Vietnam is one of the fastest-aging countries in the world with a rising number of people with Alzheimer’s disease and related dementias (ADRD). Families in Vietnam provide most of the care for persons living with dementia, yet our understanding of their experiences and needs is limited. This study examined the family caregiving experience in a semi-rural region outside of central Hanoi from the perspectives of family caregivers and other key informants.Semi-structured interviews were conducted with 21 key stakeholders . A descriptive, thematic analysis was conducted.Qualitative data analysis revealed four themes related to the family caregiving experience: 1) perceptions of dementia symptoms as a normal part of aging rather than a disease, 2) caregiving as a moral and expected familial obligation, 3) patterns of caregiving that are heavily influenced by both gender and sibling order, and 4) multiple challenges or hardships, including time constraints, loss of income, increased social isolation, a toll on their perceived physical health, and emotional distress. Caregivers rejected the notion that caregiving was a “burden” and expressed their distress through terms such as frustration, sadness, and exhaustion.In this low-resource setting, the stress of family caregiving may be amplified by lack of community resources, cultural stigma discouraging outside help-seeking, and economic impact of care provision. The study highlights the vulnerability and predicament of Vietnamese women who often face multiple challenges in their caregiving role as well as the urgent need for the development of community-based programs and supports. By the year 2050, it is projected that nearly two-thirds of the people living with dementia will reside in low- and middle-income countries (LMIC), and the vast majority are and will continue to be cared for in the home , 2. WhilThis study focused on the experience of caregiving for persons with dementia in Vietnam, a LMIC in Asia whose elderly population is projected to more than double by 2050  and is jxã) and 1 central town (thị trấn). Like many other regions in Vietnam, there are few formal supports available to family caregivers of persons with dementia. Vietnamese older adults living with dementia have been traditionally taken care of primarily by their family members  often announced about free vision checkup, health checkup, or other public health programs, so he [the care recipient] went to check by himself. He went all the time. And they said he had a neurological problem. must do” in order to serve parents (phụng dưỡng) and “payback” (báo hiếu). As one caregiver stated: “Children must take care of parents in old age, that’s just the law of life” . Another caregiver told us: “We work hard to take care of our parents, then our children will do the same to us. It comes around like that” . The moral obligation to care for parents reflects Confucian precepts of filial piety (đạo hiếu), a deeply held set of values dictating that younger generations must respect and care for older ones. The moral obligation of family caregiving was also reinforced by Buddhism through the notion that taking care of family members, especially parents, earned a person good karma and merits, thus helping him to flourish in the present and next lives.In most families, persons with dementia lived in a multigenerational household. Caregiving was an expected obligation and a matter of honor, pride, as well as an emotional bond between parents and children. As both family caregivers and non-family informants told us, caregiving was viewed as something that families “accepted” caregiving for their parents with dementia as a normal part of life, much like they accepted their parents’ dementia as a normal part of aging. Because of this normalization of caregiving for parents, “just do it” was the overarching motto of caregivers as a healthcare provider observed:Families “Now, caregivers do not really have a clear idea about taking care of a forgetful person, a person with dementia, and a normal old person. When they must take care of someone or something, they just do it. must be done.” There was also a reluctance to seek help because caregiving was viewed as a family responsibility and reaching out to others outside the family signified a moral failure on the part of the family and risked “loss of face” in the eyes of the broader community. Additionally, from participants’ views, formal resources to assist caregivers were unavailable, limiting options for seeking outside help.While many family caregivers we interviewed faced significant challenges in providing care to people living with dementia, there was a sense of resignation and acceptance of caregiving as something that “trai trưởng) and his family, with other siblings and their families playing a supportive role. In our study, 75% (9/12) of the older adults with dementia were living with the eldest son, his wife, and even grandchildren.As described by both family caregivers and non-family informants, caregiving patterns were heavily influenced by both gender and birth order, with primary responsibility for the day-to-day care of persons with dementia being shouldered by the eldest son’s wife. This pattern is consistent with Vietnamese culture, in which it is traditional for the parents to live with and be cared for by the eldest son  to care for his mother based on the closeness of their relationship. In yet another case, a wife was the primary caregiver to her husband. She explained to us: “Our children, they still have to work to raise their own children. We cannot leave it [the caregiving] to them” . In almost all cases, however, there was a clearly designated family member providing most of the hands-on care to the person with dementia, with other family members expected to contribute time, money, and efforts to various degrees depending on availability, negotiation, and family dynamics.While residing with the eldest son was the most common pattern observed in the family caregivers we interviewed, there were exceptions. In one situation, the person with dementia’s eldest son passed away, so he lived with his daughter-in-law. In another case, the care recipient lived with the youngest son because both parties and the whole family agreed that the youngest son was “Within households, the caregiving roles of the eldest son and his wife were usually highly differentiated. The eldest son was recognized by their family and local community as the official person “in charge” of the overall caregiving responsibilities. In this role, they were involved in coordinating with other family members and making major decisions related to elder care, such as major medical decisions. As we learned, the eldest son also played an important gatekeeper role in decisions about research participation. Most of the hands-on caregiving was done by the eldest daughter-in-law, who would cook, feed, bathe, clean, wash, walk, sit with, talk to, and stay all the time with the parent with dementia. One daughter-in-law described the standard care arrangements:Often the parents live with the eldest son while the eldest daughter-in-law will do the caregiving. If other children live nearby, they can lend a hand here and there, adding a little bit of help. It is like that everywhere, not just here. But those caring tasks like feeding, bathing, washing laundry are women’s job. While men were usually not the ones providing most of the hands-on caregiving, they often helped with certain “heavy duty” tasks (such as carrying the bed-ridden parent from bed to the bathroom for bathing). Other family members provided varying levels of support to the primary caregiver. Support might come in the form of cash, food, visiting the person with dementia, showing emotional support, and occasionally helping with hands-on care. The caregiver’s children might also provide help, depending on how emotional and spatially close to the grandparents they felt, or whether their parents ordered them to help. However, support from other family members could not always be relied upon:I must do everything alone from A to Z. All the hard work, from start to end. You see, it is very hard being the eldest child; you must take care of your parents, you have your own work, and you have this task or the other task to complete too. Who else will do it for you? The brothers and sisters only come by every now and then. In families, daughters-in-law often provided the most time-intensive, hands-on, day-to-day care. In the interviews, both family caregivers and non-family informants described the difficulties of caregiving, including both the time-intensive and often physically demanding nature of day-to-day care, as illustrated in the quotation above, as well as taking a social, financial, and emotional toll on caregivers.“Having no time” was the most common complaint among caregivers in this study, especially among the female hands-on caregivers. They described their caregiving routines as “around the clock,” from early morning until late at night and even throughout the night when the care recipient might need to get up to go to the toilet or talk too loudly, preventing them from sleeping. Daily caregiving tasks included cooking, feeding, bathing, managing medications, tending to all other needs of care recipients, and keeping an eye on care recipients’ safety. A widowed daughter-in-law taking care of her parents-in-law sobbed uncontrollably as she described her overwhelming daily routines:Early morning, I start taking care of them; I must cook for them, then give them medicines 3 times per day as the doctor said so, then giving them a bath, cleaning them. I have no time to rest. And then I also raise some chicken to have a bit of income. You see, it is very hard, my life is too difficult. Sometimes I just want a little of time for myself, but there is none. Another caregiver echoed the “no time to rest” theme, noting that she did not even have time to rest at noon time, as is typical of most Vietnamese living in rural areas to avoid the midday heat, because she had to keep an eye on the mother-in-law with dementia:It [caregiving] is around the clock, I have no time for rest at noon, I take my grandchild home from school at noon, give him lunch, then let him nap a little bit, then take him back to school, then go home to take her [care recipient] to the toilet. She [urinates and defecates] multiple times per day, it is not like it is just one time. Healthcare providers and community leaders had observed that some caregivers