INTRODUCTION

Adolescence is the phase of life that generates the most apprehension for parents and professionals who deal with adolescents with Autism Spectrum Disorder (ASD). There are many obstacles faced by parents in relation to the increase in aggressiveness at this stage of development, and difficulties involving hygiene care and sexual maturation, as well as a lack of guidance to pass on to their children regarding the subject ¹ .

The biological development of human sexuality basically depends on two directly related processes: organic growth and the maturation process, which are linked to the development of the nervous system, metabolism and hormone secretion, that is, any human being, whether with or without disabilities, will go through this process. Therefore, guidance is needed from parents and professionals ² .

One form of guidance that helps parents and professionals can be done in a playful way, with games being a favorable instrument, with an educational format, and in the case of this study, aimed at adolescents with ASD. In view of this, the following question arises: how to develop a playful game about sexual education for adolescents with Autism Spectrum Disorder? To answer this question, the general objective was to develop a playful game about sexual education for adolescents with Autism Spectrum Disorder. The specific objectives were: to gather information about games for adolescents with ASD; to characterize the benefits of playful games for the teaching-learning process; to define a communication method for creating the game; and to describe the steps for building a playful game about sexuality for adolescents with ASD.

Adolescents with ASD and Sexuality

Autism Spectrum Disorder (ASD) is characterized by changes in communication, social interaction, and repetitive behaviors according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders – DSM-5 ³ . These changes impair the child’s development and can increase concerns in adolescence, due to issues related to the sexuality of this individual with ASD ⁴ . This topic will describe adolescents with ASD, how the sexuality of these individuals is viewed, as well as the use of playful games as a teaching-learning tool.

Adolescence is marked by a period of development characterized by changes in different proportions, such as physical, cognitive, social, psychological, impulsive, emotional and intellectual changes ^5-6. In this phase, there is an identity crisis, in which one becomes aware of a new space, new realities and confusion of concepts, and therefore, the identity is constructed, both personal and social, occurring from the exchanges in the environment in which one is inserted ⁷ . In this period, puberty begins, occurring first in girls around 10 to 12 years old when the menstrual cycle begins, and in boys between 12 years old and ejaculation ⁶ . For adolescents with ASD, this phase occurs more slowly, which hinders their development in social and psychological aspects ⁴ .

Therefore, for healthy sexuality, it is necessary for the adolescent to receive adequate information, in order to provide: communication on the subject, sexual pleasure, autonomy, equality, privacy, sexual health ² . Sexual education contributes to this process of adolescent development, so that they can have autonomy, self-confidence, knowledge of the body and awareness in prevention. Sexuality is very important in the development and mental life of people, because regardless of reproductive potential, it is related to the search for pleasure, a fundamental need of human beings ⁸ .

For healthy development in adult life, it is necessary for adolescents with ASD to have contact with their family, school, groups of friends and leisure activities, to improve their skills in the social environment, with these groups being a base that will help them throughout their lives ⁴ . In a study ⁹ conducted with mothers of children and adolescents with ASD aged 10 to 22, they reported that their children are “childish” and “innocent” and some mothers neglect their children’s sexuality. It can be understood that it is from this representation of the child’s “childhood” that this characteristic of these children and adolescents being desexualized arose. Therefore, more information is needed for the families of adolescents with ASD about sexuality.

Adolescents with ASD may exhibit, to varying degrees, some undesirable behaviors such as aggression, isolation, sadness, suffering, self-mutilation, illness, emotional withdrawal and anguish. According to the author above9, to benefit both parents and adolescents themselves, the use of games can help explain social rules in a simple way, establishing a positive point of view regarding sexuality.

Playful Games and ASD

Games help in a playful way to learn subjects to be developed through a fun way, seeking to attract the attention of players ¹⁰. It is understood that play is an educational contact, so that the subject faces obstacles during the teaching-learning process. Playful activity contemplates more effective learning, as it draws attention to a certain subject, thus enabling a broad discussion among all those involved ¹¹ .

The game is integrative and helps in the motor, cognitive, affective and social aspects for the individual, while playful activities are intellectual activities such as memory and language, and can be enjoyed by any age, as they function as participatory and enable development ¹² . A humanoid robot was created with the objective of promoting attention, communication and socialization skills in adolescents with ASD. When using the humanoid robot, the participants reduced repetitive behaviors ¹³ .

