Critical Thinking

Dawn Autism Spectrum Disorder and will determine whether


Interdisciplinary Studies Project

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Joshua Olsberg

5th, 2018

Virtual Reality be employed as a future learning tool to improve social
interaction performance, reduce phobias and help daily living skills, such as
facial recognition with children and adolescents with high and low function

This research paper will cover the use
of virtual reality with children that are diagnosed with Autism Spectrum
Disorder and will determine whether or not virtual reality is an actual
powerful tool that may help an individual that suffer from this condition.

Spectrum Disorder (ASD) is a neurological condition. The traits of this
condition are vast and are characterized by repetitive behaviors, impaired
non-verbal and verbal communication, and challenged with social skills and
interaction. Individuals with ASD take longer than their peers to acquire
social and self-care skills without assistance. One in eighty-eight children in
the United States falls under the Autism Spectrum Disorder. ASD patients are
also divided into two categories; High Functional Autism (HFA) and Low
Functional Autism (LFA). HFA appear to be similar to their peers as they can
communicate by using a spoken language, are more aware of social conventions
and may even participate in a classroom setting, whereas LFA usually
communicate by using technology or picture boards instead of a spoken language
and their disability is more obvious and are less likely to be included in a
typical classroom. Although ASD is divided into these categories, one must
always bear in mind that individuals with this disability may react differently
in different situations and both categories may be triggered if they are not
feeling in a safe environment. In both cases “ASD has a significant economic
and social impact due to its high prevalence, the absence of specific
therapeutic intervention, comorbidity, outcome, and impact on families.
Discarding medical costs, intensive behavioral interventions for children with
ASD are estimated to cost between $40,000 to $60,000 for a year for each child
in the United States, which is an economic burden for both parents and the
government. (17 marco) That is why virtual reality has gained a particular
focus because it will reduce therapy cost drastically.

Virtual Reality (VR) addresses the possibility
of creating a computer simulation of real environments and provides safer
learning experiences for individuals with ASD. (marco). Treatment and Education
of Autistic and related Communication Handicapped Children (TEACCH) emphasis on
how important structure and repetition is during a therapy session, this also
includes a safe environment that does not overwhelm children with ASD. Virtual
Reality (VR) offers the potential for presenting learning tasks that are
realistic, but that is presented within a simplified and safe environment. VR
settings offer a greater benefit to an individual with ASD as they can
stimulate a real-world scenario in a controlled place. VR environments range
from three-dimensional environments that use a joystick and a home computer
through to fully immersive environments with a headset display, body tracker
and 3D hand controls which are now available for only several hundred dollars
per unit.  Virtual Reality therapy
started in 1990 and till today more advanced and sophisticated VR environments
are created in order to allow the individual with autism to feel safe during

During the research for this paper, the
interdisciplinary subject that covered this topic were Education, Engineering,
Health Science, and Psychology. The following paragraphs in this research paper
will be a brief narrative on some authors that covered the interdisciplinary
fields mentioned above.

Professor, Anastassios Tassos
Mikropoulos is the Dean of the School of Education and Director of the Educational
Approaches to Virtual Reality Technologies. His discipline is focused mostly on
Information & Communication Technologies (ICT) and Virtual Reality in
Education. He wrote various research articles, eight books, participate in
scientific talks and also created several educational software.

Dr. Wass gained a first-class
undergraduate degree in Experimental Psychology at Oxford University. He did
his Ph.D. at the Centre for Brain and Cognitive Development, Birkbeck, and his
postdoctoral research in Cambridge, at the Medical Research Council Cognition
and Brain Sciences Unit. He appears regularly on English television, such as
BBC News and radio such as BBC Radio Live, and has given talks at the Royal
Institution. His work also appears regularly in national newspapers in England.

Marco Simoes is a Professor at the University Of Coimbra, Portugal in the
Department of Informatics Engineering. He wrote several articles and his main
focus is on virtual reality, 3D and brain-computer interface.

Yiju Cai is an Associate Professor with
the College of Engineering, Nanyang Technological University, Singapore. He has
a joint appointment with NTU’s Institute for Media Innovation. Yiju Cai has a
Ph. D training in Engineering, MSc training in Computer Graphics &
Computer-aided Geometry Design, and BSc training in Math. He has been doing
interdisciplinary research especially at the intersection of interactive and
digital media, and biomedical sciences.