seemed “depressed,” “exhausted,” or “hopeless.” A healthcare provider recalled witnessing caregivers purposefully leaving their parents at the clinic so that they could take a break to rest:There are cases where they [caregivers] brought their parents here [to the clinic] and they felt very depressed because they did not see a way for their parents to become normal again. They spent so much time providing care that they felt exhausted and hopeless. One consequence of the time-intensive nature of caregiving was loss of income. This constituted a major source of worry for caregivers in this study. Providing “around the clock” care meant giving up or severely curtailing the amount of time working outside the home. One caregiver told us about her need to give up farm work:Like farming, I had to give it up; I only do a little bit of that; just to make enough rice for three people. Before, I worked on the rice field and raised pigs and chickens. Now I must give up raising poultry. I only have a few chickens. My income went down a lot. Before, I worked a lot in the farm, I sold the extra for cash and have some savings. Now I can only make enough for my family’s meals. Even male caregivers who were not providing hands-on caregiving expressed a strong sense of being limited in their work and mobility because they had to factor in their sick parents when making decisions about jobs. They could not accept jobs far from home, and they did not even go far from home to visit friends for fear that they would not be able to come home fast enough to take care of their sick parents. An eldest son explained his thoughts:Honestly, we are the eldest children, we cannot go far [for jobs] anymore. Our parents are old now, we cannot go far. Even when other men told me to come over their house for a drink, to be honest to you, I could not go anymore. I only work around the village in case something happens, then my children call, and I can get home right away. Healthcare providers and community workers observed that many caregivers were put into the situation of having to choose between outside work to meet financial needs or spending time caring for their parents. If they decided to maintain their jobs, they would have to spend money hiring a housemaid or helper, an option that many families could not afford. A healthcare provider emphasized financial hardship as a critical issue for families:Really, for families with someone with Alzheimer’s disease, especially at the last stage, it is truly a disaster for the family because they must hire professional caregivers or hire someone to watch over the patient, then the children must quit jobs, then even the grandchildren must take shifts with caregiving. It’s a great burden to the family members, perhaps not emotionally, but financially, it’s a great burden. Several changes over the past several decades have contributed to the difficult financial predicament that many families face when caring for persons with dementia. Family size has shrunk in recent years due to the implementation of family planning policies, so there are fewer in the younger generation to support the elder. In addition, with the development of new economic and industrial zones, many younger people now work in factories in new urban areas with less flexible schedules compared to farm work. Families who had neither the resources to hire outside help nor the ability to survive on one income faced extremely difficult choices. One healthcare provider said they were aware of other families who had resorted to locking the parents with dementia at home during the day when they had to go to work:It is the era of market economy now. Children must work, they cannot stay at home with their parents all day, so they lock the door when go to work. Otherwise, their parents may wander out of the house and get lost or fall into a pond. So, sons or daughters must lock the door or gate when they go to work. Maltreatment is rare here. Most of the adult children love their parents. While the adverse impacts, particularly economic, were felt by male and female caregivers alike, the physical, social, and emotional toll of caregiving was felt most acutely by daughters-in-law because they provided the most time-intensive and demanding aspects of caregiving. More than half of the caregivers expressed various concerns about the decline of their health due to caregiving such as lack of proper eating schedule, poor appetite, and lack of quality sleep. The mere amount of caregiving tasks were common factors contributing to their concerns about overall health:I lost a lot of weight. I used to be chubby and white, but I lost a lot of weight this year. My health declined a lot. I had gone to the doctor, I had stomachache and loss of sleep, so my blood pressure went up; every month I had to go get medicines. My head was always fuzzy and clouded. In providing care, sometimes caregivers had to use physical strength to carry their parents from bed to bathroom, to wheelchair, or to the front yard, all of which negatively affected their health. The physical challenges of caregiving were described by a daughter-in-law:I take care of bathing and washing laundry for him. He cannot do it himself. I carry him to the bath myself. My husband and children go to work until 9 or 10pm. My father-in-law is 40 kgs. I am 46 kgs. It is difficult to carry him because his body is stiff, it is not flexible. I am always scared of slipping or falling. Just a short distance to the bed but I am scared. “caregivers sometimes were so exhausted at night that they fainted, they passed out, and the nurses had to take care of them” .A healthcare provider observed that There was also a loss of social life, especially among female caregivers. Caregiving demands left little time to spend with neighbors or friends. They often could not attend community events or family events, such as weddings, funerals, and celebrations:I must select; if a wedding is on a Sunday and my husband is at home, then I can go. Or if he is not at home but I can ask one of his sisters to come, then I can go. If his sisters are busy, then I am stuck, I cannot do anything about it. Some had to give up their past membership or leadership roles in the community’s various social organizations while others had to be very selective about what social role they could still maintain. A female caregiver described her situation:[Caregiving] affects me a lot. All my social activities before, I had to give up. Like before, I participated in the women’s union, I was in the chairing committee of the union; but since my father became like this, I had to give it up, I could not go anymore. Other caregivers felt resentment that others in the family did not do enough to support them resulting in tension and contributing to their sense of isolation. A widowed caregiver who was taking care of her parents-in-law told us:I do not mind the workload, but I feel so pity for myself. Other women, when they get married, they can rely on their husbands. But me, I am alone, my husband left me with his old parents and two young children. My head is always so heavy and dizzy. Often, I felt sad. Sometimes I thought to myself I would rather die, why my life had so much suffering. Caregivers’ social isolation was amplified by a lack of local community organizations providing supports or service to persons with dementia and their families. While many local organizations exist, such as the local women’s union, people’s committee, and senior clubs, these organizations have yet to develop programs geared towards the needs of caregivers and persons with dementia.The emotional toll on caregivers was quite apparent in many of the interviews. While telling us their stories, several of the female caregivers broke out in tears:Sometimes I didn’t want to live anymore. I cried a lot at home. My children knew. The other day, it rained, and I stayed home, so I opened my daughter’s diary. She wrote in the diary “My poor mother!” So, tears just poured out from me. I did not want her to worry. vất vả,” a word indicating that someone had to use a lot of time, physical strength, and efforts on something that is very difficult. The term also conveys being occupied, busy, and consumed all the time with that task, resulting in emotional stress and exhaustion. They used other words to express their emotions when carrying caregiving tasks such as “sad, depressed” , “so shameful, pitiful” for oneself (nhục lắm), “suffering/miserable” (khổ), and “enslaving/serving” (hầu hạ).Caregivers used many other words that suggested hardship, challenges, difficulties, frustration, worry, pity for oneself, and an array of complex emotions associated with caregiving. The most frequent word used by caregivers was “there are many cases where daughters-in-law had the most pressure and they showed signs of being depressed; I just started to ask [about caregiving] and they burst out crying” . In many of the interviews we conducted, women cried as they told their stories.Distress was voiced most clearly by women, many of whom were caregivers to their parents-in-law. In some cases, there was added distress because of the perception that the husband or others in the family were not doing their fair share. A healthcare provider observed that ““of course, it [caregiving] is tiring. Very tiring. They [caregivers] do complain about that, but they dare not complain publicly” . Another healthcare provider observed that caregivers often suffered in silence because “complaining” would reflect negatively on the family:While caregivers often felt distressed, staff at local clinics and community leaders explained that family caregivers had great pressure to keep up with the image of “a good child taking care of his sick parent,” thus they would never complain publicly about caregiving. A healthcare provider mentioned that They kept it to themselves; sometimes they could tell their daughters-in-law if the two got along well; if they did not get along well, then they could not talk, could not share anything; they could not say, “Oh I felt this hard, I felt that much misery.” Sometimes they had to go over the neighbors to share but if their husbands heard, then their husbands would say “oh, you go and talk bad about your husband’s family, about your mother-in-law.” gánh nặng). Healthcare providers and community leaders explained that caregivers avoided the word “burden” because it connoted complaining or being resentful and was in direct conflict with the moral obligation of caregiving based on filial