Chung et al. ¹⁴ , showed in their studies that the game stimulates brain activities within the cingulate gyrus, frontal lobe and insular cortex, thus resulting in the recognition of facial emotions by adolescents with ASD. Another study showed the effectiveness of using cooperative toys to improve interaction, resulting in interaction between children with ASD and their peers, who felt confident and did not hesitate to ask questions to their peers ¹⁵ .

METHODOLOGY

This is an integrative review that allows the use of experimental or non-experimental studies to investigate the objective of the exploratory-descriptive research ¹⁶ , using articles indexed in databases of the Center for the Improvement of Higher Education Personnel (CAPES), as well as in the Scielo and PubMed databases . The following descriptors were used: games; sexual education; autism; adolescence, which made it possible to gather information and definitions of the research method for the problem in question and direct future research. The review provided a foundation and theoretical models for the assimilation of the creation of the board for sexual education of adolescents with ASD. The literature was searched for steps to build a board game that consisted of establishing strategies to meet the demand to be researched. The steps suggested by Jaffe ¹⁷ were used to build the board , namely: Game Concept, Game Platform, Game Theme, Gameplay and Elaboration.

In an initial search of the databases, the time period of the publications was not limited, in which 430 articles were found, 421 in the CAPES database, six articles in Pubmed and three articles in Scielo, selecting four articles, two from the CAPES database and two articles in Pubmed., as they were the only articles that met the objectives proposed in this article. After reading the abstracts, studies published between 2010 and 2018 were selected, with the following inclusion criteria being considered: 1- articles that have the theme in the title or abstract; 2- articles that answer the problem question; 3- articles published between 2010 and 2018; 4- articles that are freely available. Therefore, review articles that do not meet the criteria previously proposed were excluded.

ANALYSIS AND DISCUSSION OF RESULTS

As already described in the methodology on the researched literature, the analysis will be divided into the following categories: Games about sexuality, in which the formats of the games found in the literature will be discussed; Game Construction, which includes the steps used to build the board; and in the topic Communication Methods, which will analyze the form of communication for adolescents with ASD.

Games about sexuality

Articles that had as their theme games for sexual education of adolescents with ASD were collected, thus conducting an analysis in relation to the objective and the way in which the games were constructed.

In article 1, a board was created for children aged 6 to 9 with ASD, which aims to promote knowledge and interaction through illustrative questions (tree or chair; chicken or zebra), consisting of a board and two pieces, for two players. The PECS method was used to construct the board, to facilitate communication between the children, thus providing two illustrated answer options for each illustrative question. If the answer is correct, a green light turns on and emits a sound; if it is wrong, a red light turns on; the child only moves to the next square if he or she answers the question correctly. The board was chosen because it promotes interaction, creativity, reasoning, develops skills and stimulates through sound that can represent the image and the sound ¹⁸ .

Article 2 is a board aimed at children aged 7 to 8 with the objective of providing knowledge about sexuality, containing 10 players at a time. The board’s trail contains drawings of a healthy heart and a sick heart, and depending on the luck of the dice, a card is drawn. The cards contain tips and curiosities about sexuality. If the player lands on a space and does not know how to answer, he will not play a round ¹⁹ .

Article 3 involved developing a game shared with adolescents from Vila Cafezal, a community in a slum area of ​​Belo Horizonte. Through workshops in operational groups, a space for dialogue about sexuality and teenage pregnancy was created. The topics chosen were: dating, contraceptive methods, first sexual intercourse, sexually transmitted diseases, the human body, teenage pregnancy and drugs. The game was developed with the help of adolescents aged 10 to 14 years old, in the form of a board with questions and answers, with participants of different sexes. It was established that the rules of the game would be in the form of a competition. The game includes: eighty question and answer cards; a deck of reflection cards and a deck of locations, marking public spaces in Vila Cafezal ²⁰ .

Article 4 presents a game called G-TEA, a tool to aid the learning of children with Autism Spectrum Disorder, based on the Applied Behavior Analysis (ABA) methodology. This is a tool to assist psychology professionals who work with autistic children. The G-TEA game was designed for tablets because it is easy to use, and was initially tested on three autistic children. The tool aimed to help professionals teach colors and followed the ABA methodology. Color learning is divided into small tasks, followed by positive reinforcements every time the child gets the color right and there are no negative interactions, and the professional can make inferences when necessary to stimulate learning ²¹ .

