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Revisiting VR training in developmental disorders, is it a friend or foe? A scoping review

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25 February 2024

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26 February 2024

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Abstract
Background: Immersive and non-immersive VR technology has been increasingly employed in training. This has encouraged physicians working in skill development to try using it to improve the learning, emotional recognition, and social skills of various disorders. This study aimed to explore the controlled trials employing VR in autism, ADHD, and dyslexia. Methodology:A literature review has been conducted, on PubMed, Scopus, and Web of Science. Any controlled trial in the pediatric age group, involving the comparison of VR training with other types of therapies in autism, ADHD, and dyslexia was included. Results:Only four controlled trials were identified, comprising a total of 208 patients, with ages ranging from 6-16 years. Out of these studies, two involved patients with autism, one with ADHD, and one with dyslexia. VR was successful in improving emotional recognition but not social interaction in autism. All trials did not mention thoroughly possible complications of prolonged use of VR. Conclusion: Despite being a promising technology, there is still a long road to prove the validity of using VR in skills development. Few controlled trials have been tailored to explore VR advantages over conventional training and therapies, most of them have a limited sample size, a short training course, and no mention of possible setbacks, such as ocular effects and social isolation.
Keywords: 
Subject: Medicine and Pharmacology  -   Medicine and Pharmacology

1. Background:

Several difficulties are faced by atypical children in education as pedagogic settings are developed for typical-developing children. It highlights the importance of experiencing the learning process of children with learning disabilities or cognitive and perceptual impairments, as they may find it challenging to comprehend abstract ideas or representations. [1] Virtual reality (VR) has shown great potential for training life skills in people with intellectual disabilities. By creating immersive and interactive simulations, VR can provide a safe and controlled environment for individuals with intellectual disabilities to learn and practice real-life scenarios in a way that is impossible with traditional training methods. This can improve social, cognitive, motor, and functional skills, ultimately enhancing their quality of life and independence. [2,3]
VR holds several qualities in the development of skills; unlike human tutors, computers are patient, virtual worlds are safe, and can allow learning away from several risks in the real world. However, finally yet importantly, VR can provide learning regardless of any language and away from the decoding of letters and numbers; the latter can bridge the gap of patients with dyslexia. [4]
Despite the many advantages VR has proven, VR does not come without a risk. One of the most important drawbacks currently explored by VR technology is breeding media addiction. This media addiction can slowly result in another problem, which is triggering socially isolating behavior. [5]
Our review article aims to explore the fields of learning difficulties, where VR has been tried, and the outcomes of these trials as well as the drawbacks that can result from excessive use of this innovative technology.

2. Methodology:

-Scientific libraries:
We conducted a computer search for literature listed on PubMed, Google Scholar, Scopus, and Web of Science.
-Keywords and inclusion criteria:
We employed the following keywords: Virtual reality; learning difficulties double arm clinical trials, pediatric age group.
The inclusion criteria were double-arm randomized clinical trials performed on pediatric age groups presenting with one of the following disorders: Autism, ADHD, or dyslexia, to compare the therapeutic effect of VR (immersive and non-immersive) training on their cognitive and social skills to another form of conventional behavioral and skill training.
We excluded all small-scale studies such as case-control and feasibility studies and single-arm or uncontrolled trials involving the same disorders.
-Outcome parameters included: the age range of participants, the scope or area of training, the type of VR used (immersive via head-mounted device or non-immersive), the method to which VR is being benchmarked, and a brief description of results.

