Children with developmental disabilities often have difficulty performing activities that require well-developed visual–perceptual skills or often perform them inefficiently or with poor form. Such activities include activities of daily living that require gross motor skills or fine motor skills [1]. Children with developmental disabilities are usually referred for professional evaluation when their skill level is 20% lower than that considered to be normal for their age [2]. Parents can usually estimate the baseline ability and learning speed of children with developmental disabilities by referring to well-established childhood development standards [3,4]. Beginning therapy when the child is young—at an age when neuroplasticity is still high—can reduce future medical, educational, familial, economic, and social burdens of a developmental disability. Reducing these burdens can then enhance the dignity, adaptability, personal functional performance, and quality of life of the child and help to avoid development of emotional and psychological issues. Therefore, beginning therapy early after diagnosis of a developmental abnormality is vitally important [5].

Developmental disabilities in children are usually complicated by visual–perceptual problems. Although these problems can be improved by stimulation and training, conventional methods of visual–perceptual training have limited effectiveness because their training patterns lack extensibility, which limits the motivation, goal orientation, and sense of achievement in the learner.

The numerous scientific and technological advances in computer and digital learning technologies that have successively emerged in recent decades are currently driving broad applications of computer technology in education and therapy as well as changes in the patterns of education delivery, especially for students with special needs. Thus, researchers have begun to investigate the extent to which interactive digital games can replace traditional paper-based teaching modes.

Some research suggests that digital game designs must provide an enjoyable experience to attract users and maintain their engagement. Clinical use of multimedia for early rehabilitation and therapy for children is now very common. For example, a multimedia game used for rehabilitation may depict a skill training item as an animation of a fictitious character that provides interactive feedback, for example, dynamic acoustic-optic sounds or static images, to introduce learning concepts, provide sensory stimulation, and guide learning. The emergence of interactive digital games indeed provides clinicians with an attractive option for rehabilitation that can effectively arouse a sense of participation in the learner and sustain the interest of the learner [6-10]. Thus, to motivate learners and to stimulate their interest in the content, positive feedback and increasingly difficult skill levels should be essential elements of a multimedia digital game used as treatment to improve developmental disability. Researchers have identified therapeutic effects for multimedia digital games designed for children—improving learning in mathematics [9], find motor skill [8], or visual perception abilities [10-13] in children with autism [6], poor academic performance [7], developmental delay [8], intelligence disorder [9], attention deficit hyperactivity disorder [10], and developmental disabilities [11-13]. One of these studies [11] used the Test of Visual Perceptual Skills (TVPS) to evaluate the effectiveness of multimedia digital games for improving developmental disability but only investigated changes in a limited selection of TVPS items. Another study [12] recently reported the use of kinesthetic games for improving visual–perceptual skills in children with delayed development of these skills [13]; although the novel design of the kinesthetic games included the integration of gesture-based interaction in a digital game environment, the kinesthetic games were mainly designed to provide training in integrating visual and motor skills. Thus, Wuang et al [13] expected that the functional improvements achieved by training on the kinesthetic games would be jointly contributed by improvements in both visual attention and motor control rather than by improvements in cognitive skills alone. In order to improve cognitive skills alone, we aimed to design a digital game that provides cognitive training in the full range of TVPS items and to evaluate its feasibility for testing visual–perceptual skills.

Pre- and postintervention scores in the digital game group differed for all items except spatial relationships, figure-ground, and visual closure (Table 1). Previous literature has indicated that children with growth delays have low scores on visual discrimination and spatial relationships tests because insufficient visual attention and cortical visual dysfunction limits discrimination and classification capabilities [21]. Thus, these capabilities cannot be enhanced by a short period of training. In visuospatial ability training studies, verbal and visual prompts are the key factors for training success [22]. An effective digital multimedia system for learners should integrate multisensory stimulation and widely varying teaching strategies (eg, use of visual prompts such as photographs, auditory prompts, repetition) [23,24]. An example of a visual prompt is stimulus fading (ie, simultaneously presenting subjective and pictorial prompts and then fading the prompted picture in the sequence), which allows children to visually slowly concentrate on the subject or guides them to learn how to judge the subject with graphic animation paired with line changes. Moreover, so that children could more easily discriminate and judge the images, voice prompts were used to facilitate repeated training to help them learn through visualized clues [23,24].