Game Construction

• 1st stage: Game concept

In order for the game to take place, some topics must be raised, including: the game’s theme, the definition of the target audience, the choice of the platform and the game’s operation based on what was raised in the literature. It can be seen that article 3 allowed the adolescents to choose the game’s theme. In articles 1 and 3 ^17-19-20-22 , the authors created themes based on the game’s objective and purpose, to provide adolescents with knowledge about sexuality with the design of a city or forest. The game designed by the authors of this article, called “Adventure of the adolescent with ASD: discovering sexuality”, will target adolescents in level 1 – mild degree of ASD, in the age range of 12 to 18 years, according to the age established by the Statute of the Child and Adolescent (ECA) ²³ . The game will have as its theme a camp with the aim of teaching about sexuality in adolescence in various scenarios of the chosen theme ²⁴. It was through the location that we thought about the possibilities of supporting the subtopics involving sexuality, such as the campers’ houses, the difference between boys and girls; the forest, signifying the dangers they may encounter (sexual abuse).

• 2nd stage: Game platform

In articles 1, 2 and 3, a board game was chosen to provide interaction and entertainment among the participants. The composition of the material will contemplate interaction, creativity, reasoning and the development of skills and stimuli ¹⁸ . Article 4 ²¹ opted for technology using a tablet , as it is a method that attracts the child’s attention more easily.

To achieve the objective of passing on information to adolescents in a way that players could exchange experiences, we decided to build a board game to help develop interpersonal relationships and teach a specific subject ²⁵ .

• 3rd stage: Game theme

To develop a game, it is necessary to characterize the experiences you want to pass on to the player. Articles 2 and 3 discuss different topics related to sexual education for adolescents, such as: dating, contraceptive methods, first sexual intercourse, sexually transmitted diseases, the human body, teenage pregnancy, and drug use ^17-19-20 . Therefore, the board was developed with the aim of being a strategy to be used by parents and professionals to contribute to sexual education, since it is a delicate topic to be addressed by parents of adolescents with ASD ⁹ . Based on the discussions of Nogueira ²⁰ and the Adolescent Handbook ²⁶ , the following subtopics were chosen for the present study to address sexual education for adolescents with ASD: discovering the body; intimate hygiene; the difference between men and women; the menstrual cycle; contraception; dating; and sexual abuse. Based on the data described, it was necessary to create steps and methods to explain the topics mentioned in a playful and interactive way for adolescents.

• 4th stage: Gameplay

In articles 1 and 2 it was observed that the gameplay works through trial and error, that is, depending on the player’s questions, he will remain or advance one space ^18-19 . The number of participants varies according to the authors and the objectives of the game, but it can be observed that the games involve one to three players ^18-19-21 .

The number of participants for the gameplay of this study will be two to three players, requiring an instructor (mediator), whether a parent or professional, to guide the adolescent(s) during the game. The instructor must be familiar with the manual that contains the step-by-step instructions (Appendix A) and the objectives, where an illustrative book was created to explain the theme in a playful way, seeking to attract the attention of the players to venture into the board game ¹¹ . This will provide interaction between the adolescent(s) and the instructor in a dynamic and fun way, allowing the players to communicate in different ways ¹⁸ .

• 5th stage: Preparation

In this last stage, the other preparations for the board game will be made: the manual, the pieces for the game, the creation of the board designer . From this, the materials that made up the board were found in articles 1 and 3: two pieces (pawns), eighty question and answer cards, a deck of reflection cards and a deck of local places, which in this case marked the public spaces of Vila Cafezal where the work was developed ^17-20-18 .

It was proposed to create the game “The adventure of the adolescent with ASD: discovering sexuality”, the insertion of the questions and answers on the board itself, with the aim of facilitating the understanding and handling of the game, both for the adolescent and for the instructor who will be using it. The questions and answers will be supported by illustrations containing objects and situations to identify what is being discussed.

Figure 1 shows how the board is composed, with 17 illustrated squares, three pawns, a dice and an illustrative book to introduce the theme to the players (Figures 2 and 3), in addition to a puzzle of the human body.

Thus, during the game, the reinforcement will be used for campers to advance one space even if they do not get the answer right and to win a piece of the puzzle, since it is known that reinforcement encourages campers to continue playing ²⁷ . This reinforcement is used by Behavior Analysis, developed by Skinner between the 1950s and 1960s, which uses the basic processes of behavior. This method is supported by evidence of scientific knowledge and treatment efficacy ²⁸ . The game was intended to open up our teaching and learning possibilities by focusing on helping adolescents to perceive and learn about their bodies and reduce behavioral problems regarding sexuality.

