Examination of Interpersonal Attachment with the Help of a Digital

Tablet Application: A Proof of Concept Study

Sebastian Unger

1,3

, Cony Theis

and Thomas Ostermann

Didactics and Educational Research in Health Science, Faculty of Health, Witten/Herdecke University, Germany

Fine Arts, University of Applied Sciences and Arts Ottersberg, Germany

Department of Psychology and Psychotherapy, Faculty of Health, Witten/Herdecke University, Germany

Keywords: Interpersonal Attachment, Sizer Analysis, Digital Tablet Application, Screen Recording, C# Programming.

Abstract: At present, interpersonal attachment has a subordinate role in the field of healthcare, but recent research results

assume this as an important parameter, especially in prevention and mental health. Our aim was to develop a

digital application that extends the previous approaches with a measurement over a specific time interval.

Designed specifically for Windows-based tablets, this application performs a drawing test while capturing the

transitions of two mental states, transmitted by the users. The results were collected over a period of three

minutes, allowing the application itself, along with the SiZer analysis, to determine how closely the

participants were mentally connected. The tablet application has shown its first usefulness to enhance the

healthcare, but further investigations are strongly recommended. In addition, its ease to use allows an

uncomplicated integration into similar areas.

1 INTRODUCTION

Attachment describes the tendency of humans to seek

contact among themselves as a specific part of

interpersonal relationships (Fearon et al., 2017). It

addresses a bundle of topics from developmental

aspects (i.e. the relationship of children to their

parents) to adult relationships or group coherence

(Ein-Dor and Hirschberger, 2016). Recent studies

suggest that attachment on a higher level can also

contribute to understand socio cultural phenomena,

which may affect actual problems such as migration

or the feeling of social inequality (Sroufe, 2016).

In the field of healthcare, interpersonal attachment

has been ignored for a long time as a specific

parameter to enhance therapeutic outcome, i.e. in

group settings or in the field of individual care, giving

in nursing (Blanco et al, 2018). Recent research

suggests that such interpersonal relationships play an

important role for prevention and healthcare

especially in the field of mental health (Degnan et al.,

2016, Diener et al., 2011).

However, when it comes to measure attachment

dynamics, most of the approaches use questionnaire

assessments for single time points, i.e. using

questionnaires like the Interpersonal Relationship

Anxiety Questionnaire (Naz and Kauser, 2015) or

maternal and paternal antenatal attachment scales

(Göbel et al, 2019). Sándor et al. (2012) who used a

pictorial assessment for the description of

interpersonal relationship in children presented an

unconventional idea beyond questionnaires. Still, in a

similar context, it has already been proposed to

perform a detailed moment-by-moment analysis, as

assessments that only capture a snapshot may neglect

the fluidity and interactions of a parameter (Shaw et

al., 2019). Taking into account recent research on the

dynamics in the tree drawing process in patients with

Alzheimer’s disease (Robens et al., 2019) and based

on communications with art therapists, we developed

a prototype of a digital app to measure interpersonal

attachment over the course of time called IU, which

due to its easy to use design has a low threshold and

thus can be used in various contexts.

2 MATERIAL AND METHODS

2.1 Overall Description

As a new approach to determine interpersonal

attachment between two people, the digital tablet

application IU was created. The name IU has emerged

from the main function of the application, the

310

Unger, S., Theis, C. and Ostermann, T.

Examination of Interpersonal Attachment with the Help of a Digital Tablet Application: A Proof of Concept Study.

DOI: 10.5220/0008881003100315

In Proceedings of the 13th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2020) - Volume 5: HEALTHINF, pages 310-315

ISBN: 978-989-758-398-8; ISSN: 2184-4305

measurement of two mental states of a person (see

also Figure 3). The first state is to be with oneself and

the second is to be with the other. The letters “I” and

“U” stand for the English personal pronouns “I” and

“You”, representing these two states. In addition, the

IU is the first application that supports that kind of

data in a digital from used in a further step of

determining interpersonal attachment: the evaluation

of measurement results.

2.2 Setting

No ethical permission was required for this proof of

concept study in healthy subjects. However, each

participant had to sign a consent form. After agreeing

to participate, they were asked to sit opposite each

other in pairs, holding eye contact during the whole

drawing process. A tablet with an installed version of

the IU-App was in front of both. The starting point of

the digital pen was a centerline, which divides the

screen into two sections. The one closest to the

subject is defined as the “I”-state, while the area near

the counterpart is defined as the “U”-state. When

participants feel attached to the other, they are

advised to move their pen beyond the centerline

towards the “U”-state until they feel unconnected or

more connected to themselves. In that case, the pen is

moved to the “I”-state and probably crosses the

centerline. This process continues for three minutes

(min). Within this period, both participants have

created a line drawing. One example is presented in

Figure 1. Although the final drawings might look

similar, the attachment of participants might either be

“in touch”, meaning that both participants mainly

were interconnected with both pens, located in the

“U”-state, or they were not attached to each other,

resulting in different locations of the pen (“I” versus

“U”).

