According to the Merriam-Webster dictionary (2018), the definition of virtual reality is “an artificial environment which is experienced through sensory stimuli (such as sights and sounds) provided by a computer and in which one’s actions partially determine what happens in the environment”. Since 1987, virtual reality, also known as augmented reality, has become increasingly popular as a treatment approach in different aspects of healthcare (Mesa-Gresa et al., 2018). For instance, occupational therapists have used consoles like the Nintendo Wii as physical rehabilitation for elderly clients with stroke, as well as development of skills in children with various types of disabilities (Naumes, 2013; Aran et al., 2017).
As technology and virtual reality are becoming increasingly accessible, studies are beginning to incorporate virtual reality as an intervention for populations on the autism spectrum, particularly to improve their social skills and social interactions (Cheng and Jun, 2010; Ke and Im, 2013; Lorenzo et al., 2016; Ip et al., 2018). As such, this essay will discuss the strengths and limitations of using of virtual reality to improve social skills for children and adolescents diagnosed with Autism Spectrum Disorder (ASD), and the potential for future research of the use of virtual reality as an intervention technique.
Description of Autism and Virtual Reality
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes ASD as “persistent deficits in social communication and social interaction across multiple contexts”, and “restricted, repetitive behaviour, interests, or activities” (American Psychiatric Association, 2013). All studies reviewed have included the criteria for children and adolescents to be under the age of 18 years and have a diagnosis of ASD, targeting the subjects’ difficulties in the social aspect. This includes social interaction with a communicative partner as well as dealing with daily life situations, such as crossing a road and responding to emergency situations (Parsons and Cobb, 2011).
Virtual reality systems and technology have improved over the course of time, where head-mounted gear has reduced in size or has been rendered unnecessary due to other options of capturing data (Ip et al., 2018). Various types of virtual reality systems are used in the studies, but the common systems used are desktop-based programs, which use desktop computers, and Immersive Virtual Reality Systems (IVRS) or collaborative virtual learning environments (CVLE), where multiple users are able to interact within the virtual environment to provide feedback or support to the learner (Cheng and Jun, 2010; Ip et al., 2018).
Strengths of using virtual reality with children and adolescents with autism
Tissot and Evans (2003) established that people with ASD learn best with visual supports and structured teaching, rather than auditory instruction. They process and recall visual information better, and often have difficulty deriving meaning from verbal communication. Similarly, Parsons and Cobb (2011) maintains that using visual materials draws on the learners’ strengths, which makes virtual reality a potentially valuable educational tool for children with autism. Grandin (as cited in Lorenzo et al., 2016) further supports this by claiming that visual supports can affect social skills, both directly and indirectly. However, Ip et al. (2018) warns that such stimuli should be adjusted accordingly to avoid overwhelming the learner with excessive visual and verbal input.
Many studies have highlighted that using virtual reality allowed the teaching of appropriate social and emotional behaviours in a safe and controlled environment (Parsons and Cobb, 2011; Lorenzo et al., 2016; Ip et al, 2018, Mesa-Gresa et al., 2018). Furthermore, there is opportunity for repeated practice in various social situations, which allows for errorless learning. In Lorenzo et al.’s (2016) study, the equipment used was able to detect changes in the learner’s facial expressions, which then prompted the program to vary the interacting character’s responses to elicit the appropriate response from the learner. This helps the learners to develop an understanding of appropriate and inappropriate behaviour being displayed.
Parsons and Cobb (2011) call attention to virtual reality as a highly engaging motivator for both learners and families to participate. This is also dependent on the type of virtual reality system, comparing desktop-based programs to IVRS. Firstly, the likelihood of using a desktop-based program might be preferable to an IVRS, which are extremely expensive to obtain. Secondly, a desktop-based program is more accessible for families that already own a personal computer and can easily be installed to practice at home. Mesa-Gresa et al. (2018) goes on to state technology, such as the Nintendo Wii, are relatively low-cost, readily available, and accessible to caregivers. They further elaborate that the engaging nature of using virtual reality also supports learners to develop longer attention spans and focus in completing tasks in the program, as well as adherence to the program.
