{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T09:32:06Z","timestamp":1792143126939,"version":"4.4.0"},"reference-count":57,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Serious Games"],"abstract":"\n Background<\/jats:title>\n Children with autism spectrum disorder (ASD) exhibit cognitive, motor, and social difficulties that affect engagement, causing developmental delays, behavioral challenges, and obesity\u2014interrelated concerns in daily functioning and well-being. Although interactive interventions have incorporated physical activity, they often rely on limited physical involvement and lack iterative, expert-informed design, as built on pre-existing game frameworks. Physical activity is often operationalized as constrained input (eg, gestures or in-place actions) rather than exertion-intensive, whole-body exercise, and design guidance for adapting exercise content under ASD-oriented safety and cognitive-sensory constraints remains limited. These limitations highlight the need for exergames that promote sustained, full-body participation aligned with developmental goals, motivating formative, co-design with expertise and initial field testing in this population.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n We aim to iteratively design exercise-based serious games (SGs) for children with ASD through a structured, expert-informed co-design process involving 21 professionals across special education, adapted physical education, and human-computer interaction, and to examine feasibility and use contexts through an exploratory multiple-case pilot study.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We derived serious exergames using 4 design methods\u2014stakeholder interview, concept mapping, creative matrix, and visualize the vote. Two exergames\u2014\u201cFruit Sorting Run\u201d and \u201cHazard Avoiding Ride\u201d\u2014were developed, integrating full-body running and cycling movements into goal-directed tasks under ASD-oriented constraints. We conducted a multiple-case pilot with 3 children with ASD. During gameplay, caregivers labeled engagement using a binary input interface, and we conducted postsession caregiver interviews to capture complementary observations.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n Engagement in both exergames tended to increase over normalized time. Generalized estimating equations with a logit link and an autoregressive working correlation of order 1 (AR1), including participant indicators, showed a statistically significant association between normalized time and engagement in Fruit Sorting Run (per 0.1 increase: \u03b2=0.48; odds ratio 1.62, 95% CI 1.09-2.38; P=.02) and Hazard Avoiding Ride (per 0.1 increase: \u03b2=0.66; odds ratio 1.93, 95% CI 1.04-3.60, P=.04). Caregiver interviews reinforced these findings, reporting increased attention, motivation, and enjoyment across both activities.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n The findings support the applicability of an expert-informed design approach and the viability of the resulting exergames, integrating goal-directed physical activity, virtual agent\u2013based prompting, and stakeholder-informed considerations such as motor-cognitive alignment, interactive scaffolding, and support for daily living skills. Distinct from prior SG approaches that operationalize physical activity through discrete gestures or in-place interactions, the proposed exergames embed sustained, exertion-intensive, whole-body movement within structured gameplay. Within this exploratory multiple-case pilot, engagement trajectories tended to increase over time. These preliminary observations provide an initial basis for a testable hypothesis that exertion-intensive, full-body SGs with virtual agent\u2013based prompting may be associated with increasing engagement over time, meriting further examination in larger samples and applied educational and therapeutic contexts.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/77727","type":"journal-article","created":{"date-parts":[[2026,1,13]],"date-time":"2026-01-13T07:55:08Z","timestamp":1768290908000},"page":"e77727","source":"Crossref","is-referenced-by-count":3,"title":["Design and Iterative Development of Serious Exergames for Children With Autism Spectrum Disorder: Formative Multiple-Case Pilot 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