Effects of artificial intelligence aibo intervention on alleviating distress and fear in children

Vaccination of children is widely used as a medical procedure for health care. However, procedures and actions such as injections and immobilization cause pain and distress to children. Intense pain and distress in medical procedures are known to cause medical trauma and behavioral problems such as anxiety, depression, fear, and non-compliance with treatment in children and their families [1], and there is a need for interventions and support aimed at alleviating pain and distress from medical procedures in the pediatric field.

Distraction is one of the ways to alleviate pain in medical treatment. Distraction is a method in which a parent attends an examination or procedure that the child finds "scary" to support the child's natural coping skills, or to help the child relax by focusing attention on something other than the medical procedure.

Beran et al. [2] conducted a study to evaluate the effects of distraction by a humanoid robot programmed to interact with 57 children receiving the influenza vaccine during the vaccination process. The distraction effect was examined using a control group. The results showed that compared to the control group, the children in the intervention group did not stop crying but smiled more during vaccination. Other studies have reported that humanoid robots intervening during the procedure can distract children [3], help reduce anxiety, cope with stress, and improve behavior during the procedure [4]. Such AI-based distraction, as a non-pharmacological method, can be widely applied in the field of pediatric medicine.

Tanaka et al. [5] conducted a pilot study of group robot intervention (GRI) using the AI robot aibo (Fig. 1) on hospitalized chronically ill children (127 in total) and their caregivers (116 in total) and observed the language and behavioral characteristics of the children and their caregivers. As a result, about two-thirds of the total expressions of children and caregivers during GRI were positive, and we have reported that interaction through aibo may lead to children's acquisition of social skills, reduction of anxiety, and improvement of caregivers' mental health. The aibo was released by SONY Corporation ("SONY") in 2018. The robot aibo is a social entertainment robot with a rounded, dog-like appearance and the ability to develop through communication with those it interacts with. It was originally intended for use in daily-life situations. Although aibo was not originally developed to be used in clinical situations, its characteristics are similar to those of humanoid interaction and animal-assisted therapy, and it is expected to have the same distraction effect as animal-assisted therapy in pediatric medicine. In addition, AIBO, an older version of aibo, has been introduced into the medical field and is recognized as one of the SAR (Social Assistive Robot and Companion) [6].

We conducted an intervention study using SONY's aibo, dividing caregivers and children who came to the hospital for Japanese encephalitis vaccination into an intervention group and a control group, in accordance with our objectives. The following is a description of the study subjects, survey period, intervention method, contents of the survey and analysis method in the study.

A total of 57 children were included in the study, of which 32 were in the intervention group and 25 in the control group. The intervention group had a mean age of 4.41 years (3–12 years, median 3 years) and 10 boys (31%), whereas the control group had a mean age of 3.96 years (3–9 years, median 3 years) and 14 boys (56%) (Table 1).

Table 2 compares the scores of the intervention group and the control group for each index. For the FS, there was no significant difference between the intervention and control groups before vaccination (t₍₅₅₎ = 0.657, p = 0.514, d = 0.18). On the other hand, after vaccination, the intervention group was significantly lower than the control group (t₍₅₅₎ = 2.582, p = 0.0125, d = 0.69). For the behavioral observation scale, there was no significant difference between the intervention and control groups immediately after vaccination (t₍₅₅₎ = 1.040, p = 0.303, d = 0.28), but 5 min after vaccination, the intervention group was significantly lower than the control group (t₍₅₅₎ = 2.772, p = 0.00759, d = 0.74).

This study compared the possibility that an interactive play intervention with an artificially intelligent aibo before and after vaccination could alleviate children's anxiety and fear, using a play intervention with a stuffed animal without artificial intelligence as a control group. The results showed that compared to the control group using a stuffed animal, the aibo intervention group had significantly lower scores at the FS post vaccination and the behavior observation scale 5 min after vaccination. This result supports the hypothesis that the aibo intervention group will be able to reduce distress and calm down more quickly after vaccination than the control group. Repeated injections during infancy can be a traumatic experience for children. Previously, pediatric medical trauma can result in a strong pain response and negative feelings during medical procedures [10]. In order to prevent medical trauma, the DEF protocol is recommended [11], and it is said to be effective in expressing the painful feelings. It involves explaining the situation clearly to the child, providing a way to ease the pain and distress, and also provides support to the family. In this study, pain and anxiety immediately after the procedure were not significantly different between the intervention and control groups, but 5 min after the procedure, pain and anxiety were subjectively and altruistically reduced in the intervention group. These results suggest that an interactive play intervention using an aibo may reduce negative emotions after the treatment.