Lorenzo et al. (2016) also concludes that using an IVRS is more beneficial in the generalisation of skills learnt during the intervention, compared to other types of virtual reality systems. This conclusion is similarly agreed to by Parsons and Cobb (2011), who state that the authentic state of a virtual environment promotes better generalisation and enhanced transferability of skills into the natural setting.
Developing an individualised virtual reality program may also present as a strength and a limitation. Having to work in a multi-disciplinary team allows researchers to draw input from different people who interact with these children, which helps in the personalisation of the program and the characters that interact with the subject’s avatar. For example, Ip et al. (2018) received regular feedback and updates from the learners’ school teachers and parents to customise the social situations to suit the learner’s needs, as well as to track their progress. However, this may also be time consuming as well as cost incurring, which may eventually demand more man-power for studies with larger experimental groups.
Limitations of using virtual reality with children and adolescents with autism
Despite the evidence surrounding the positive effects of using virtual reality, there are many similar factors that contribute to the limitations of each study. A frequently occurring theme in the limitations of these studies is the lack of generalisation in the population, which is contributed to by multiple factors (Parsons and Cobb, 2011; Ke and Im, 2013; Lorenzo et al., 2016; Ip et al., 2018; Mesa-Gresa et al., 2018). The most common limitation identified in all studies are the small sample sizes of subjects. Most studies either used a single-subject design or small group sizes. According to Ke and Im (2013), studies involving specific populations, such as children with autism, claim to be “extremely difficult, if not impossible” to obtain a large sample.
In addition, some authors have also identified the short time frame in which the studies were conducted. For example, one of the studies with the shortest intervention time frame was by Cheng and Jun (2010), who conducted their experimental study over a course of 17 days, with their maintenance phase and follow-up scheduled within 3 days of the final experimental session. Additionally, learners should be given time to explore the system and be familiarised with the user interface of the program, as observed by Ke and Im (2011).
ASD presents with various levels of severity and development differs for each person. Most studies have mentioned that most of the subjects chosen were children with high-functioning autism, and children between the age of seven and eighteen years old. It is likely that older children as well as higher-functioning children with ASD are better able to grasp using the equipment and following instructions, compared to younger and less able children (Parsons and Cobb, 2011; Mesa-Gresa et al., 2018). Prior to this, Corsello (2005) suggested that early intervention for children with autism led to better outcomes compared to older children. Thus, there is a delicate balance between finding the right age, understanding, and level of severity of autism, in order to adjust the level of complexity of using virtual reality systems as intervention.
Potential for further research
Some studies use control and experimental groups to compare the effectiveness between different types of virtual reality systems, which operates under the assumption that all learners and stakeholders have access to these systems in school or at home. However, there does not seem to be any comparison studies to existing social skills training methods, such as social stories. Further research could be done in this area to provide a clearer distinction between both methods.
In addition, only a few papers (Lorenzo et al., 2016; Ip et al., 2018; Mesa-Gresa et al., 2018) mention involvement of families and school teachers in the personalisation of the programs, according to the learners’ collective needs. However, none mention the opportunity of educating and coaching siblings and parents as well as other stakeholders, such as teachers, to supplement the use of virtual reality intervention systems in different contexts. Thus, future research could also implement such training for parents and stakeholders, to help with generalisation of these skills learnt into the natural environment.
Conclusion
In summary, virtual reality, along with technology, has been continuously developing to resolve various issues. These range from the types of social skills and social situations that children have the most difficulty in to the setup of hardware and software that can be used for different children. The literature has proven that virtual reality has demonstrated many positive effects in teaching children and adolescents to improve their social skills, especially for teaching skills that would otherwise compromise safety in the natural setting. Then again, due to the divergent nature of ASD, and the availability of resources and expertise, there is no one-size-fits-all program that can be used with the generalised population of children and adolescents with ASD. Despite this, virtual reality has immense potential to be a useful intervention for teaching social skills in children and adolescents with ASD.
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