Communication methods

There are some methods that are more appropriate for communicating with children, adolescents and adults with ASD, since they have a different perception than other people, and these methods are: ABA, Teach and PECS.

Applied behavior analysis (ABA) is a method that encompasses language, motor, social and body care skills, and is evidence-based for changing undesirable behaviors ²⁹ . The Teacch method (treatment and education for autistic children and children with communication-related deficits) aims to develop autonomy skills and improve the behavior of people with ASD. This method has some established principles, such as: 1- improvement in adaptation; 2- individual intervention; 3- organization in teaching; 4- action on emerging skills; 5- active parents in implementing the method. For Schopler, his method was used to teach parents behavioral techniques to help with the lack of certain skills ³⁰ .

PECS (Picture Exchange Communication System) is based on the ABA methodology and can be applied from childhood to adulthood. This method has as support material a plastic folder with Velcro and pictures to be attached to this instrument. It consists of six stages, which are: the first in which the child will use the figure that he/she likes the most; the second stage will involve searching for the figures that he/she likes the most; the third will involve discriminating the desired illustrations; in the fourth stage, the child will learn to form sentences with the images; in the fifth stage, the child will learn to respond to the sentences made by the figures; and in the sixth and final stage, the child will learn to make comments ²¹ .

After describing the communication methods for adolescents with ASD, PECS was chosen to be used in the construction of the board with the illustrative questions to facilitate communication ¹⁸ .

FINAL CONSIDERATIONS

The game “The Adventure of an Adolescent with ASD: Discovering Sexuality” aimed to provide interaction between parents/caregivers and adolescents, using the PECS method for teaching and learning about sexual education for players, through a playful way, with a guide on some themes that are present in adolescence.

The bibliographic research revealed a lack of theoretical productions in Portuguese, as well as games aimed at sexual education for adolescents with ASD. However, it was easy to find games and literature aimed at sexual education for adolescents. However, these games were not suitable for adolescents with ASD, since they do not have the same perception as other adolescents and, in addition, some games contained many scenes of aggression and violence.

Based on the literature review and the lack of materials on sexual education for ASD, subthemes were used to create the questions on the board, based on Nogueira ²⁰ and the Adolescent Handbook ^26, which defined necessary themes regarding sexual education.

The decision was made to create a game to playfully explore the learning of topics to be developed in a fun way, seeking to attract the attention of players ¹¹ . The greatest difficulty encountered in developing the game was selecting the most effective means of communication with adolescents with ASD, since each one has its positive points, but also its limitations, capacity for understanding and perception. After analyzing the literature and the theme of the game, PECS was chosen, so that the game would be easy to communicate and understand.

More materials and research aimed at sexual education for adolescents with ASD that can be used by professionals and parents are suggested. The need for informative materials for families about the transition from childhood to adulthood was also observed, demystifying the sexuality of adolescents with ASD.

After the bibliographical research, the board game was created, but it was not possible to test the game. Therefore, it is not possible to affirm its effectiveness and whether it covers all the needs of adolescents with ASD, thus constituting the limitations of this study.

ACKNOWLEDGMENTS

We would like to thank the people who participated in the creation of the board game, Natanael, our illustrator, for giving life to our work, and Tais, for bringing life through the color of the illustrations.

APPENDIX A

Game manual

In this game, you and the other campers will spend your vacation at a summer camp. In order for everyone to have a great summer, you will need to work as a team. So, pay attention to the instructions below, as they are very important for the camp:

The trail can be used by two or three campers, remembering that one must be the instructor (mediator) to guide them throughout the game and read the book “The Adventure of the Teenager with ASD: Discovering Sexuality” so that everyone knows the rules and how the summer camp works.

The adventure begins with the camper on the right side of the instructor and so on. As soon as the camper rolls the dice, the instructor, together with the player(s), will read the question in the corresponding box and help by asking which of the two options would be the correct answer. If the camper does not know the answer, he/she can ask the instructor or the other campers for help; if the camper does not get the answer right, the instructor can explain to all the campers what the correct answer would be, and can use the initial book to help with the explanation.

The instructor may make changes to the instructions or rules as needed by the campers. Use your imagination, instructor, and have a great game, everyone.