Dr. Daniel J. Cox is a Professor of
Psychiatric Medicine and Professor of Internal Medicine at the University of
Virginia in Charlottesville. His research interests are diabetes: hypoglycemia,
cognitive deficits, driving; pediatrics: encopresis, enuresis, constipation;
driving impairment with acute and chronic medical conditions; and
attention-deficit/hyperactivity disorder. ( 

Dr. Morag Maskey currently works as a
research assistant in the Institute of Neuroscience, at Newcastle University.
Dr. Maskey published two articles on autism however her professional exposure
was mostly made on the third eye neurotechnology which will be mentioned in
this research paper.

Amy Swanson, M.A., is a research and
training coordinator at the Vanderbilt Kennedy Center. She received her
bachelor’s degree in Psychology from Berea College and earned a Master’s degree
in Social Science from the University of Chicago. She has ten years of
experience focusing on technology-based intervention and training mechanisms to
serve both pediatric health care providers and families of young children with
autism spectrum disorder. In her current role, Swanson coordinates training on
the Screening Tool for Autism in Toddlers and Young Children (STAT), Autism
Diagnostic Autism Schedule (ADOS-2).

Dr. Kwanguk Kim is a postdoctoral fellow
at the M.I.N.D. Institute and a member of Dr. Peter C. Mundy’s Social Attention
and Virtual-reality Laboratories. His previous and ongoing research centers
around the use of virtual reality as a tool to understand psychopathology such
as autism, schizophrenia, obsessive-compulsive disorder, and personality
disorder, the human-computer interaction (HCI), and the treatment of children
with autism spectrum disorder. (

Children with ASD both HFA and LFA have
difficulty in recognizing facial emotional expression such as happy, anger,
sad, disgust, surprised. Amy Swanson and her colleagues developed an innovative
VR-based facial emotional expression presentation system that allows monitoring
of eye gaze and physiological signals related to emotion identification in a
synchronous manner. The major objectives of their work were “to develop an
innovative VR-based facial emotional recognition system that allows monitoring
of eye gaze and physiological signal, perform a usability study to demonstrate
the benefit of such a system in understanding the fundamental mechanism of
emotion recognition.” (Swanson et al). The eye gaze apparatus measured the
dilation of the pupil, the fixation duration and the rate of blinking, whereas
the physiological was monitored by electrocardiogram, pulse plethysmograph,
skin temperature and galvanic response. Apart from the skin temperature
monitoring, all other are associated with the sympathetic response of the
autonomic nervous system. Thus when an individual is exposed to an external
factor such as stress the sympathetic nervous system will automatically
increase the heart rate, raises blood pressure and skin temperature. During
their investigation, the emotional expressions were “enjoyment, surprise,
contempt, sadness, fear, disgust and anger and all emotions had four levels of
arousal. All children participating in this research were HFA with average to
above average intelligence and were all drafted through other clinical
programs. When the HFA subject was shown the emotional expression through an
avatar, the gaze pattern concluded that HFA focused more on the forehead area
and less to the mouth area and had an abnormal eye blink and lower pupil diameter
than the control group. From this experiment, the results did not indicate a
large difference between the HFA and the control group as they did recognize
the facial expression, however, the results of the eye gaze were significantly
different because the HFA focused more on the forehead area, paid less
attention to the eye area than on the whole face. This research concluded that
children with ASD spent more time examining the facial expression prior to
responding and they were often less confident in their rating (Bekele et al).
Using this VR system, the findings were “useful in understanding heterogeneous
deficits individuals with ASD often display in processing and responding to the
nonverbal communication of others”. (Bekele et al). Another similar research to
study emotional responses and social motivation in children with ASD was
conducted by Dr. Kim. “The paradigm used in this study provided a measure of
preference for interpersonal distance exhibited by children with higher
functioning HF ASD in a task involving their ability to recognize different
types and intensities of emotion expressed by an avatar”. (Kim All
participants, same as the research mentioned above had already received a
clinical diagnosis of HFA. The facial emotions and the intensity level that
this research had were very similar to the research above. The facial emotions
were happy, fear, anger, disgust, sadness, and surprise. However, unlike the
other experiment, the research had two avatars with both genders. The participants
were not monitored using the eye gaze and physiological signals. The HFA
participants were instructed to select the best emotional word from a list that
matches the avatar expression. Also, the HFA participants were instructed “to
use a joystick to move close to, or far from, the avatar as they would if the
situation was occurring in real life. (Kim et al). This research concluded that
the child with HFA did not have a tendency to move towards someone that is
happy or to move away from some that are angry when compared to the control
group. On the other hand, both HFA and the control group recognized the happy
emotion. Kim et al concluded that “children with HFA may not experience the
same level of rewards and approach behavior in response to positive affect or
the opportunity to share positive effect with other people”. In her research
paper, Olga Mantzios et al. mentioned a different experiment which included
avatars in teaching and assessing of facial emotional expressions. The game she
mentioned in her research developed by Miranda et al. is known as “Life is
Game” and it is designed for children with ASD. This game encourages the
children with ASD to “identify a specific expression from a set of presented
expressions regarding full faces, half faces or mixed faces of avatars in comic
cartons format, to construct a facial expression in order to match the emotion
and to modify the expression of an avatar according to instructions given.”
(Mantziou et al). The children suffering from ASD had a positive relationship
between the use of the game and the development of facial emotion recognition
skills in real life. (Mantziou et al). However, one must also mention that the
test subjects had HAF and not LAF. In fact in another case study of 30 children
with HFA and four with LFA that also used a single computer with an avatar that
had four facial expression happy, sad, angry and frightened, the children with
HAF managed to use the game at a level higher, whereas the children with LAF
had difficulties in reading the avatars emotions (Mantziou et al). In fact the
“child with LAF did not interact at all with ICT modalities, but preferred only
face to face interaction. (Mantziou et al).

