Author: Bryan P. White
Original Publication: 05/05/2020
Autism spectrum disorder (ASD) is a complex social disorder often marked by a disruption of social skills and the engagement in repetitive behaviors which generally elicits negative perceptions towards these individuals in social settings. Since ASD is generally a disorder of social functions, treatment for the disorder itself can be marked by setbacks and drawbacks due to the difficulty of engaging individuals with ASD as well as potential frustration by the individual’s peers and family. One such solution to this problem is the use of technology that can mitigate the difficulties seen in traditional therapy settings. It has already been documented that the use of technologies such as social media can aid individuals with ASD in social settings because of their inability to intuitively read social queues like facial expressions or recognize emotions. Additionally, alternative therapy mechanisms such as art therapy and game playing have shown success with ASD individuals because these types of therapy focus more on interactions surrounding the activity (e.g., describing the objects in a picture to a friend) rather than the skills development portion of the activity (e.g., actual artistic ability). Improving social and communication skills through these therapeutic techniques can have lifelong benefits for the individuals with ASD in terms of health and career outcomes.
Recently, the use of virtual reality (VR) or augmented reality (AR) has been looked at as a means of using technology to engage in alternative social-therapy mechanisms for youth or young adults with ASD. VR systems have the benefit of allowing therapists to design interactive environments that can be repeated within and across learning subjects (e.g., individuals with ASD). Furthermore, therapists or peers of the subjects can engage with each other in the virtual environments. In this evaluation, I examine two such studies that have measured the effects of utilizing VR in a therapeutic setting for youths with ASD.
Training Emotional and Social Skills in Children with ASD
In this study (Yuan et al., 2018), a group of school children from Hong Kong were chosen to evaluate the use of a VR system on the training of emotional and social skills. In a traditional setting, the use of social stories can be beneficial to children with ASD as a teaching mechanism, but the traditional written or video forms do not have the opportunity for direct interaction of the child. In a VR setting, a child could interact safely with the environment while learning new behaviors without fear of social or physical risk. For example, in the case of crossing the crosswalk and waiting for a red or green light, in a VR setting, the child has no risk of making a social mistake while engaging the road crossing behavior.
While there are multiple types of VR systems available today that could be used for therapeutic interventions, the one used in this study is a four-sided CAVE system – Cave Automatic Virtual Environment (CAVE). The CAVE system allows multiple people to be in the same room while the virtual world is projected on screens around the participants. In the case of a therapeutic setting, this system would more easily allow a therapist to interact and guide the child during the VR experience. The primary participant in the CAVE scenario must wear a pair of headset goggles. The types of scenarios designed in this study included a relaxation scenario, skills-training scenarios, and a consolidation scenario. These scenarios were designed to match typical real-life scenarios a primary school-aged student might encounter in Hong Kong. While 127 students signed up for the study, only 72 total children were included in the final analysis. Exclusion criteria included documented intellectual disability or age filtering (mean age = 106.3 months, or 8.9 years). The sample was predominantly male (88.9%), which is slightly skewed but still representative for increased rates of male diagnoses for ASD in terms of the overall population.
Results of the study included increases on an emotion expression and regulation test and higher social interaction and adaptation after training in the VR scenarios. Parents noted qualitative feedback such as their children being more proactive in their greetings and communication, as well as exhibiting more flexible social behaviors during school activities. In terms of VR specific effects, some students were initially anxious about using the VR goggles, but after coaching with their therapist were able to use the goggles without distress. Trainers played a major role in successfully implementing the training scenarios. Future studies would include looking at more portable systems (the CAVE system is expensive as it consists of 4 projected screens), expanding the sample size, and potentially extending training scenarios to other similar disorders like anxiety disorders or a means to reduce public stigma towards mental disorders in general.
Social Cognition Training in Children with High Functioning Autism
A second study utilizing VR techniques is one from Didehbani et al. (2016) who sought to understand how VR training can enhance the social cognitive function of individuals with high function (level 1) ASD. According to the DSM-V, ASD can split into three levels, or categories. Level 3 is the highest and most severe in terms of functional impairment. Level 3 individuals are not typically self-sufficient and require a high amount of social support in their daily lives. Level 1 individuals, on the other hand, are mostly functional and have some notable ASD traits such as difficulty processing social cues, difficulty inhibiting thoughts, and difficulty regulating emotions. Overall, these social traits can have a negative impact on executive function, even in Level 1 individuals.
