognition Task (ERT) - This task, measures the ability to identify six
           basic emotions in facial expressions along a continuum of expression magnitude.

           b) Functional magnetic resonance imaging (FMRI)

           i. A classic test of inhibitory control (Go-No-go task) will be used; another test will
           be adapted using images from the e-book of the "Incredible Adventures of the Anastácio,
           the Explorer". 2. Self-Report Questionnaires

      3. Effort Measures 4. Interviews

      a) Self-Regulation Learning (Rosário et al., 2011)

      i. SRL Strategies Inventory

        1. Comprises nine self-regulated learning strategies presented in a Likert-like format of 5
           points (1=never to 5=always)

        2. Items assess the three phases of SRL model: PLEE (three items per each phase) i.
           Planning (e.g., ''I make a plan before I begin writing. I think about what I want to say
           and how I need to write it.'' - α=.80), ii. Execution (e.g., ''If I become distracted or
           lose concentration while I am in class or studying, then I usually try to regain my
           goals.'' - α=.85) iii. Evaluation (e.g., ''I compare the grades I receive with the goals
           I set for that subject.''- α=.87)

           b) Engagement

      ii. School Engagement Scale (Fredricks et al., 2005)

        1. The scale comprises 14 items presented in a Likert-like format of 5 points (1=never to
           5=always).

        2. Items cluster in the three SE dimensions (i.e., behavioral, emotional, and cognitive).

           i. Behavioral Engagement scale comprises 5 items (e.g., "I follow the rules at school.")
           (α=.77);

           ii. Emotional Engagement scale comprises 6 items (e.g., "I feel happy in school.)
           (α=.86); iii. Cognitive Engagement scale comprises 8 items (e.g., I study at home even
           when I don't have a test.) (α=.82).

             1. Throughout the interventions, children will be asked to complete different tasks on
                a voluntary basis (e.g., viewing videos, participation in the discussion forums).

             2. The fulfillment of these tasks and of the session's goals will be on-task measures
                of children's involvement with the intervention program

             1. Children, therapists, and parents/caregivers will be selected for a purposeful
                sample upon completion of the program.

             2. Interviews will be semi-structured to further understand the effectiveness of the
                intervention.
    

Intervention name(s): Online-intervention group I (IGI); Online-intervention group II (IGII)
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Narrative-based online intervention program to promote self-regulatory competences.; Narrative-based online intervention program to promote self-regulatory competencies plus gamification strategies.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A randomized controlled trial will be developed with three groups. After obtaining informed consent from parents/caregivers, participants meeting criteria will be randomly assigned to one condition. The control group (CG) will not have access to the online platform, i.e. no intervention. The intervention group 1 (IG1) will receive on a weekly basis tasks and activities on the online platform to promote SR and SE, as well as chapters of the narrative. The intervention group 2 (IG2) will receive the same tasks and materials as IG1 but embedded with Gamification Strategies.
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Self-Regulation; Engagement; Gamification; Executive Function