2.3 Hard- and Software

In order to ensure the user a realistic and best possible

drawing experience, the application was developed

especially for tablet computers with touch function,

using a digital pen or a finger as interaction medium.

The wide range of user acceptance of Windows

operating systems and the support of a stylus with

pressure sensitivity of 1024 for future purposes led to

use an ASUS Transformer Mini T102HA (see Figure

1) for these needs.

It is also equipped with a high definition (HD)

display, having a resolution of 1280 x 800 pixels, and

4 gigabytes (GB) of random-access memory (RAM),

resulting in adequate image quality and system

performance.

Figure 1: Data acquisition via ASUS Tablet.

As programming language for the back-end of the

application, C# was chosen. This dynamic language

is used by a growing community of developers and

convinces by its simple object model, small libraries

resulting in efficient syntax and coding which finally

enables more agile development (Thomas, 2008).

The used development environment was

Microsoft Visual Studios along with the .NET

framework 4.5.2. The framework is compatible to the

Microsoft Expression Encoder 4 application,

recording the tablet’s screen during the drawing, and

includes Windows Presentation Foundation (WPF),

an approach to a Graphical User Interface (GUI)

framework. The Extensible Markup Language

(XML)-based WPF was applied for designing the

front-end.

2.4 Functionality

The GUI of the application can be divided into three

main parts: First, the start page, second, the drawing

page and, third, the review page. All pages are

designed in order to be user-friendly according to the

same principle. They have a bar for selecting the

general functions on the top and interaction options

designed to be touchable.

The start page is the center of the IU. It shows up

after launching the application and is the same page

to close it again. Furthermore, users can switch to the

other two pages from this hub.

The data acquisition is accomplished in the

drawing page. The figure 2 shows the process up to

saving the result. At the beginning, users have to

provide some personal data. In addition to age, gender,

Examination of Interpersonal Attachment with the Help of a Digital Tablet Application: A Proof of Concept Study

311

Figure 2: Activity diagram of the drawing page.

profession and user (identifier) ID a questionnaire on

social orientation was implemented. The

questionnaire consists of ten items with four possible

answers to choose. An ID to specify the measurement

itself is automatically generated from the current date

and time. Once the data is completed, the drawing can

be started. To clarify the beginning and the end of the

drawing, they are initiated by a beep sound. The

measurement has a fixed time span during which the

drawing is being recorded as video and coordinates

(x, y) of the touched screen pixels are being tracked

with an interval of 100 milliseconds (ms). After

finishing the measurement, users can decide to either

store or delete the current result including the

measured data and the drawn picture. If it gets

deleted, the measurement can easily be repeated. By

saving the result the IU generates a XML file for the

raw data, a Portable Network Graphics (PNG) file for

the picture and an Expression Encoder Screen

Capture (XESC) file for the video.

The visualization of results takes place on the last

of the three pages, the review page. To load a result,

a list box displays all available results by their ID

from where it can be chosen. The application imports

the data of the XML file. In addition to the personal

information, the transitions (see Figure 3) between

the states are displayed in percent. Each percentage is

calculated based on the length of stay in relation to

the total time. All information can be faded in and out.

The PNG and XESC file are being linked during

the load process. Simultaneously, a time course of the

y-coordinates is being created. The IU is designed to

show

only one of this visual information at a time.

Figure 3: Diagram of mental states.

Users can decide at which information they want to

look at. By selecting the video, they can pause and

play it at any time. Moreover, by selecting the time

course, they can add the time course of the partner for

comparison purposes as well.

2.5 Sizer Analysis

For statistical evaluation, the data analysis tool

SIgniﬁcance of ZERo crossing of the diﬀerences

(SiZer) was used. It was first introduced with the goal

to identify and locate local extrema of a derivative

(Chaudhuri and Marron, 1999). Instead of coloring

these extrema as signiﬁcant features, this extended

version of SiZer compares two time series based on

the diﬀerence of two kernel estimates (Park et al.,

2009).

The drawing process was analyzed on filtered data

from the XML files and displayed as time series t(y,

s), using the y-coordinate of the digital pen location

as outcome parameter. The SiZer tool uses a local

linear smoothing of length 2h around a measured

value for the time series to be considered. The value

h is also referred to statistically as bandwidth and is

varied for the comparison of the two time series, so

that smoothing windows with large and small

bandwidths arise. The smoothing is performed by the

least squares method, with the weights normally

being distributed. For each bandwidth h and each time

of the time series t the difference between the two

regression lines f

1,h

(t) and f

2,h

(t) is tested. Therefore,

the null hypothesis can be formulated as:

: f

1,h

(t) = f

2,h

(t) (1)

while the alternative hypothesis is:

: f

1,h

(t) ≠ f

2,h

(t) (2)

The test is carried out by using the properties of

the standard normal distribution over the confidence

interval (CI) of the difference between the empirically

ascertained adjustments:

1,h

(t) - f

2,h

(t)

(3)

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If the CI contains the value zero, then there is no

significance. Otherwise, if the zero is not contained,

the two adjustments are significantly different. Hence,

the initial name SiZer arises: SIgnificant ZERo

crossing of the derivatives. The SiZer analysis plots

the result of this test graphically over the time t and

the bandwidth h in the coordinate system (t, h). A blue

1,h

(t) > f

2,h

(t)

)

or red point

1,h

(t) < f

2,h

(t)

)

at the position (t, h) indicates a significant difference

in time series, while a purple dot does not mark a

significant difference. Inadequate data is shown in

grey in this illustration.

