Can Virtual Reality Be Used to Enhance Social Skills Learning in Under-9-Year-Old Children with Autism Spectrum Disorder?
Recent technological advances enabled the usage of Virtual Reality (VR) in more user-friendly ways. VR is a computer-generated real-time simulation of real-world scenarios originally developed for gaming purposes. However, nowadays, the literature increasingly recognises VR as a promising and cost-efficient technology for therapeutic and educational contexts as well, particularly for children with autism spectrum disorder (ASD) (Bellani et al., 2011; Parsons & Cobb, 2011). Virtual environments (VE) used in VR and possibilities to interact with such differ according to hardware, software as well as inputs/stimuli (visual, auditory, touch, motion) used and their complexity. For example, both regular desktop computers with standard input devices as well as more advanced technologies, such as VR head mounts and sensory gloves can be used to create VR settings. Stimuli in VEs can range from simple information cues in an information-restricted environment, for example, to enhance the learning of specific characteristics or relationships between objects, to more advanced cues such as navigating through complex and interactive environments to learn (e.g. social) cues applicable in real-world scenarios.
ASD is characterised by difficulties in social interaction, communication and repetitive/restricted behaviours impeding standard classroom-learning situations (APA, 2013; WHO, 2016). VR offers the possibility to create engaging and easily administrable training programs which allow cross-contextual learning in a safe, controllable environment, for example, to improve social skills (Bellani et al., 2011; Goodwin, 2008; Vera et al., 2007). Such programs suit specifically children with ASD as they allow the manipulation of environment and stimuli. For example, replays are possible in VEs and no face-to-face interactions are necessary which can particularly help children with ASD to rehearse actions and responses in different situation to improve social skills (Bellani et al., 2011; Parsons & Cobb, 2011; Vera et al., 2007). On the other hand, VR is not an established intervention tool when working with children with ASD and no predominant state-of-the-art intervention to improve social skills, including specific hardware and software, has been identified by the literature. Moreover, no review of literate has yet focussed on the usage of VR for social skills learning in ASD in early childhood (under-9-year-olds). Accordingly, it is important to critically review the field and to give implications for practitioners and further research. Hence, in the following, firstly, an overview of the current state of research on the improvement of social interactions and communication behaviours in children with ASD will be presented, and secondly, advantages and disadvantages of using VR with children with ASD will be discussed.
The available evidence supports VR as a promising intervention tool to improve social skills such as interaction and communication skills, but simultaneously lacks depth and rigor. For example, Grynszpan et al. (2014) could identify in their meta-analysis a post-test medium effect size (d=.47) for technology-based interventions for ASD but outline that there is still a lack of evidence for VR and technology-based interventions making comparisons to classical treatments/interventions difficult. Ploog and colleagues (2013) conclude their review of literature stating that computer-aided interventions could help improving ASD children’s adaptive functioning. However, many of the reviewed studies were found to include flaws and limitations in their intervention programs. Generally, VR and other technologies have mostly not yet been validated beyond a preliminary study stage and their application remains limited (Boucenna et al., 2014).
According to Parsons (2015), the research community seems to agree that technologies for children with ASD should be used for main difficulties related to the disorder: communication and interaction skills. Hence, a review of literature by Parsons and Cobb (2011) showed that, similar to non-technological interventions, VR interventions for children with ASD were focussed on operant conditioning or social learning. These methods constitute efficient intervention methods for children with ASD, for example to teach social skills (Schuetze et al., 2017; White, Keonig, & Scahill, 2007).
Studies designed to improve social skills/competence in under-9-year-old children with ASD generally show positive results across intervention with different goals and methods.However, only limited, case-study-based evidence could be identified. For example, in a VR study by Cheng and Ye (2010), ASD children’s social competence improved after a VR intervention and for 2 of the 3 observed children the improvement was persistent also in 10-day post-intervention follow-up tests. In another case study by Herrera et al. (2008) two children with ASD completed tasks in a virtual supermarket thrice a week for a period of 10 weeks. The children showed post-intervention improvement of functional use of objects, pretend play, and understanding of imagination and differing between real and unreal/’magic’ situations improving their ability to participate in social situations. In a study by Manju, Padmavathi, and Tamilselvi (2017), five ASD children’s social interactions could be enhanced by the repeated participation in a VR ball game. Parsons (2015) could show that a collaborative virtual learning suite supported 8-year-old children with ASD to be more reciprocal and collaborative. And Wang and Reid (2013) found that VR training to process objects contextually improved cognitive flexibility and contextual processing of four 6-8-year-olds with ASD. The presented case studies suggest that social skills can be improved through VR interventions, but follow-up research will be necessary to validate this general claim and which specific social skills can be supported by which intervention. Furthermore, most evidence on VR interventions in children with ASD includes children aged 9 years of age and older, also showing improvements in different domains of social skills. For example, Ip et al. (2018) could show that children with ASD aged 8-12 could improve emotion recognition and social-emotional reciprocity after a VR intervention using social scenarios/incidents. In a similar intervention, Yuan and Ip (2018) found children with ASD to improve emotion expression and regulation as well as social adaptation and integration. Although the literature describes a variety of benefits when using VR in interventions with children and adolescents with ASD, there is no congruency in the used methods and more research is needed (see review by Mesa-Gresa et al., 2018)