In this study, children's pain behaviors were attenuated after the treatment by the interactive play intervention with the aibo compared to the play intervention with the dog-shaped stuffed animal. Beran et al. [2] intervened with a humanoid robot with interaction capabilities during a child vaccination procedure, and found that the group in which the humanoid robot intervened was more likely to smile than the group in which it did not intervene, but the degree of crying did not change. In contrast, Beran et al. [2] found that either the children recovered more quickly or that the robot minimized their distress, but that when robots are designed and programmed with human-like characteristics, they are very attractive to children and can elicit positive responses in the form of smiles. Our results extend the findings of Beran et al. [2] in the sense that an interactive play reduces distress not during the procedure but also in post-treatment interventions.　Furthermore it was reported that when postoperative patients used Systematic Relaxation, significant reductions in pain sensation and distress were observed [12]. And also studies examining the effectiveness of canine home visitation therapy (CVT) have reported that it may activate pleasant thoughts that keep children away from pain-related cognitions [13]. Distress control for medical trauma prevention also includes cognitive behavioral therapy (CBT), distraction and meditation methods, and psychological preparation [14]. For infants and children, CBT and meditation methods using cognitive techniques are developmentally limited, so distraction through the five senses is more effective. According to Mitchell and Boss [15], pain experienced in childhood alters the formation of neural networks, when they encounter noxious stimuli. Taddio et al. [16] reported that in a large sample of immunized children, self-reported fear of needles was "strong" at 68% among 6–8 year-olds, 65% among 9–12 year-olds, and 51% among 13–17 year-olds. This suggests that many children experience the pain of injections as a fear. Distraction has been shown to be effective in reducing pain and fear related to needles [17, 18]. Multisensory strategies that combine visual, auditory, and tactile sensations are thought to have a greater impact on pain than unisensory strategies [19], and one of the principles of attentional theory is that the distractor stimulus must be stronger than the pain stimulus in order to get the child's attention [20], and that novel, interactive, and multisensory distractions are necessary [2]. The possibility that anxiety reduction before and after prophylaxis may lead to the prevention of medical trauma is promising from the paper by Birnie KA et al. [18] but further intervention studies are needed in the future.

Future work should further examine the effectiveness of the aibo intervention in reducing anxiety and nervousness when undergoing medical tests or receiving immunizations in the future as a way to test the effectiveness of the aibo as a preventive measure against medical trauma in multiple medical procedures such as immunizations, and for how long.

With the recent increase in opportunities to vaccinate children due to the covid-19 epidemic, it is more expected than ever that methods to alleviate children's anxiety and fear in healthcare and the application of artificial intelligence as an infection control measure will become more prevalent.

As the observer pain scale was evaluated by an investigator knowing the hypothesis, the investigator's expectations may have influenced the results. In addition, Some cases answered FS by caregivers’ proxy. However, the result that we also found an effect in the children and caregiver did not know the hypothesis minimizes the possibility of observer bias. In this study, we were not able to adjust for confounding factors, such as the possibility that the children's attention was diverted elsewhere due to the accompanying caregiver's involvement in "distraction" and "chasing". In addition, in order to verify the effect of aibo with artificial intelligence as a preventive measure for medical trauma, it is necessary to examine the possibility that aibo may lead to a reduction in anxiety about subsequent medical treatment in the intervention group. Although this is a non-randomized two-group study, we have adjusted for gender and age, but have added the following potential confounding factors: presence or absence of developmental disabilities, attachment relationships, and vaccination history, as limitations of this study. Moreover, it is necessary to further examine at which point in the vaccination process aibo intervention is most effective in reducing children’s anxiety.