3 RESULTS

The first case presents two adults (male 18 and

diverse 58) which were familiar with each other as

nephew and uncle. After a total time of three min, the

examination was completed. Figure 4 displays

snapshots, which were taken at intervals of 1 minute

from the videos recorded and played with the IU. As

can be seen already, there is an observable

congruence in the graphics, which may indicate a

high amount of interpersonal attachment.

Figure 4: Snapshots of test group A.

Another user pair with unknown relationship

(female 21 and male 26) represents the second case.

As shown in Figure 5, they have behaved completely

Figure 5: Snapshots of test group B.

different. While user A stayed on the partner’s side

most of the time (except for one move at a time of two

min and 35 seconds (s)), user B tried to attach his

counterpart several times. However, the SiZer plot

visualized no measurable response.

The complete drawing process in the course of

time together with the results of the SiZer analysis is

presented in figure 6.

Figure 6: Results of the SiZer analysis tool.

Examination of Interpersonal Attachment with the Help of a Digital Tablet Application: A Proof of Concept Study

313

As expected from the snapshots in Figure 4, a high

amount of similarity was found in the first two

participants. This is on the one hand indicated by

similar curves, which in 88 % (user A) and 91.4 %

(user B) of the time were above the border, depicted

by the black line. In the associated SiZer map (1. User

group), the purple pixels are widely distributed in

mostly the lower bandwidths, indicating a high

amount of correlation. This leads to the assumption

that the user pair was most of the time mentally

attached to each other. Thus, the null hypothesis in (1)

cannot be neglected.

In contrast to this and in accordance with Figure

5, the curves of the second two participants are

unequivocally different. User A remained 90.6 % and

user B only 54.9 % of the time above the border.

There is almost no correlation between these curves,

represented by the SiZer map (2. User group) with

mostly blue pixels in all bandwidths. Likewise, a

reflection of the y-coordinates of one of the users led

to a significant dissimilarity, confirming the

alternative hypothesis in (2). This suggests the

assumption that this user pair had completely

different trains of thought.

4 DISCUSSION

In this proof of concept study on the analysis of a

digital tablet application for the examination of

interpersonal attachment, we were able to measure

the attachment of two people by analyzing the drawn

lines on a tablet by the IU-App. That the first user

pair was mostly mentally attached could be associated

with nonverbal interpersonal synchrony such as

smiling or blinking, meaning that social-cognitive

functions such as self-esteem or the feeling of being

connected to the partner (Lumsden et al., 2014) might

be reflected in the synchronous trains of thought of a

familiar pair. This is supported by Ramseyer and

Tschacher (2011), who observed that nonverbal

synchrony is expressed in the perceived quality of the

relationship, which here is probably rated higher by

the first user pair than by the second user pair, whose

relationship is unknown. At least in our two

examples, we found a good correspondence between

the drawing process in the course of time and the

results of the SiZer analysis. Hence, a future study

with a higher number of participants should be

observed to obtain results that are more meaningful.

Moreover, it might be interesting to compare the

results with those of electroencephalography (EEG),

skin resistance or similar physiological measures.

Although the analysis of digital drawing

processes actually has been given a high amount of

attention in the field of health informatics, i.e. in the

analysis the tree drawing process of patients with

mental impairments such as dementia (Robens et al.,

2019), the kinematic analysis of the clock drawing

test in elderly people with depressive disorders

(Heinik et al., 2010) or the neuropsychological testing

of perceptual and motor skills in children (Lange-

Küttner, 1998), this application, to our knowledge, is

the first that uses a tablet application for the analysis

of interpersonal attachment.

In line of the suggestions of Zapata et al. (2015),

we were able to demonstrate that our app is easy to

use and was understood and accepted by the

participants. Especially its easiness in use is an

important feature of this app, which points to the use

in clients with high thresholds for written

psychological test instruments, such as young

children or participants with language barriers or

speech or writing delay (Gómez-Durán et al., 2018).

This app thus may contribute to mitigate these

barriers.

After having shown its usability, the next step is

to evaluate this app by means of its validity and

reliability. Therefore, its congruence with

relationships scales or social skills inventories (see

Jewell et al. (2019) for a review of instruments) will

be performed in a next step.

Apart from measuring interpersonal attachment,

our app might also be used as a rating instrument for

assessing agreement and disagreement or sympathy

and antipathy with a given situation in the course of

time. Especially in the case of dynamic process of

changing, i.e. in the observation of therapeutic

processes such as therapists and clients emotional

expression (Peluso et al., 2018) or the classification

of behaviour into normal or abnormal states

(Mabrouk et al., 2018) or movement analysis as

narratively described in Chyle et al. (2018), this app

might be adapted as a rating instrument for processes

within a continuum between two opposite end points.

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