piety. The term “burden,” when translated literally into Vietnamese as “gánh nặng,” evokes the image of someone being forced to carry a heavy weight on one’s back, making him miserable yet he might not be able to put it down even if one wished to. To be seen by neighbors or others (including researchers) in the community as complaining risked a loss of face for not only the caregiver but also the entire family.Despite their distress, caregivers were reluctant to describe caregiving as a “burden”  taking on primary responsibility for day-to-day “hands-on” care and supervision, with variable support from other family members and little formal community support, and men playing a prominent role in decision-making. Family caregivers experience multiple challenges, including time constraints, negative financial impact, social isolation, and a perceived toll on their physical health and emotional well-being.Our study highlights the vulnerability and predicament of Vietnamese women who often face many challenges in their caregiving role. While men and other family members often helped with various aspects of caregiving, most of the time-intensive aspects of caregiving were the responsibility of women. Our findings are consistent with a recent report on dementia caregiving in LMIC which concluded that 81% of the hours of caregiving are provided by women  and a glThe theme of social isolation and lack of support outside of the family was prominent in our study. Like many other LMIC, Vietnam lacks community-level programs to support caregivers and has a primary healthcare system that for the most part lacks the capacity for dementia care, including diagnosis and family support . EquallyOur study has several practical implications for the adaptation of multi-component caregiver interventions for use in Vietnam. Because male heads of the household (often sons) often have important gatekeeping and decision-making roles in elder care, engaging their support at the beginning of the research process may be important to facilitate recruitment of other family members who may be more involved in day-to-day care. Intervention approaches may also need to allow for the inclusion of multiple family members as many people with dementia live in multi-generational households. Given the low levels of knowledge about dementia and high levels of stress among caregivers, the educational, problem-solving, and stress-reduction components of interventions may be highly relevant. Because of the low level of public awareness of dementia, the educational component may require more time compared with HIC. Finally, many caregivers seemed to experience some relief in simply being able to tell their story. As we reported elsewhere, an important part of training interventionists is to allow the caregiver tell their story as part of the intervention and to listen empathically .This study has several limitations. Our study is based on a relatively small sample of caregivers and stakeholders from one semi-rural area in Vietnam and may not be representative of other parts of Vietnam, particularly areas that are more rural or urban. In addition, the family caregivers in our study were caring for older adults with more advanced dementia and intense caregiving needs and may not reflect the experience of families caring for older adults with milder dementia. Future research is needed to examine the experience of caregiving for older adults with milder dementia as well as those residing in more rural and urban areas. Future studies can also examine the differences in caregiving issues among areas severely affected by the Vietnam War and those not much affected. Moreover, a comparison of perspectives of family caregivers and other key informants was beyond the scope of this analysis but might be explored in future studies.Our study contributes to our understanding of the experience and impacts of caregiving for families in Vietnam and adds to research on caregiving experience in lower resource settings . In thisS1 Appendix(DOCX)Click here for additional data file.


This study addresses the novel concept of two types of parental academic support (PAS), namely, as a companion and as a manager, and identifies the effect of children’s perceived PAS on their psychological attributes and academic achievements. The data include a nationally representative sample of 6836 students from the Korean Education Longitudinal Study 2013. A correlation analysis showed that the two types of PAS had a positive relation with adolescents’ development; however, a structural equation model showed a negative effect of PAS as a manager. Children’s perceived PAS as managers had no effect on their self-regulation or academic achievement after 3 years, surprisingly, was found to increase their amotivation. Children’s perceived PAS as companions had a long-term, positive effect on adolescents’ development and academic achievements. The results suggest that parents should recognize their children’s autonomy and provide academic support on an equal level. Further multidimensional PAS studies should be conducted with more detailed questions. Parental support for their children’s studies has been discussed regarding various concepts, such as academic support, emotional support, attention to achievement, parental involvement and school participation. Some studies show that parental support for children positively impacts their achievement ,2; howevParental academic support refers to the economic and environmental support provided by parents for their children’s successful academic achievement. Parental support, compared to teacher or peer support, predicts adolescents’ motivations, achievements and adjustment in various cultures ,9. ConsiIn this study, we noted parents’ views of their children in considering PAS. Korea is a country with strong educational values and academic elitism, and Korean adolescents feel a strong sense of obligation to recompense their parents with high scholastic achievement for the support and the sacrifices that their parents have given them . In the We examined parents’ roles in academic support regarding whether parents learn with the child as a companion or force the child to study as a manager. In addition, we discuss academic support and academic achievement in terms of process and motivation. Parenting affects not only children’s achievements ,11 but aThe concept of “educational manager mothers” or “educational managers” is familiar in South Korea, and some studies have discussed this concept ,19. ManaWe surmise that parents who provide academic support as companions, that is, learning with and giving advice to their children, are likely to respect their children’s opinions and autonomy because they share the same position as their children. In contrast, parents who manage their children’s lives and academic grades are likely to force their will and thoughts on their children and to adopt a dominant position over their children rather than an equal level of control. They may attempt to control the psychology of their children by making them feel guilty or withdrawing parental affection when their children do not comply with their wishes. Parents’ autonomy support is related to children’s motivation and self-regulated academic efficacy among elementary school students ,22,23, wThese two types of PAS share similar aspects with parental autonomy support and psychological control. Parental autonomy support refers to parenting behaviour in which parents offer children the opportunity to select and set their own direction, which minimizes forceful evaluations, externally imposed objectives, and parental needs . In contThese two approaches to PAS can be seen as similar to learning goals and performance goals, which affect subsequent human behaviour patterns according to motivational research. People with learning goals aim to learn new things and solve problems in learning situations. Therefore, students with learning goals tend to prefer difficult and challenging tasks and learn more effectively ,29. In cAccording to the self-determination theory , one of We expect that parenting, especially managerial academic support, will affect children’s amotivation. It is difficult to find a prior study that conceptualizes PAS in this way. However, as previously discussed, parents who support children’s studies as managers are likely to control their children’s autonomy, to control their children psychologically and to have performance goals. These characteristics were the variables that predicted children’s amotivation in prior studies. Schiffrin and Liss (2017) found that overinvolved parenting, such as helicopter parenting, was associated with extrinsic academic motivation, which may be adversely related to academic achievement . AutonomSelf-regulation is an important variable that affects children’s academic achievement and development. Self-regulation, sometimes referred to as “self-monitoring or self-control”, is based on the principle of metacognition. Self-regulation is the ability to plan, check, evaluate, and control one’s own behaviour. It involves regulating the starting and stopping of actions and the intensity, frequency and persistence of activities in line with socially accepted behaviour in specific environments . AccordiPAS is related to various aspects of children’s self-regulation and to academic self-regulation ,48. The The Korean Education Longitudinal Study (KELS) 2013 database included measures of parental support, self-regulation and achievement goals along with scores from the national standardized academic achievement test.The data for this study are derived from the 2013 KELS conducted by the Korean Educational Development Institute (KEDI). The KELS began in 2013, and 8070 students from 242 schools were extracted from 524,117 fifth graders  who were attending 5509 elementary schools nationwide by using the stratified cluster random sampling method. Finally, 7324 students from 242 schools participated in the study, with a student sampling rate of 1.40% and a school sampling rate of 4.39%. Korea has a 6-3-3 education system, including 6 years of elementary school followed by 3 years each of middle and high school education. After promoting the survey to schools and parents, KEDI selected cooperative teachers and conducted a presentation about KELS. Of the 8070 students, 7324 who agreed to the study were used as final samples, and self-reporting surveys were conducted through structured questionnaires. The survey questions included a wide range of