Improvements after the digital game intervention for most TVPS-3 items were satisfactory, which is consistent with the findings of previous studies [10-13]. Multimedia provide acoustic-optic effects and interactivity, which attract the attention of learners and guides their learning. In comparison with traditional teaching materials (eg, static pictures) and traditional teaching methods (eg, paper-based activities), multimedia teaching materials can provide greater audiovisual stimuli (eg, animations and sound) to increase learning efficiency and motivation [24-27]. Additionally, a digital multimedia interface can motivate and guide the user to explore issues and accept challenges by providing highlights or keywords [28]. According to the literature [29], 60% of the learners achieve better learning outcomes when learning is supported by digital assistance multimedia. Thus, the abovementioned research results indicate that a digital multimedia program is more effective than traditional paper-based training. Integrating a digital multimedia interface in teaching can enhance learning motivation and efficiency.

There were moderate to high correlations between the TVPS-3 and digital game test (spatial relationships: r=0.66; figure-ground: r=0.65; full score: r=0.47) (Table 3); however, only the visual discrimination component (P=.03) and the full score (P=.01) in the digital game group exhibited significant differences between the pre- and postintervention scores. We investigated why the digital game test had lower sensitivity in detecting pre versus postintervention change compared to the TVPS-3. The digital game test was based on the 7 TVPS-3 themes (10 questions per theme and 70 total questions). The standard TVPS-3 had 16 questions per theme and 112 total questions. Therefore, the lower number of questions on the digital game test resulted in a higher rate of repetition, which decreased its sensitivity in detecting change. In addition to the high rate of repetition, the difficulty level was not high enough, since the questions in the digital game test were chosen from the primary version. Thus, digital game test questions may not have been sufficiently challenging for the identification and assessment of children with relatively higher function or older age. In future studies, the instrument should be modified so that the number of test items is identical to that of the TVPS-3, which would reduce repeatability of the image gallery and possibly enhance the credibility and validity of the system.

On the satisfaction questionnaire, 5 items had scores higher than 4 points (Table 4), which indicated that parents and therapists were highly satisfied with the interactive digital game system. The 2 clinical therapists who had participated in the course reported that the digital game could be a useful intervention for improving visual–perceptual skills in children since the operating interface was easy to use and visually attractive to children. Additionally, the improvement was comparable to that obtained from conventional paper-based game training. The 24 parents reported that their children found the digital game easy to play and found the Bluetooth controller easy to operate. As a result, their scores on the visual perception test increased, which indicates that development of visual–perceptual abilities can be enhanced when rehabilitation includes an interactive digital game assistance system [30]. Relevant literature also mentions that a digital game system that attracts the interest of users tends to have high user satisfaction and high continued use [16,17].

Additionally, traditional teaching materials are mainly paper-based. They are not easily modified and have limited modes of interactivity (mainly paper-pen mode). They cannot be shared conveniently; paper-based media can only be shared by making additional paper copies whereas digital media can be easily shared and copied via the internet. While digital multimedia has good interactivity (online synchronous learning application or operating mode combined with other virtual reality equipment), is strong in media integrity, can be flexibly adjusted at any time, can be conveniently downloaded from the cloud, and can be represented and edited with 3C software in real time [31].

In summary, the interactive digital game assistance system developed in this study has practical applications in clinical rehabilitation treatment. The system is applicable and suitable for visual–perceptual training in children with developmental disabilities.. Thus, application of this learning mode in specialized rehabilitation for children with visual–perceptual defects can substantially improve their visual–perceptual skills and can potentially increase active participation in other relevant courses of treatment.

The interactive digital game designed and developed in this study positively benefitted visual perception training for children with developmental disabilities. When used in combination with conventional training, the interactive digital game system not only confers larger improvements in vision and perception in children with developmental disabilities, it also increases their willingness to participate in the training. The interactive digital game training system developed in this study can be implemented by medical institutions, family care givers, and school educators to increase the effectiveness of conventional programs for developing visual–perceptual skills in children with developmental disabilities. To improve the applicability of the proposed system as a testing tool, our future work will expand the question bank to enable it to have a broader range of skill levels.