Social Play and Bimanual Activities for Children with Cerebral Palsy

This investigation explores the design of a digital interactive system as a means for promoting social play and the mastery of everyday activities that involve both hands simultaneously in children between six and eight years old with Cerebral Palsy (CP).








Children with unilateral spastic Cerebral Palsy (CP)—a permanent disorder that affects one side of the body, and frequently involves the hand more than the leg—have activity limitations, hindering social and motor skills.

Increasing bimanual activity levels for children with CP can prevent subsequent functional limitations resulting from muscle weakness. Also, achievements of both of these goals may improve their performance in daily activities and have roles that are more active in social settings.

Prototypes shown feature the design of multiplayer interactive experiences in combination with Tangible User Interfaces (TUI)—a type of interface that combines physical objects and digital interfaces—adding the therapeutic benefit gained from manipulating physical objects.



Researchable Question

How can the design of Touch and Tangible User Interfaces (TUI) multiplayer interactive system encourage social play and the practice of bimanual activities in children from six to eight years old with Cerebral Palsy?

Subsidiary Questions

1. How can the design of avatars by children with CP in an interactive environment contribute to their sense of mastery in bimanual activities?
2. How can cooperative play stimulate the acquisition of social skills in children with CP?
3. How can the combination of a touch and a TUI in cooperative quests stimulate the practice of bimanual activities in children with CP?


The final prototypes of the proposed activities are shown in this video:


The video below shows the early stage of paper prototypes for the selected fine motor skills and was the starting point for testing interaction between potential participants, touch, and TUIs.

Paper Prototyping TUI and Touch-based Interface
The prototypes show possible applications when designing for the development of social and fine motor skills for children with unilateral spastic CP through multiplayer experiences. The design of discrete moments demonstrate how interactive systems would live in the existing environment, and exhibit ways in which different stakeholders would approach this new activity.

The two videos posted here show a proposed layout, in which the TUIs interact with multiple tablets that communicate with each other based on proximity. The designed activities are for a school environment, where children play socially in their spare time. Having multiple devices instead of a single tabletop provides two major affordances. On one hand, a group of children can arrange the devices in a variety of ways, providing flexibility and a wide array of gameplay options. On the other hand, a child can use a single tablet for individual play, in settings other than school.

Research Methods

Semi-structured interviews (n=3) with teachers and a program manager from two non-profit organizations focused on children with CP were conducted individually.

The aim of the interviews was to gather qualitative data regarding the lives of children with CP before and after they turn six years old in social and educational contexts. One of the purposes was to identify how schools integrate play in physical rehabilitation and social environments through tools, technologies, and activities available for the children. Each interview had an approximate duration of 40 to 60 minutes; a list of questions guided the interviewer through the process, providing flexibility to focus on specific areas and allowing fluid communication.

To get a better understanding of shared mental models regarding collaborative games this investigation included a semi-structured focus group with gamers (n=5) of collaborative role-playing games. The prompts used were open-ended, asking participants to share their experiences, perceptions, opinions, feelings and attitudes about these types of games.

At the end, they generated a list of key topics that emerged from the conversation:

  • A good role distribution is vital for succeeding on a quest.
  • Avatar selection and how collecting items makes an avatar more powerful.
  • Playing a game is primarily about having fun, players are not serious about completing a quest all the time; at the end “it is just a game”.
  • Group members have to trust each other.
  • Groups perform decision-making with a democratic approach.
  • Leadership emerges in an organic fashion.
  • Players communicate a lot during the game.
  • Social connections arise within the magic circle and they permeate outside the circle even if players abandon the game environment.

Charlie Gaddy Children‘s Center (Raleigh, USA) and APAC –Association Pro People with CP (Hermosillo, Mexico) were the two Non-Profit Organization Focused on Children with CP that participated on the interviews for this study

Additionally, observational studies (n=13) were done with the purpose of witnessing the ways in which six- to eight-year-olds interact with each other, parents, staff members, and with physical objects in a setting where they are encouraged to learn through play.

Using a customized data collection sheet (See Sample) based on the AEIOU (Robinson et al. 1997) organizational framework—Activities, Environments, Interactions, Objects and Users (Stakeholders)—the study not only takes into consideration interactions but also the context within which they unfold. The interactions were coded into two main categories, divided by types of communications (verbal vs. non-verbal) and types of interactions (exchange, competition, conflict, collaboration, and accommodation).
20130130ObservationThesis Data collection sheet used for the observational studies. (Click image to enlarge)[/one_half_last]

Design Methods

The aim of using design methods was to figure out the activities and functions that a new system should incorporate in order to satisfy the different stakeholders’ needs and desires. This approach helped in the generation of a series of principles that guide the new activities in the current space where the participants currently interact with each other. Consequently, it aided in the identification of leverage points that could be expanded by the design of artifacts using the capabilities of digital technologies, as well as a place and time where these activities could fit in the lives of the participants. The principles, patterns, and leverage points guided the process for designing prototypical artifacts that mediate activities of participants’ new practices.


Affinity Diagramming

To begin the analysis of the interviews and observations, the data went through rounds of interpretation, capturing key moments into notes. The process consisted of recounting the interview and observations guided by transcriptions and notes without summarizing or leaving anything behind. The approach used for capturing and classifying the different moments was to think in terms of observations, gaps, questions, issues, insights, and design ideas during descriptions of specific events, use of artifacts, important characteristics, and cultural differences.