topics, such as school and home experiences and educational resources and support. The respondents will be resurveyed each year with different questionnaires until they reach the age of 28 in 2030. Surveys were administered separately to students and their families, teachers, and schools to collect a wide range of information.This study used two out of four waves from the 2013 KELS, specifically, the first (5th grade) and fourth (middle school and 2nd grade) waves, which yielded a sample of 6836 cases  that participated in all four waves and included responses arranged by students and their schools. PAS was measured with eight items that were classified by a factor analysis into four questions each . “PAS asIn this study, the psychological attributes of children included self-regulation and amotivation. Psychological attributes were defined in various aspects, but this study aimed to discuss the psychological attributes related to academic achievement as a student. A mindset with a motivation for study, while properly regulating oneself for optimal academic achievement, was defined as psychologically healthy. Self-regulation was measured with five items and referred to academic self-regulation, such as “I do not put off what I have to do today”. Amotivation also consisted of four items that measured amotivation towards school or studies, such as “I do not know what I’m doing at school” . PsycholSchool achievement consisted of Korean, mathematics, and English scores and was measured by tests. This measure was developed based on item response theory (IRT) on a common scale  to compare the scores by grade in an attempt to interpret the changes in test scores for each grade as ability levels changed. The vertical scale was developed by applying a multigroup concurrent parameter estimation method. The theoretical achievement parameter was then linearly converted to an average of 200 points and a standard deviation of 40 points based on the fifth grade of elementary school.The descriptive statistics of the major variables, such as the mean, standard deviation, skewness, and kurtosis, were confirmed. The Cronbach’s α was presented to confirm the internal consistency of the scales. The descriptive statistics, Cronbach’s α coefficients, Pearson correlation coefficients and factor analyses were conducted with the SPSS 26 program. A factor analysis  with a Varimax rotation was used to classify PAS . We assuThe means and standard deviations of the main variables are presented in p < 0.000). PAS was positively related to adolescents’ self-regulation and academic achievement. However, PAS was negatively related to adolescent amotivation. The findings suggest a high probability that PAS can positively affect adolescents’ development.The results of the correlations between PAS and adolescents’ psychological attributes and academic achievements can be found in The subfactors of PAS showed the same aspects of adolescents’ psychological attribute and academic achievement. Both PAS as a companion and PAS as a manager showed correlations with adolescents’ self-regulation and Korean, Math, and English grades; however, both types of PAS showed a negative correlation with amotivation. The correlation coefficients differed, and the coefficients were generally higher for PAS as a companion than for PAS as a manager, except for Math . It is most likely possible that both PAS as a companion and PAS as a manager might have a positive effect on children’s development or academic achievement.A structural equation analysis was conducted on the assumption that PAS would affect adolescents’ psychological attributes and academic achievements, and that adolescents’ psychological attributes would affect their academic achievements. The model was a good fit for the data. The coefficients are presented in However, the structural equation model showed quite different results. PAS as a companion had a positive effect on adolescents’ self-regulation and academic achievements and a negative effect on their amotivation. PAS as a manager, however, did not affect adolescents’ self-regulation and academic achievements and had a positive effect on amotivation. Self-regulation had a positive effect on academic achievement, while amotivation had a negative effect. PAS as a manager, which strives for young children’s academic achievements, did not affect children’s self-regulation or academic achievement three years later but instead increased motivation. In contrast, children who perceived PAS as a companion in the first year attained a high academic achievement by having high levels of self-regulation and low levels of amotivation.This study was conducted to identify the effects of children’s perceived PAS on the psychological attributes of adolescents and their academic achievements. Unlike previous studies, this study classified PAS into two types through a factor analysis and identified the different effects of each type of PAS on adolescents. PAS was divided into PAS as a companion and PAS as a manager. PAS as a companion is parental support such as studying with children, teaching children personally, advising them how to study, and creating a study-friendly environment at home. PAS as a manager is parental support such as deciding on children’s private tutoring or private educational institutes, sparing no money for children’s studies, and managing children’s grades and schedules. In this study, we discussed more desirable parental roles for children’s academic support.Children’s perceptions of PAS as both companions and managers were correlated with adolescents’ psychological attributes and academic achievements. In this study, PAS had a positive relation with adolescents’ development and academic achievements. However, the two types of PAS had different correlation coefficients, although the directions of the correlation were the same. This occurred because the two types of PAS were originally one concept. That is, the concepts of PAS as a companion and PAS as a manager were not contradictory; although they had different characteristics, it was reasonable to assume that they shared certain aspects. According to prior research ,51, exteThe structural equation model analysis results were striking. The correlation analysis showed that the two types of PAS had a positive relationship with adolescents’ development; however, the structural equation model showed a negative effect of PAS as a manager. Children’s perceived PAS as a companion positively affected adolescent self-regulation and academic achievement and reduced amotivation. However, children’s perceived PAS as a manager had no effect on adolescent self-regulation and academic achievement and surprisingly, was shown to increase amotivation. Amotivation had a significant negative impact on academic achievement. In the same context, parents’ attention to achievement increased children’s academic self-efficacy; however, parents’ attention to achievement did not affect children’s motivation , which wThrough this study, we confirmed that PAS as a companion has a long-term and positive impact on adolescents’ development and academic achievements. Parents should not support their children’s studies by acting as a manager of their children’s time and grades but by learning with and accompanying their children. Parents who study with their children and support their studies as companions understand and support their children’s interests, preferences, and perspectives more than parents who support their children as managers. PAS as companion parenting may increase children’s autonomy. This result is explained by considering that parental social support affects children’s motivations and achievements . In addiWhen children perceived that their parents managed their grades, schedules and private education, their level of adolescent amotivation was higher. Predictably, this perception increased the likelihood that children would expect their parents to manage their studies even if they did not manage them themselves. Furthermore, these adolescents may have a reduced motivation and willingness to learn and control themselves. Children who experience negative reactions to their independent and autonomous endeavours rely on external approval, such as parental approval or management, and tend to follow externally set goals, thereby reducing their motivation to act autonomously. Parental support as a manager does not directly affect adolescents’ self-regulation; however, it does affect adolescents’ amotivation. For adolescents, amotivation negatively affects their academic achievement, which aligns with the findings that autonomy control and intrusive parenting negatively impact children’s development and academic achievements ,53,54.Humans are autonomous beings, and autonomy is very important in academic aspects. It is desirable for parents to stand by their children, create a learning environment and be an advisor to help their children when they are in trouble, rather than managing children’s schedules and private education. It is important when supporting children’s studies to respect their autonomy, and parents and children should be on an equal footing. Even if the child is young, the role of a parent as a companion is important, and has a longitudinal effect. This study discusses the importance of the parental role as a companion in supporting and strengthening children’s motivation and self-regulation. When parents learn and grow together while respecting their children’s will and coordinating their opinions, children will be able to achieve their optimal development. Parents are the strongest source of perceived support for adolescents . ChildreAlthough this study has the advantage of having a large number of subjects due to the use of panel data, there was a limit to the number and content of the variable items. Specifically, more items are needed to discern the PAS type. In further studies, the two types of PAS (PAS as a companion and PAS as a manager) must be more clearly discussed and defined by a factor analysis with more questions. Due to the large number of cases, some variables were statistically significant, despite the low correlation coefficient. In the future, various studies and discussions that use these variables are needed. Moreover, some of the relationships associated with parents might be stronger in Korean children than they would be in Western samples because of sociocultural factors specific to the Korean context. Future studies may require the use of samples from various cultures.