Virtual Reality is also used to treat
and reduce specific Phobias in young children with ASD through a VR
intervention.  In her research Maskey et
al developed and evaluated a unique treatment combing cognitive behavior with
graduated exposure in a Virtual reality environment (VRE). During a research on
fear in ASD children, 41% of the children were scared and had an unusual phobia
such as toilets, buses, cars etcetera. 
As explained previously, the cost to take care of a child with ASD is
fairly expensive and time-consuming. Also, not enough therapists are available
for dealing with ASD children that suffer from anxiety. Therefore, “there has
been interesting in adapting treatments for anxiety for people with ASD, with
much of this work based on the principles of cognitive behavior therapy
(CBT)…which is particularly important given doubts about whether ASD specific
social and cognitive impairments would render CBT inaccessible”. (Maskey et
al). Virtual Reality Environment will increase the accessibility of specific
fear in a controlled environment, which will then help people with ASD to
overcome their phobia. Also “newly learned skills can be rehearsed and
reinforced in a safe and controlled setting” (Maskey et al). With the
collaboration of the staff at Third Eye Technologies Maskey et al developed a
VRE called “the blue room”. “The blue room uses audiovisual images projected
onto the walls and ceilings of a 360 degree seamless screened room.
Participants are not required to wear a headset or googles and can move around
the room freely, interacting and navigating through the scenario at their own
discretion. (Masket et al). The selected candidates were screened by Masket and
a psychology assistant. Masket and the psychology assistant met with the ASD
child and their parents in the comfort of their house, where they discussed the
specific phobia of the child. The psychology assistant “explored with the ASD
child the possible steps to full exposure, including starting with short blue
VRE sessions and increasing the length of exposure or increasing aspects of the
scene.” (Maskey et al). During these home visits, the psychology also prepared
the ASD child and introduced relaxation techniques such as deep breathing, and
how to use positive coping when experience anxiety. These 45 min session were a
good foundation before introducing the ASD child to the blue room as they
mentally prepared the child. The Blue Room therapy sessions were delivered by
the psychology assistant, overseen by a consultant clinical psychologist.
(Maskey et al). Unlike other VR mentioned in the above research, this research
mentally prepared the ASD child. In the first steps when entering the room, the
child is not immersed directly in his phobia virtual reality environment. On
the contrary, the trial starts with relaxing sounds with the therapist coaching
the ASD child through breathing and stretching exercises. The VRE will only
start when the ASD child is ready to proceed. When the ASD child is mentally
prepared to start the exercise, the VRE scene that will appear will be on a low
anxiety level. For example, if the ASD child is scared to ride a crowded bus
the scene would start with just a bus stop and an empty bus. The level will
increase after the ASD child is confident enough to proceed to the second
level. The psychologist is in the blue room too and is also evaluating the body
language and response of the ASD child to proceed further. Most importantly the
parents were also able to watch their child from another room and monitored
their improvement and even learn the techniques that the psychologist used.
Nine ASD children were chosen for this experiment and only one did not improve
his phobia condition. Four of the ASD children completely overcame their phobia
and normalized and these effects were maintained six months, a year and a year
and a half post-treatment (Maskey et al). 
“The major change for the majority of the children in this study was
their functional ability to handle the real-life situation they were previously
afraid of”. (Maskey et al). Maskey et al concluded that modified CBT can be
effective for young people with ASD and high anxiety…CBT techniques delivered
by a therapist in an immersive VRE has potential to be developed as a widely
available treatment for phobias in children with ASD. This is because the VRE
with CBT offers a greater degree of control over the stimuli than with CBT
alone…the therapist and child have a common point of reference for therapeutic
work, without the need for verbal exchange and because VRE taps into a number
of strengths and characteristics, and interest of those with ASD.

