Impairments in social communication skills and deficient social and emotional competence are thought to be core deficits of children with autism spectrum disorder (ASD). In recent years, several assistive technologies, particularly Virtual Reality (VR), have been adapted to help in the evaluation and training of emotional reactivity and social skills training in this patient population. These platforms can help capture real-time responses to VR social interaction scenes.

In the past few years, VR technology has undergone a transformation by merging with new inexpensive systems like Oculus Rift, and now has the chance to transform from an “expensive toy” for entertainment into a functional technology for clinical research in autism. VR systems have a huge potential as a viable tool for a wide range of clinical and research applications that are not limited exclusively to exposure applications (e.g., for phobias treatment). Rights for Oculus Rift VR system was recently acquired by Facebook and soon it will be in a mass production and widely available to prospective users at a very affordable price.

There is a strong rationale for the integration of VR with real-time psychophysiological monitoring for advanced cognitive and affective neuroscience research. In the area of psychophysiology the technology for non-invasive recording of physiological activity is used to investigate and understand correlates of cognitive processes and emotional states. The use of VR now allows for the measurement of interaction within a more realistic and dynamic 3D environment using precise emotional and socially meaningful stimulus delivery within more naturalistic scenarios well-matched for the specifics of autism research and treatment.

There are only a few reported VR studies in ASD. These studies have found that VR can be utilized in ASD as a learning tool, to teach safety skills, to engage their interest, monitor eye gaze, aid learning of pretend play, and more accurately interpret emotions of VR avatars. It is of interest to note that VR applications were also used in the past as therapeutic tools to help people with autism to recognize emotions and improve their mentalizing (i.e., theory-of-mind) or other businesses in adolescents with ASD. The VR software provided users an opportunity to maneuver an avatar and engage in simplified interactions, such as finding a place to sit, placing an order to a waiter, etc. Parsons et al. (2002,2004) investigated the use of the virtual café in teenagers with ASD having only mild impairments. When compared to matched controls, the ASD group had difficulties maneuvering avatars. The ASD children were reported to engage in the virtual environment as a representation of reality. A qualitative case-study of two adolescents was conducted to further investigate the use of VR in ASD interventions (Parsons et al., 2004) and results indicated that the ASD adolescents interpreted the VR as life-like, while enjoying the task and discussions with the real-life facilitator seated next to them. A subsequent study utilized trained raters to quantify social judgment and reasoning in 6 adolescents using Likert scales at three time points. These preliminary studies have demonstrated that individuals with ASD can use, appropriately understand, enjoy, and practice social interactions in VR settings.

While these previous VR studies showed some promise and perspective, they were limited in several ways. First, the VR software in those studies used technical and non-natural ways to activate feedback on programmed social decisions, e.g., keyboard, mouse or joystick to click on the screen. Second, measurements of social performance over time was limited to few experimental indices and raters evaluations. Measurement of social skills and social competence behavior is difficult, especially since few social measures are published or standardized. A further complication is the lack of sensitive measures of physiological responses to emotional stimuli and social cues. The need for reliable and valid tools to measure social cognition and function remains a challenge, particularly for adolescents and young adults with ASD. Other limitations of prior studies were the absence of psychophysiological measurements, a reduced flexibility of the skills training programs, and an inability from the participants to dynamically interact based on their emotional status. A majority of these VR social skills training studies were limited to children, used simplistic VR scripts.  Only few studies were conducted on adolescents and young adults with ASD, the population that might benefit most from ability to use VR for evaluation and training of more advanced social skills. In addition to the listed limitations, it must be specifically noted that some of the studies cited above were “virtual simulators” on regular 2D screen computers, rather than actual immersive helmet based VR studies, and such studies cannot even qualify to use VR terminology in their titles.

In summary, VR can become a useful tool for conducting controlled experimental trials where precise emotive or social stimuli can be delivered to participants with ASD, while perceptual, attentional, and emotional responses can be objectively recorded using psychophysiological measures such as skin conductance level (SCL), heart rate variability (HRV) indices, respiration rate, electromyogram (EMG), eye-tracking, and other similar peripheral variables, and potentially also electroencephalogram (EEG) and event-related potentials (ERP). Unlike other therapeutic test options, such as role-playing, VR provides for a more realistic experience in a safe, controllable manner that allows for repeated practice and exposure, which is a key element in any training or occupational treatment.  The flexibility of the VR environment, without the added stress of face-to-face interactions with an instructor, may be very appealing to individuals with ASD. All of the above stated advantages of VR-based psychophysiological profiling system suggest that VR may prove to be a more effective platform for functional assessment of social skills, social cognition, emotional and social reciprocity in children with ASD compared to other diagnostic tools. This requires a careful examination and review of the current state of VR applications in autism research and treatment.

References

Parsons, S., Mitchell, P., & Leonard, A. (2004). The use and understanding of virtual environments by adolescents with autistic spectrum disorders. Journal of Autism and Developmental Disorders, 34(4), 449-466.

Parsons, S., & Mitchell, P. (2002). The potential of virtual reality in social skills training for people with autistic spectrum disorders. Journal of Intellectual Disability Research, 46(5), 430-443.

A general review on this subject can be found in Bellani, M., Fornasari L., Chittaro L., & Brambilla, P. (2011). Virtual reality in autism: state of the art. Epidemiology Psychiatry Sciences, 20(3), 235-238.