In recent years, an increasing enthusiasm has been observed towards artificial intelligence and machine learning, involving different areas of medicine. Among these, although still in the embryonic stage, the dermatopathological field has also been partially involved, with the attempt to develop and train algorithms that could assist the pathologist in the differential diagnosis of complex melanocytic lesions. In this article, we face this new challenge of the modern era, carry out a review of the literature regarding the state of the art and try to determine promising future perspectives. In the last two decades, an unprecedented development of information technologies associated with a considerable increase in memory units has allowed giant strides to be made in the futuristic field of artificial intelligence (AI). Although this is the prerogative of the informatics and technological branches, the use of software and new technologies has spread to many different fields of medicine, indeed to practically all branches, including pathological anatomy and, therefore, also the subbranch of dermatopathology ,2. For sA systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of the PubMed, Medline and Web of Science (WoS) databases was performed until 17 July 2021 using the terms “artificial intelligence” OR “machine learning” OR “digital pathology” in combination with “dermatopathology” OR “skin pathology” OR “digital skin pathology”. Only articles in English were selected.An independent extraction of articles was performed by two investigators according to the inclusion criteria. Disagreement was resolved by discussion between the two review authors.In total, 28 records were initially identified in the literature search, of which five were related only to the application of AI to clinical dermatology. After screening for eligibility and inclusion criteria, 22 publications were ultimately included . The stuArtificial intelligence applied to pathological anatomy  has attrHekler et al.  analyzedJiang et al.  aimed toCruz-Roa et al.  used a dPeizhen et al.  built a New technologies are making possible what was considered futuristic only a few years ago. AI and ML as machine learning models have shown that they can learn from their mistakes, self-correct and thus be able to provide valid support to dermatopathologists. We have not reached such levels as to allow a complete “replacement” of pathologists, but they can provide a good aid in histopathological diagnosis. On the other hand, the dermatopathological diagnosis consists of a whole corollary of clinical information, such as the age of the patient, topography of the lesion, dermoscopic characteristics, color variations, ulceration, that a neural network is not able to take into account, being based fundamentally on image discrimination. It is also important to underline how much dermatopathology is a terrain of diagnostic debate among the pathologists themselves and how much the atypical lesions that are not easily framed in defined criteria  are far from finding agreement in “real life”, affecting all this, even in the difficulty in being able to train a convolutional neural network in certain recognition of an entity. Finally, we must not overlook the fact that any artificial intelligence algorithm is trained by a “human being” and, therefore, will always suffer from “involvement” on the part of the pathologist.This confirms the need for new studies and discoveries in areas that have not yet been sufficiently explored, such as dermatopathological diagnosis served by AI.


The automatic emotion recognition domain brings new methods and technologies that might be used to enhance therapy of children with autism. The paper aims at the exploration of methods and tools used to recognize emotions in children. It presents a literature review study that was performed using a systematic approach and PRISMA methodology for reporting quantitative and qualitative results. Diverse observation channels and modalities are used in the analyzed studies, including facial expressions, prosody of speech, and physiological signals. Regarding representation models, the basic emotions are the most frequently recognized, especially happiness, fear, and sadness. Both single-channel and multichannel approaches are applied, with a preference for the first one. For multimodal recognition, early fusion was the most frequently applied. SVM and neural networks were the most popular for building classifiers. Qualitative analysis revealed important clues on participant group construction and the most common combinations of modalities and methods. All channels are reported to be prone to some disturbance, and as a result, information on a specific symptoms of emotions might be temporarily or permanently unavailable. The challenges of proper stimuli, labelling methods, and the creation of open datasets were also identified. Autism spectrum disorder (ASD) is a lifelong, neurodevelopmental disorder that can occur to different degrees and in a variety of forms . The fifAffective loop in Socially Assistive Robotics as an intervention for Children with Autism . The project aims to implement, evaluate, and develop guidelines into the feasibility of applying emotion recognition technologies in robot-supported intervention for children with autism in order to create an affective loop in child–robot interactions. The project combines three domains: autism therapy, social robots, and automatic emotion recognition )A systematic literature review was used in the study as a methodological approach for capturing the state of the art in the domain of interest. The systematic method was chosen as the study aimed at finding key studies and performing the review with transparency and rigour that would allow replicating the study ,11. AccoRQ1: What emotions are recognized in children with autism in these studies?RQ2: Which observation channels are used in emotion recognition in children with autism?RQ3: Which techniques are used in emotion recognition in children with autism?RQ4: What techniques are used for multimodal recognition?In the study, we aimed at the identification of the key previous studies, covering all aspects, technical and psychological, related to automatic emotion recognition applied on children with autism. We finished up with four research questions:Regarding research question 1, the question covers the issues of distinct emotions that are automatically tracked in autism-related studies. The question also spans over the issue of emotion representation for the use of emotion recognition—whether they are yes–no labels or have a scale assigned. There are several popular models for the representation of emotions in affective computing . The firRegarding RQ2, by observation channel we mean a type of signal holding information on observable symptoms of emotional state that was used for emotion recognition. From the observation channels, one might extract modalities, e.g., facial expressions, body posture, skin conductance, or eye fixation areas. Modality is a type of information on a specific observable symptom extracted from the signal that is further analyzed to estimate an emotional state. Please note that one recorded channel might bring several modalities to analyze . A single modality might be obtained from multiple channels . The question addressed in this paper is which channels and which modalities are used in the automatic recognition of emotions in children with autism.Regarding RQ3 and RQ4, by technique we mean a technical data-processing method for the extraction of emotional state. One might find machine-learning algorithms, such as support vector machine (SVM) or neural networks, among frequent techniques for emotion recognition. Research question RQ4 was added because multimodal emotion recognition is frequently used to obtain more reliable and accurate results, and diverse fusion/integration mechanisms are applied. Therefore, in this study, we want to identify the recognition and fusion methods used in emotion recognition in children with autism.The keywords defined were grouped into the cluster related to emotions , related to children , and related to autism . The final search query appears as follows: AND (children OR child OR young)AND (autism OR ASD OR ASC OR autistic   OR ‘‘pervasive disorder’’) Please note that with a keyword “autism” we also cover phrases “autism spectrum disorder”, “autism spectrum”, and “autism spectrum condition”.We settled on including in the SLR only original research and review papers written in English and published in journals or conference proceedings. We agreed to exclude papers written in other languages from the other phase of SLR for those databases where no language filter was available. Since emotion recognition in children with ASD is relatively new, and since we are interested in all psychological discoveries related to emotions in autism, no constraints on the publication date were made. We also decided to exclude short communications. These are our report eligibility criteria.In addition to research questions and report eligibility criteria, we defined study eligibility criteria for studies to be included in the further stage of the SLR. We required that a paper concerns emotion recognition, and that there were children with ASD involved in the study. However, we also agreed to include some papers that do not satisfy these criteria  if they brought some value, such as a well-described challenge or a guideline.We decided to use seven scientific databases: ACM Digital Library, Elsevier Science Direct, IEEE Xplore, Scopus, SpringerLink, Web of Science, and PubMed. The first ones are the most popular scientific databases in technical sciences. The last one is important for scientists in medical and psychological domains and we chose to include it.In the beginning, we performed an initial analysis to decide which search field we should use to obtain a feasible number of records for the SLR. We considered three options, i.e., all fields, title only, and topic/keywords only. Please note that some engines provide search by topic and some by keywords, which are not exactly the same, but were treated as equivalent in the study. The search was performed in two rounds—the first one dates October and November 2019 on technical databases and in January 2020 on PubMed, and the second round was performed in January 2022 to update the review with papers from years 2020 and 2021.Each scientific database has its own search engine, resulting in a different query format. Thus, we had to slightly modify our search query to fit these requirements. For example, for IEEE Xplore, we had to add the field name to each keyword. The query for a title of a scientific paper is shown below. AND (‘‘Document Title’’:children OR   ‘‘Document Title’’:child