Apart from the above VRE, the other
research that I found interesting was the design and development of a virtual
dolphinarium for children with autism. This research was done by Yiyu Cai et
al. In his research Cai et al also emphasis that “intervention and treatment
methods for children with autism are rare and costly and often involving a
trained therapist to work one-on-one or small group sessions for a 40 hour per
week therapy”. The dolphin-assisted therapy is not always available and not
affordable to many. Only thirty-two ASD children attended this therapy in a
span of four years. This therapy consists of the child with ASD to interact in
the pool with a real pink dolphin. There are steps before the child with ASD
can enter the pool. The child same as the VRE blue room mentioned above is
mentally being prepared using the following procedures. The ASD child watches
various dolphin videos and listen to dolphin sounds and feels a model dolphin
made of fiberglass. “Claims of benefits from this form of autism therapy
include better attention, increased somatic awareness of the surrounding
environment, improvement in gross and fine motor skills and nonverbal
communication, especially in using hand gestures”. (Cai et al). However, this
therapy also includes a degree of risks, because at the end of the day the
dolphin is a very strong animal and even though these dolphins are well trained
they can snap at any point in time during the therapy. Therefore Cai and his
team decided to “design and development a virtual dolphinarium to assist
children with autism to learn nonverbally communication through gesturing. The
difference between the real dolphin therapy and the virtual dolphin interaction
(VDI) is that during the VDI the ASD child does not swim with the dolphin but
rather is the dolphin’s trainer, which will improve their motor skills and
learn nonverbal communication through hand gesture control. This VDI was
developed inside an immersive room in Singapore. This immersive room is “an
infrastructure design for all NTU researchers to visualize and simulate any
objects or purposes” (Cai et al.) Same as the other research in the immersive
room conducted by Maskey, “a video of the real dolphin training performance is
shown to the ASD children before they are invited to the immersive room. (Cai
et al.)  To allow the child with autism
to do gesturing at poolside, they had to stand close to the screen wearing a
pair of 3-D shutter glasses to enable an active stereographic view during the
interactive program. (Cai et al.) When they successfully command the dolphin to
do a command, several affects where activated such as water and dolphin sounds.
The initial study involved of randomly selecting fifteen children with autism
from the thirty-two children with autism that participated in the real dolphin
therapy. However, unfortunately, from this study out of the fifteen
participants, only eight participated without any problems and easily learned hand
gestures, whereas the other participants encounter a problem with the immersive
room and the 3D google, because they were not feeling in a safe environment
even though they were accompanied by their parents.

In conclusion from the above research
from different fields, one may conclude that the main goal, irrelevant of the
field is to find a better way to help children with autism spectrum disorder by
using virtual technology. Virtual technology is capable of providing a wide
range of situations and scenarios that can be used to teach and help children
with HFA and LFA in a safe environment where the child will feel at ease. Not
all the results of the above research were a success, yet I firmly believe that
virtual reality will help children with autism to improve their condition and
will be used as a future learning tool to improve social interaction
performance, reduce phobias and help daily living skills, such as facial
recognition. However, although some results were promising, further studies
need to be performed especially for children with LFA because from the above
research the greatest result was achieved by children with HFA. 









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