Individuals with High Functioning ASD (HFA) might score lower on language and executive function testing, but higher on intellectual abilities. In some cases, this might exclude them from obtaining the social benefits due to a lack of qualifying intellectual disability, making therapeutic interventions for individuals with HFA all the more important. In some cases, individuals with HFA might perform well in social cognitive measures, but this is only due to the practicing of compensatory strategies that tend to break down during more true, spontaneous social interactions. In general, while individuals with HFA might have high intellectual abilities that aid them in academic settings, inhibited social interactions can have negative consequences in school due to the net effect of low self-esteem.
Using VR systems to practice difficult or challenging types of social interactions might benefit these HFA individuals. VR social-skills training has a few benefits in this scenario compared to traditional therapeutic interventions because it can provide a safe, unlimited space to practice social scenarios in, such as practicing sitting down in the lunch room or inviting people to a birthday party. Practicing these behaviors in VR can result in overall reduction in social anxiety. Furthermore, this can also provide dynamic situations by allowing the simulated VR environments to differ slightly between sessions, which allows the individuals to develop more generalized social responses to these scenarios. Additionally, it can also allow the individuals to enter a supportive environment where they can make social mistakes without the fear of rejection. Finally, the use of computer systems in themselves can be rewarding and motivational in nature, which creates an engaging system for an individual with HFA to train in.
In order to study these training scenarios, the authors implemented a Virtual Reality Social Cognition Training (VR-SCT) framework. This framework included scenarios such as greeting friends (skill: starting a conversation), birthday invitations (skill: perceiving emotions), classroom group project (skill: collaborating with others), encounter a school bully (skill: self-assertion & decision making), and engaging in an after-school activity (skill: developing relationships). Individuals participating in this VR-SCT framework were able to develop these skills which were related to the cognitive learning objectives of recognizing behaviors and emotions in others, responding to others emotions, and self-assertion and decision making.
Participants in this study ranged from ages 7 to 16 years and included 26 males and 4 females. The group had an estimated IQ of 112.6 on average. The researchers found that after completing 10 sessions/hours of VR-SCT, improvements were seen in affect recognition (recognizing behaviors/emotions in others), ToM (theory of mind, responding to emotions), and analogical reasoning (a measure of executive function). As a pilot study, the authors concluded that this suggested the feasibility of the VR-SCT method for a social cognitive intervention in children aged 7 to 16 years old. Unlike other VR training systems, this system is dynamic (it is not a “rote” – a repeatable skill trainer), which should allow for more generalized skills to develop (skills are more useful in social settings). The primary limitation of this study, however, is a small sample size, and the authors also note that VR systems lack the ability to display facial expressions, which might impede social skills training.
Comparison of the Studies
Both studies examined here represent small-scale, pilot type studies for the use of VR in cognitive-social interventions in children and adolescents. The first study (Yuan et al., 2018) focused more on emotional skills-building, and the CAVE system allowed for a more direct interaction between the therapist and the trainee. This might have made more sense in this scenario since the average age was around 8 years old. However, the second study (Didehbani et al., 2016) also included younger children, and the training scenarios (VR-SCT) were primarily focused on the scripted nature of the scenarios with the therapists (clinicians) acting as coaches, although in the second study, coaching was more limited in their interactions during the VR-SCT sessions. In both studies moderate positive results were seen, although the expected outcomes were slightly different. In the first study, functional level was not controlled for or assessed. In the second study, only high functioning (HFA) children were evaluated. This suggests that in general, individuals with ASD will benefit from a VR intervention with close interaction between them and a therapist/clinician, and that depending on functional level, individuals might also benefit additionally from more structured, dynamic scenarios that can increase the breadth of social-skills training possible. These results suggest that the use of VR technology in ASD therapeutic interventions can be a very broad range of diagnostic procedures and serve as a good addition to the “non-traditional” set of ASD social-cognitive therapies.
Didehbani, N., Allen, T., Kandalaft, M., Krawczyk, D., & Chapman, S. (2016). Virtual reality social cognition training for children with high functioning autism. Computers in human behavior, 62, 703-711.
Yuan, S. N. V., & Ip, H. H. S. (2018). Using virtual reality to train emotional and social skills in children with autism spectrum disorder. London journal of primary care, 10(4), 110-112.