OR   ‘‘Document Title’’:young)AND (‘‘Document Title’’:autism OR   ‘‘Document Title’’:ASD OR   ‘‘Document Title’’:ASC OR   ‘‘Document Title’’:autistic OR   (‘‘Document Title’’:pervasive AND   ‘‘Document Title’’:disorder)) Elsevier Science Direct allows the usage of only eight logical operators in a single query. Our search query contains fourteen ones. Therefore, we decided to split our query into six queries based on the first parenthesis and merge their results at the end of the searching process.The number of obtained records for each database and search field in the initial search is presented in Finally, we decided to use the title field because 1565 records is feasible to analyze, in contradiction to multiple-times more results from other fields. However, we are aware that this could lead to publication bias in our study. Some papers could be missing because they have not fitted into our selection criteria. On the other side, some studies could be reported in multiple papers and, thus, counted multiple times in the quantitative analysis.We settled on a manual selection of papers for their relevance to the eligibility criteria by title only. The papers should be evaluated on a three-point scale: 0—irrelevant, 1—somehow relevant, 2—strongly relevant. Four independent investigators recruited from the authors of this paper performed the tagging. Further decisions were made based on the sum of scores for taggers. Papers that scored 8 were taken to the next stage automatically. Papers that scored less than 4 were excluded automatically. Other papers with a score of 4–7 underwent screening by the abstract procedure. The Fleiss kappa coefficient was used to determine inter-rater consistency of tagging. Papers that passed the screening phase were analyzed in detail. We assumed that we could add additional papers during reading by noting out highly relevant papers from the bibliography that did not occur in the primary list of papers .We prepared forms in spreadsheets to extract the key findings in emotion recognition in children with autism. We were interested in several research issues related to automatic emotion recognition, i.e., which emotions are recognized in children with autism, which channels and techniques are used for emotion recognition, and how multiple modalities are handled. We also planned to analyze demographic data, including the number of children in the study , their gender, and age. We also wanted to note all challenges, recommendations, and other relevant observations. We agreed that a tagger could extend the forms, i.e., by new emotions or modalities that were not considered at the beginning of this study.After we had read the papers and filled in the forms, we extended some of them which had too little information and repeated the process of the key findings extraction. For example, we extended a spreadsheet with information about children by adding vocabulary (wording) describing children. In some papers, authors used the expression “child with autism” while in others, “autistic child” was used. This procedure of repetition was to avoid selective reporting bias.We decided to analyze the data by means of quantitative and qualitative analysis. For quantitative analysis, we used a simple count measure. We decided to unify some columns from the final spreadsheets, e.g., we grouped some emotion names under labels from the two emotion models: Ekman’s basic emotions or two-dimensional ones.The results of this study are presented in three subsections. In We performed queries on selected scientific databases and obtained 1565 papers. After that, we unified the file format and merged all records to remove duplicates. We were left with 637 unique papers to perform an initial analysis on. We had to exclude one of them before tagging because there was no full-text version available anywhere.First, the papers were manually tagged for their relevance by title only. The scale was: 0—irrelevant, 1—somehow relevant, 2—strongly relevant. The inter-rater consistency for the four taggers measured with Fleiss’ kappa coefficient was equal to 0.543. The sum of scores for the four taggers was calculated, and further decisions were made based on the total score. A total of 29 papers that scored 8 were taken to the next stage automatically; a total of 308 papers that scored less than 4  were excluded automatically, while 299 papers that scored 4–7  underwent screening by the abstract procedure. After the second tagging, we qualified 40 papers to the next stage, finishing with 69 papers for reading. We have identified 11 additional papers by the snowballing technique. From 80 papers, only 36 were qualified for detailed analysis and reporting. Another 44 papers were excluded after reading because there were no real participants or automatic emotion recognition. At this stage, we also excluded some short communications. Results from this phase of SLR are presented in We identified two studies that were reported in multiple papers: one in two ,18, and In January 2022, we performed additional searches on each scientific database to fill in the gap between the first search and a current date. We identified 512 papers. After removing duplicates, we were left with 209 papers for additional analysis. We repeated the same procedure as in the first search. Manual tagging by title was performed by four independent experts whose agreement measured with Fleiss kappa was equal to 0.607. After screening by title phase, we were left with 57 papers for the next phase. A total of 15 papers which obtained scores equal to 8 were taken to the full-text read phase automatically. Others had to pass a screening-by-abstract phase, in which we identified 15 relevant papers to include in the analysis. However, two of them were unavailable and two were in languages other than English (we agreed to include only papers written in English). Thus, we finished with 26 papers for the full-text read phase. After the last phase, we obtained 14 papers to include in the qualitative analysis and 10 papers to include in the quantitative analysis. Results from this phase of SLR are presented in In this subsection, the quantitative analysis is presented. First, we present a discussion of notions (words) that are used to describe emotions in diverse studies in Another part of the analysis concerns used channels registering various modalities in the process of emotion recognition . AdditioNext, the techniques of emotion recognition were analyzed to address the 3rd and 4th research questions. In Most of the papers use two emotion models: Ekman’s basic emotions  and/or a two-dimensional model of valence and arousal;For Ekman’s basic model, papers use a subset rather than the complete set of emotions;Papers use different wordings to describe the emotions, and additional attention should be paid to the meaning of those in a particular study;The set of emotions resulting from the recognition process is not limited to the ones described by these two models. Thus, all the emotions recognized within the studies described in the analyzed papers were grouped into some subsets and further discussed;Some notions used in the papers can be treated as moods or mental states, but all of them were included in the analysis. Emotions are analyzed in two ways: separately and in groups;All notions other than dimensional representation are treated as discrete emotions.In psychological research, there is no unambiguous definition of human emotion. However, a discrete emotions concept is widely accepted. There are multiple models to represent emotions. Analyzing papers that deal with emotion recognition, we have to address the issue of how emotions are distinguished and named in those papers. Some observations that influenced our analysis follow:There are studies that treat attention, engagement, involvement, and boredom as emotional states. They are more like mental states; however, they are emotion-related and were used in the context of emotion recognition in the analyzed papers.There is a group of studies analyzing fear-related emotions; however, apart from the word “fear”, the words “anxiety” ,22,25 anThere is a number of papers for joy-related emotions, using terms of ‘joy’, ‘liking’, ‘happiness’, ‘smile’, and ‘relaxation’. Relaxation was added to that group, as in study , the recApart from the emotions presented above, calmness (1), hunger (1), and nerves (1) are also recognized in those papers. Hunger and nerves are both recognized in the same study , and calA quite-different approach from any other works is presented in , where tThe quantitative analysis for papers describing the recognition of emotions comprises the emotions in the Ekman model  in As mentioned above, Ekman’s basic emotions are frequently combined and recognized together, however rarely the complete set of emotions is used. Joy  is the most frequently recognized emotional state (21 times). Rarely recognized states are disgust and surprise (both only 7 times). The basic emotions are also combined with a neutral state.The combinations of basic emotions that occurred in the analyzed papers are shown in In some papers, only two-class recognition was performed. In those papers, joy is recognized as a class combined with no-joy in three papers, with a neutral state in two papers, and with sadness in two papers. The other basic emotions are occurring combined with joy. The complete set of basic emotions (as proposed by Ekman) is rare—appearing five times . In , a neutrAn interesting study combines joy and sadness with hunger, trepidation, relaxation, and nervous states . RegardiThere are studies that deal with compound emotion concepts ,46. A colife activities, i.e., conscious and unconscious actions of a human body, which generate a specified symptom of an emotional state that can be further analyzed in the process of emotion recognition. The following life activities were analyzed in the selected papers: various types of movement, a sound made by a human, and physiological activities such as heart activity, unconscious muscle activity, respiration, and thermal regulation. The activation of the human body’s nervous system induces changes in life activities, and those might be interpreted as symptoms of emotions.When analyzing inputs used for emotion recognition, it is important to define this analytical process on the generic level and distinguish between life activities, observation channels, and modalities. The process of emotion recognition is analyzed with respect to observation channels, which are mediums for the registration of a signal holding information about observable symptoms. The channel refers to a type of signal obtained rather than a physical medium. The channels that were used in the studies of emotion recognition in children with autism include RGB video, depth video (Kinect mainly), images, audio, ECG (electrocardiography), BVP (blood-volume pulse), chest size, EMG (electromyography), fMRI , EDA , and temperature.The life activities might be recorded via modalities, which are understood as a type of information observable and used as a proxy for emotion recognition. In our study, modalities are grouped according to life activities:movement: facial expressions, body postures, eye gaze, head movement, gestures , and any other not-previously classified motion;sound expressions: vocalizations, the prosody of speech;heart activity: heart rate, HRV (heart rate variablity);muscle activity not related to movement: muscle tension;perspiration: skin conductance;respiration: intensity and period, ECG;thermal regulation: peripheral temperature;brain activity: neural activity.The life activities generate There are also some other modalities not mentioned here—only modalities identified for the need of this paper are listed.Further, each modality could be paired with the observation channel that it was extracted from. Thus, one modality can be observed using various channels and one channel can contain information about more than one modality. In There are some usual combinations of channels and modalities extracted from them , but Interestingly, a lot of attention is paid to physiological signal measurements and speech analysis. The reason for that might be assigned to the atypical expressivity of children with autism in terms of mimicked expressions, which was observed in the psychological studies multiple times. Moreover, at least some children with autism would not use active speech as well. Therefore, other vocalisations and physiological responses of the nervous system are more frequently used.Another analysis performed was the collation of analyzed modality and the emotion recognized from it. In the consequent Joy/happiness versus a neutral state was the most commonly recognized of almost all types of modalities. Quite interestingly, while physiological signals are observed and processed, joy was almost exclusively the emotion recognized from it see . There iThere is another very interesting study that uses an atypical observation method for recognition of affect in children with autism, namely, the analysis of children’s drawings . The autKnowing which channels were analyzed, various machine-learning techniques were identified, such as the ones used for emotion recognition, ie., neural networks (NN), fuzzy c-means clustering (FC-M), support vector machine (SVM), random forest (RF), hidden Markov model (HMM), linear discriminant analysis (LDA), k-nearest neighbors (k-NN) and fuzzy logic (FL). In two papers ,37, therWhen one or more modalities or channels are analyzed together, the discussion must also concern the applied approach for multimodal processing. There are two main techniques: early fusion and late fusion. Early fusion combines features extracted for various modalities and channels, and these merged features are further analyzed using statistical or machine-learning techniques. On the other hand, by using late fusion, it is assumed that the emotions are recognized from each channel for the specified modality separately, and then the new emotion is determined using a machine-learning technique basing on previously recognized emotions. Additionally, there is also a hybrid fusion approach. This approach combines early fusion with late fusion. As some features may be combined as an input for machine-learning techniques (early fusion for selected groups of features), the late fusion is also applied afterwards.Two unimodal approaches are presented: only one channel for one modality is analyzed, marked as a single-channel-only approach, or more than one channel, or modality is analyzed but independently from other modalities and channels, which is marked as a multiple-channels separately analyzed approach. This approach is also marked when more than one channel is analyzed but only one channel is used to recognize the specific emotion. It is worth noticing that in two papers ,37, therThe analysis presented in Apart from quantitative analysis, 50 papers were analyzed in a qualitative manner (36 from the first and 14 more from the second round). We were looking for recommendations and best practices in terms of techniques used, study preparation, and conduct.We have studied papers that referred to a group of children with autism. We noticed that papers differed in vocabulary (wording) when describing children. In some papers, authors used the expression “child/children with autism”, while in others, the expression “autistic child” was used. The latter one is deprecated, as the tendency now is to put “a person first”. Moreover, papers differed in the reference to a control group—“typically developing children” or “neurotypical children” are preferred over “normal children”. More vocabulary items are presented in Approximately half of the papers that had emotion recognition and children with autism in the title reported only preliminary studies. Some researchers referred to children with autism as a target group of their solution in their studies, but did not report the children’s actual measurements. They reported results for adults, a group of typically developing children, or they did no validation at all. Two studies used previously generated datasets of recordings or measurement data ,67. ThosOnly 17 studies provided validation with children with autism. The observations regarding participants are as follows.construct the control group according to developmental age and/or intelligence factor rather than the chronological age of ASD group;making an openly available dataset of recordings is a highly recommended approach, as it fosters further research;regarding the construction of participant group, it might be hard to balance girls’/boys’ inclusion due to population skewness (autism is diagnosed in boys more frequently); similarly, it might be hard to balance the group regarding low-/high-functioning children, as low-functioning children might refuse to participate more frequently and their participation also depends on the type of activities under study.The participants’ groups were relatively small—most of the studies involved 1–7 children, and a maximum of 20 participants was reached in 2 studies; however, the number of children with autism was 14 at most. There was one study using a dataset produced by the deENIGMA project, with recordings from 35 children with autism. In only six studies, children with ASD were paired with a group of typically developing children, while the other studies involved children with ASD only. In most of the studies, children with autism were treated as a homogeneous group with no further distinction between high- and low-functioning ones. For only six papers, the functioning of children was provided, and in four of those, only high-functioning children were included in the study. Most of the studies reported the age of participants, which varied from 2 up to 20 years . Four out of seventeen studies did not provide age. Most of the studies reported the sex of the children, and among children with autism, girls were underrepresented . Recommendations regarding the construction of participants group include:Additionally, the other systematic review study reports the following as future works: widen the age range (in two studies), varied demographics (four), larger sample size (four), prior ASD clinical test (one), repeat to the same age group (one) .As autism deficits occur in a variety of forms and levels in individuals, the challenge of generalizability of the results remains inherent in all of the studies. Therefore, regardless of the group construction, in each study, it would be valuable to provide information on participants that is as detailed as possible, including, at least: chronological as well as developmental age, gender, and level of functioning.There were multiple strategies used in the studies for evoking emotions (stimuli) and tagging them. Regarding the stimuli, both evoked emotions and natural interaction approaches were used, and the challenge of collecting a proper training set of data from children with autism was raised .The most common stimuli used in the studies included pictures and video resources. However, a study  on galvaThere are differences in reactions to positive and negative emotions presented in stimuli;Live videos of natural, real humans are good stimuli for tracking reaction patterns in children with ASD;There are differences in fixation duration time regarding different areas of interest  between children with ASD and typically developing children.In another study, eye gaze patterns were analyzed as a reaction to stimuli of videos containing human faces . Main fiAlthough video stimulus was the most frequently used one, other studies tried: serious game approach , computeThe assignment of a proper (accurate) label to the data gathered is another challenge in emotion recognition in general, not only in autism. The internal emotional state (ground truth) is hard to determine in a continuous manner, sometimes even for a person who experiences it. Several strategies might be used for labelling the data. In , skilledthe measurement procedure or environment might be disturbing for a child with autism;the data obtained are not of high quality (hold no significant information on a child’s symptoms of emotions);the obtained modalities are hard to analyze due to atypical patterns of symptoms.Regarding the challenge of the measurement procedure, the more we want to measure in the study, the more complex the procedure becomes, and all the devices introduced in the environment might be disturbing for a child. Children with autism usually like repeatable, familiar environments, and all intrusions, including devices put on the body, devices in the room, and extra people, might cause a refusal to participate or might be a reason to behave differently. For example, a study on smile recognition  utilizeschildren with ASD had significantly lower amplitudes of respiratory sinus arrhythmia and faster heart rates than typically developing children at baseline, suggesting lower overall vagal regulation of heart rate;a large percentage of children with autism had abnormally high sympathetic activity, i.e., skin conductance response;it is difficult to employ eye-tracking technologies with lower-functioning children because the calibration and data-collection processes require the child to sit still.The second challenge is that even though one will record the session using devices, the data will not contain the information sufficient to draw conclusions on symptoms of emotions. This applies, for example, to eye gaze tracking, which is hard to calibrate, but also to other modalities. For example,  describeAnother