The captured key moments from the interview and observation experiences were assembled into an affinity diagram. Looking beyond key words and focusing on how the moment revealed relevant issues for the new practice, clusters of notes emerged in an organic way based on the type of reasoning the notes were addressing.[/one_half]



Identifying patterns and relevant issues through Affinity Diagramming with the collaboration of  Kezra Cornell




Drawing on insights from the affinity diagram and activating the participants’ voice through first-person statements it was possible to define the children’s core behaviors and needs through the creation of personas, a method first described by Alan Cooper (2004).


Personas for designing to develop social and fine motor skills in children with CP. (Click image to enlarge)




Extracted from the analysis done through the affinity diagram and the creation of personas were a set of design ideas that guided the early prototype iteration:

  • Avatar creation and digital exhibit
  • Collaborative quests and role distribution
  • Activities for verbal and non-verbal communication



  • Customization of level design
  • Tracking and documentation system with progress visualization
  • Multisensory experience including physical objects for haptic, visual, and audio feedback

These fundamental design ideas made it possible to create a high-level concept storyboard as a starting point for sketching user interface ideas.  The storyboard reflected big pieces of the system’s workflow, and a vision of how activities unfold in future participants’ use of the system. See figure below.


System map of the envisioned design environment. (Click image to enlarge)


TUI and Touch-Based Interface for Practicing Bimanual Activities. 

The combination of Tangible User Interfaces (TUI) and Touch-based User Interfaces –such as the iPad or Android tablets–can work together to create enjoyable and fun experiences for children with CP.

One of the purposes of the prototypes was to display potential interactions that involve bimanual activities with a specific range of motor skills such as gripping, reaching, releasing, coordination, and stabilization. The selected motor skills are a deconstruction from a list of daily activities found on CHEQ (Sköld et al. 2009), a questionnaire designed to assess children and adolescents’—6 to 18 years old—hand-use experiences. The questionnaire assesses 29 daily activities; this project analyzes six specific activities: inserting a straw in a juice box, buttering a slice of soft bread, putting toothpaste on a toothbrush, cutting on a chopping board, pulling the zipper of a jacket, and screwing off the cap of a small, unopened soft drink bottle (see table below). As a result, the prototypes include interactions to practice the fine motor skills most frequently found on this set of six every day activities.


Deconstruction of fine motor skills from selected set of daily activities from CHEQ Questionnaire. (Click image to enlarge)

Prototype 1. Design of Avatars Contributes to the Sense of Mastery in Bimanual Activities

According to James Paul Gee “Video games recruit identities and encourage identity work and reflection on identities in clear and powerful ways” (2007). As a child develops a virtual identity (see slideshow below), he or she projects his/her real identity on the virtual character. Once a child gets involved with the character, he/she will look for the success of the virtual identity. The child achieves success through activities that involve the practice of fine motor skills (see slideshow below). The aspirations a child has for the virtual identity becomes the motivator to keep practicing  these activities.

The interface consistently requires the use of fine motor skills used in everyday activities when a child interacts with the system or with his/her peers. For instance, the images below show how responding to prompts related to personal preferences requires the use of gestures such as dragging, and twisting, skills used in daily activities such as putting toothpaste on a toothbrush or unscrewing the cap of a bottle of soda.








The child develops a virtual identity while choosing an avatar using bimanual gestures.

Prototype 2. Collaborative Play for the Development of Social Skills

In this case, the children engage with a collaborative drawing activity that encourages the practice of social skills. During the activity, each child begins by drawing in the game (see slideshow below). After a while, each child receives an alert announcing that the system will assign his/her current drawing to a peer. Continuing the activity on their peer’s drawing, the children exercise social skills such as, social awareness, by showing understanding and empathy for others; responsible decision making, by making constructive choices both as an individual and as a group; and relationship skills, by working in teams (see slideshow below).















Prototype 3. Collaborative Play for the Development of Social Skills

The combination of Tangible User Interfaces (TUI) and Touch-based User Interfaces –such as the iPad or Android tablets– can work together to create enjoyable and fun experiences for children with CP. This prototype displays potential interactions that involve bimanual activities with a specific range of motor skills such as gripping, reaching, releasing, coordination, and stabilization. The selected motor skills are a deconstruction from a list of daily activities found on CHEQ (Sköld et al. 2009), a questionnaire designed to assess children and adolescents’—6 to 18 years old—hand-use experiences. See slideshow below.













Providing new challenging and engaging activities for children with CP to practice social and fine motor skills can lead to the development of continuous and enduring habits that could increase their well-being. One of the main goals of the design environment is to increase motor capabilities, motor performance, and a sense of mastery. This is achieved by providing status and encouragement, and applying an important principle from video games through elements of gamification: it is okay to fail, you can—and should—always try again.

During the design of the prototypes, it was important to find ways of interaction that were similar to current activities that children do in physical therapy and/or at school. Furthermore, the implemented gestures are movements that form parts of sequences for performing daily activities. This investigation strongly relies on the concept of transferability, in which children practice a set of motor skills that may be successfully applied in activities not directly related to, but require an analogous set of skills.



Cooper, Alan. 2004. The Inmates Are Running The Asylum. Indianapolis: Sams-Pearson Education.
Gee, James Paul. 2007. What Video Games Have to Teach Us About Learning and Literacy. New York, New York, USA: Palgrave Macmillan.
Robinson, Rick, Ilya Prokopoff, John Cain, and Julie Pokorny. 1997. AEIOU Framework. E-Lab. aeiou-framework.
Sköld, Annika, Liselotte Hermansson, Lena Krumlinde-Sundholm, Ann-Christin Eliasson, and Karolinska Institutet. 2009. Children’s
Hand-use Experience Questionnaire – CHEQ.

Creative Commons License

Social Play and Bimanual Activities through Multiplayer Interactive Experiences for Children with Cerebral Palsy by Marysol Ortega Pallanez is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
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