Virtual Reality in Autistic Spectrum Disorder: From Second Life to Real Life

Andrew N. Wilner, MD; Dana I. Allison


May 10, 2023

This transcript has been edited for clarity.

Andrew N. Wilner, MD: Welcome to Medscape. I'm your host, Dr Andrew Wilner, reporting virtually from the 2023 American Academy of Neurology Meeting in Boston, Massachusetts.

Today I have the pleasure of speaking with Dana Allison about her presentation, "A Survey of Virtual Reality Interventions for Autistic Spectrum Disorder Therapy: A Neuroscience Perspective." Dana is a medical student at the University of Vermont Larner College of Medicine.

Greetings, Dana. Thanks for joining us.

Dana I. Allison: Thank you, Dr Wilner, for having me.

Wilner: I'm excited to learn more about your presentation, so why don't we start? Give us your background and how you got interested in this topic.

Allison: I was introduced to autism in the summers that I spent volunteering at a Head Start program. At that time, I was working with preschool-aged children and I became fascinated with the fact that some children with autism spectrum disorder (ASD) were more interactive and social whereas others were more restrictive.

I combined that with my background in computer science and augmented reality/virtual reality. I thought that maybe we can use this virtual tool to help children on the spectrum at this critical age to obtain the social and communicative skills necessary for them to be able to thrive as adults.

How Was ASD Defined?

Wilner: In your presentation, how did you define autism? As you mentioned, it's a spectrum, so which children did you choose?

Allison: When I was surveying the literature, many of the studies focused on high-functioning autism, both genders, and from ages 6 to 16 years.

Wilner: Tell us about virtual reality. When I think about virtual reality, I think about some fancy headset and a guy walking through a swamp or outer space. How would you apply this with these children? Do they wear some sort of headset or is it a screen?

Allison: There were a few studies that would give the child a device that they would wear on their head in a controlled, safe environment. The clinician would also use the device to be able to interact with the child in a virtual environment. This was helpful for the children because it provided a safe space for them without distraction or any kind of stimuli that would induce anxiety, so that they could focus on the critical social skills and be able to reinforce that without any disruption.

That is one element of it. Another element is to have the child look at a screen where an embodied agent or a conversational agent would interact with them without the device. The program would be designed by the computer scientist and the clinician to be able to provide the child with cues where they can interact accordingly. With that, they would be able to quantify the number of positive interactions to be able to understand how this population responds with the technology.

Virtual Reality as Therapy or Diagnostic?

Wilner: You reviewed studies that had all used virtual reality in one way or another. Was the primary goal of these research studies diagnostic? Was it to understand the children better as to what they could do and what they couldn't do, with strengths and weaknesses? Or was the primary goal for it to be an adjunctive therapeutic modality? There's only so much one-on-one that the teachers can do. Is it a therapy? Was that the plan?

Allison: I selected four articles. Three of the articles were used to train the children to acquire social skills and to be able to recognize facial expressions within specific contexts. Only one of them was, in a way, assessing how interactive a child could be in the context of diagnosis to be able to convey a baseline.

Wilner: Was there any comparison with neurotypical children? In other words, were children on the autistic spectrum more likely or less likely to respond to virtual reality? Was there any information about that?

Allison: Yes. The outcome of one of the studies that I included in my investigation basically conveyed that children with ASD were preferably interacting with the technology compared with their control counterparts.

Wilner: That's very exciting because part of the difficulty in teaching children with autism is getting them to engage, right?

Allison: Yes. 

Second Life and Real Life

Wilner: They're self-engaged in whatever it is they're doing and not necessarily interested in engaging with the teacher, colleagues, or peers. If you have a modality where they want to engage with it, presumably that would be a good entry point for teaching. Was that your assessment too?

Allison: Yes, that was my assessment. An example would be a software program called Second Life. In this software program, the child would be able to take on an avatar within a virtual-reality environment.

The clinician would also take on an avatar, and a second clinician would also take on an avatar. Clinician 1 would be able to give the child instructions about where to be in this environment and what exercises to complete, whether it's maintaining the relationship, conflict resolution, or things of that sort. The second clinician would function as a decoy.

It would provide this safe, realistic environment where they're able to control for many of the factors that might interfere with optimal skill acquisition. For the most part, it yielded positive feedback and it shows great promise.

Wilner: I recently did an interview with a company in Australia that created a virtual-reality system for children who are requiring medical procedures, such as insertion of an IV or some uncomfortable kind of hospital situation. They found that it worked very well. It was based on the same idea, where it gave them a space and they had animated characters.

Here comes a butterfly. It's going to give a little pinch, and that was the IV. It seemed to really relax the kids. To me, it's a little antithetical that you can get a better response virtually. You would think there would be nothing better than one-on-one with a human being.

It may be for children on the spectrum that you can actually get their attention better by removing that or at least putting some distance between the real human being and the child, with the hope that the skills that are acquired virtually would then be transferable at some point to the real world. That's the goal, right?

Allison: I agree. Yes, I'm happy that you provided this example. That was also another one of the studies that I included in my investigation, where they were surveying children with ASD and their ability to self-regulate their emotions in the context of anxiety-producing triggers. With that, there was a pre-survey and a post-survey done. Virtual agents would basically expose the child to increasing levels of their trigger.

Over time, the child was able to understand the cues and the context, and they reported lesser levels of experienced anxiety and greater confidence in their ability to manage those same scenarios. This was quantified over a 6-month follow-up to a 12-month follow-up and a 16-month follow-up, with lasting results. I'm happy that this technology is able to elicit effective and lasting results.

Wilner: So it really worked in the real world.

Allison: Yes, it did.

Wilner: That's pretty exciting. You are a fourth-year medical student. You are ready to go out into the real world yourself, right?

Allison: Yes.

Wilner: Is research into autism going to be part of this or are you not sure yet? Do you have another direction?

Allison: I'm happy that my work was recognized at this conference. That provides me with the encouragement to continue on this same line of research. My preceptor, Dr Patricia Prelock, and Dr Jeremiah Dickerson are the experts here in autism at UVM. I was fortunate in being able to connect with them.

They provided me with the necessary resources so that I can understand the clinical portion of autism to understand how this technology can further evolve and provide us with better outcomes, in a sense.

Wilner: Soon-to-be Dr Dana Allison, I want to thank you very much for sharing your research with Medscape.

Allison: Thank you so much for having me. Thank you, Medscape.

Wilner: I'm Dr Andrew Wilner, reporting for Medscape.

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