study  reports The third challenge refers to atypical patterns of emotion expression by children with autism. Paper  summarizHow will the children’s emotions be displayed (in autism)?Does emotional affect vary with the severity of the disorder? How can this be accounted for and by the model?In one study , galvaniAnother study of cross-modal coordination of emotion expressions reveals that the coordination is lower in the ASD group when compared to neurotypical children . ChildreOut of the life activities and modalities that are used as proxy symptoms for emotion recognition, all are prone to some disturbance. Eye gaze is hard to calibrate, as it requires child cooperation and sitting still. As emotion processing and expression is a deficit in autism, facial expressions might be disturbed and misleading. Some children are non-verbal, which limits the analysis of vocal clues of an emotional state. In addition, regarding physiological signals, the studies revealed atypical patterns.Once symptoms of emotions are captured, and the emotion classifiers are trained, one might consider applying them in various forms in real-life situations. Most of the studies analyzed are conceptual or laboratory-based ones, and they refer to therapy and/or diagnosis of autism as their future application areas. However, some contain more practical observations referring to real-life applications of emotion recognition in autism.Paper  raises tThe paper  summarizThe main aim of  was to dThe paper  describeAmong the real-life application areas, interaction with social robots is a frequently represented one in the analyzed subset of papers. The study  processeThe study  aims to Another study proposed a framework to determine a child’s emotional state at any given point during an interaction to facilitate the delivery of robot-assisted tailored therapy interventions that can evoke a higher level of engagement from children with ASD .Before automatic emotion recognition is performed, it is advisable to define a list of emotional states that would provide a value from the intervention perspective;Children with autism deficits in communication skills make it hard to apply classic methods of tagging emotional states;Physiological signals are continuously available and are not impacted by deficits;For the enhancement of the reliability of tagging, a clinical observer and a caregiver who knows the participant shall be included in the study;A preliminary phase might be added to train recognition models before the actual tasks to be monitored are performed.The paper  presentsThe dissertation  presentsFor what purpose are emotions recognized—is it to better understand the phenomena, or support intervention, or adjust technology  behavior?In what way would emotion recognition help to develop skills in children with autism?The training of which skill would require automatic emotion recognition?Which emotions are of the primary interest? Perhaps the most frequently used set of six basic emotions is not the set that we shall be looking for, as practical studies point, rather, to engagement as a crucial affective state for the therapy effectiveness.Analyzing the variety of studies in the development of real-life applications of emotion recognition in autism therapy, some questions seem of the highest importance to be asked at the very beginning of each study:Summing up the study, we were surprised by the fact that out of so many studies that dealt with emotion recognition in autism, we reduced it down to 50 papers (36 in the first search and 14 in the second one) included in the qualitative and 27 papers (17 in the first search and 10 in the second one) included in the quantitative analysis. There are several reasons for that. First of all, the domain is relatively young and, thus, the number of papers related to it is limited. This was partially proven by our second search, which revealed 10 relevant papers from only two years to be included in the quantitative analysis. Secondly, we excluded many interesting papers at first sight, but they described ideas or plans of studies that were not validated yet. Some papers turned out to be short communications only, and most of the papers were excluded due to no real participants’ involvement.The first research question regards the issues of distinct emotions that are automatically tracked in autism-related studies and the representation models of those emotions. The most common model of emotions used is Ekman’s six basic emotions set, but usually only a subset of them is actually recognized in a particular study. A valence–arousal model is also used in several studies. The observations are compliant with those by Rashidan et al. —the studWe noticed that some authors refer to emotional states from the basic set or other ones with their own labels, and those labels are not further defined from a psychological perspective. Some terms used by authors could be grouped. For example, happy, happiness, joy, and smile are hard to differentiate; therefore, we treated them as a group of joy-related emotions. Another example is fear-related emotions such as fear, anxiety, and trepidation. None of those terms is explicitly defined in the studies. Some states addressed in the studies are more attention-related than emotion-related , and that seems more of the real interest in studying children with autism (and not six basic emotions). An interesting concept of compound emotions, such as fearful surprise or happily disgusted, was also raised in the context of the meltdown crisis of a child; however, those were not automatically recognized and require further investigation. More detailed observations regarding emotional states addressed by the analyzed studies are provided in The second research question concerned observation channels that are used in emotion recognition in children with autism. We noticed that papers usually mix terms related to life activities observed, channels of observations, signals, and modalities analyzed. Authors frequently use those concepts interchangeably, for example, assuming that facial activity is connected with analyzing the RGB video channel only. We first defined the distinction between observation channel as a medium and modality as a type of information analyzed to obtain an emotional state estimate see , and theThe modalities that were analyzed by the papers in order to obtain emotional state included : facial expressions (14), skin conductance (10), heart rate (8) and heart rate variability (7), peripheral temperature (6), prosody of speech (6) and vocalisations (5), muscle tension (4), hand gestures (3), body motion (3) and body posture (3), head movements (2), respiration (2), eye gaze (1), and neural activity (1). The observation channels used included: video (RGB or depth), audio, EDA , BVP (blood-volume pulse) or ECG (electrocardiograhy), EMG (electromyography), and other physiological sensors as well as fMRI . We also found an interesting paper that analyzed children’s drawings in order to recognize emotional states . SectionThe third research question concerns techniques used in emotion recognition in children with autism, especially the classifiers or alternative approaches used. Diverse machine-learning methods are used : SVM classifier (11), neural networks (7), k-nearest neighbors (3), linear discriminant analysis (2), random forest (2), fuzzy logic (1), and hidden Markov models (1). The dominance of SVM classifiers is compliant with the finding in ; howeverThe fourth research question concerned techniques used for multimodal or multichannel emotion recognition (if more than one channel was used). The most popular was the unimodal approach . Fusion was used in 11 papers, with early fusion at the feature level being the most popular (10 papers), followed by late fusion (1 paper) and hybrid fusion (1 paper)—those do not sum up to 11, as one paper covered both early and hybrid fusion. We have also pointed out studies that used multiple channels and/or modalities, but separately analyzed and not integrated at any level (5 papers). The study allowed us to answer the Research questions RQ1, RQ2, and RQ4 comprehensively. The third research question, RQ3, was partially addressed—we covered machine-learning techniques, but methods for signal processing would require a separate in-depth study.Apart from quantitative analysis, some observations and lessons learned are also gathered. The most important observations could be summarized as follows.Participant groups used in the analyzed studies were relatively small and skewed in terms of representation of male/female and high-/low-functioning individuals. That might result in lower generalizability of the findings;Regarding the stimuli, various approaches were used, including emotions evoked via pictures, videos, and serious games, as well as natural interaction. The applied stimuli were frequently treated as labels, as the “ground truth” was hard to determine. Labels were also applied by self-assessment, assessment by therapist and/or caregiver, or as a combination of those. The problem of stimuli and labelling is known in affective computing; however, in autism-related and child-related studies, it is even more challenging, as children with autism might react to stimuli differently than typically developing children. Moreover, even qualified therapists might find it hard to assign a label to a child’s behavior;Physiological signals are most frequently used for the recognition of happiness versus a neutral state, which is surprising, as they reveal more information on arousal (intensity) of the emotional state rather than on valence (positive/negative dimension);All channels are prone to some disturbance, and information on a specific symptom might be temporarily or permanently unavailable. The disturbances might be divided into activity-based (depending on a task), child condition-based (depending on child deficits or current state), and setup-based ones .Some papers could have been omitted due to the search of the keywords in the title only, and we are aware of that limitation of our study. We were considering alternative approache;, however, we wanted to search in multiple and diverse scientific databases/search engines to discover both technical  and more medical/psychological  studies. Consideration of searching in keywords and topic revealed that not all of the chosen set of search engines covers the two search fields  the participants’ group construction taking into account sex, developmental age, and level of functioning; (2) the mixed (compound) labelling approaches; (3) creating datasets for further research—with measurement and label data related only to children with autism, or (4) which emotions are of real interest in the analyzed interaction rather than starting with a basic emotions model.