3. Results:

-No statistical analysis was conducted, but rather study results were presented in the form of table summarizing the parameters for each included study.
-Results of the included studies:
We identified several systematic reviews on ADHD and autism, utilizing results of studies on VR in these respective disorders, notably that of Li and colleagues and Dechsling et al. [6,7] They both recognized that studies included in their work, are mostly small-scale case-control or feasibility studies, or to the best single-arm randomized trials. Another review on ADHD showed essentially the same pattern of the included studies. We explored the reports covered by these reviews using our inclusion and exclusion criteria, to determine which of them qualify for our review.
After careful examination, we identified two studies on Autism [8,9], and one on ADHD [10], that fulfill our criteria of selection, to which we added one randomized controlled trial in the context of dyslexia. [11]. Prisma flow chart in Figure 1 shows the selection process implemented in this study.
Regarding autism, Frolli et al [9] limited the scope of their work to the improvement of emotional recognition, while Ip et al extended their testing to adaptive skills. Both studies showed that VR might be superior to conventional training in improving emotional recognition, while conventional training was proven better in the context of adaptive skills. [8]
In patients with ADHD, Biolac used a computer-based test, to compare the number of omission and commission errors across the study groups. While the occurrence of omission errors has been unchanged between the two groups. [10]
In dyslexia, the processing speed index markedly improved in patients under VR training. [11]
Table 1 discusses the results of the 4 included trials.

4. Discussion

During the primary search, to elaborate on this review, we had the initial impression, that VR has been extensively applied and tried in skill development in various disorders; abstracts and conclusions of most of the explored studies tend to showcase the positive effect of this new technology, without acknowledging the fact that of the studies are small-scaled, single-armed, without any control arm. Nevertheless, most of the mentioned reports in systematic reviews do not mention monitoring complications of this technology, as if it comes with pure benefit. [6,7,12,13]
In this study, we identified a total of 4 controlled trials on skill development in autism, ADHD, and dyslexia; comprising a total of 208 patients, a sample size that does not match a very large population of interest. [8,9,10,11]
Moreover, the age ranged in the four studies from 6-16 years, which means that VR technology is still not extensively available for early training of patients with learning difficulties. This makes the use of VR unfavorable as it is increasingly recognized that early identification and early childhood intervention can improve cognitive skills and lead to better integration in society and mainstream education. [14]
A study that was mainly sight-opening is the controlled trial conducted by Ip and colleagues which did not overlook one of the major setbacks of VR technology. Ip et al demonstrated, that VR was able to improve emotional recognition in patients with autism, however, it was less efficient than conventional training in developing social and adaptive skills. [8]
The use of Virtual Reality (VR) in educational and therapeutic settings for children with disabilities presents several challenges and potential disadvantages. One disadvantage is its ability to isolate children from other kids and their surroundings. Especially with children with disabilities who might prefer spending time in a closed environment; VR emphasizes that and decreases the opportunities for natural interactions. Hence why It's crucial to find a balance and integrate VR as a supplementary tool rather than a sole means of intervention. [15]
We also realize that the controlled studies did not mention thoroughly other drawbacks of VR-prolonged use, such as sensory overstimulation, and myopia in HMD especially if employed in early years of life.
The risk of sensory overstimulation, especially for individuals with Auditory Processing Disorders (APD), due to their intense sensitivity to auditory stimuli, should not be overlooked. Careful consideration and customization of VR experiences are essential to prevent overwhelming sensory input, ensuring a positive and effective learning environment for individuals with APD. Moreover,
A specific drawback that was highlighted in studies was the potential of VR to cause discomfort, anxiety, and fatigue with its prolonged use. Some children expressed unease with VR headsets, and there were fluctuations in pulse rates, suggesting increased anxiety during VR sessions. Additionally, factors such as VR difficulty, potential biases in technologies, and limitations of VR eyewear should be carefully considered. Despite the potential benefits of VR, it may not be suitable for all cases, particularly for children with certain medical conditions. Balancing the integration of VR with real-world experiences and ensuring gradual exposure and supervision are crucial for effective and safe implementation in educational settings. [16]
Ocular effects of VR remain unleashed, a study by Turnbull et al showed that VR use on a short-term basis was not associated with an increased risk of myopia, however, a significant choroidal thickening was noted. [17,18]
High costs can also be a burden, since the expenses associated with VR technology, including both hardware and software, pose a barrier to its widespread adoption and accessibility. Therefore, addressing the cost factor is critical to making VR interventions more accessible.(19)

5. Conclusions

The use of VR in skills development seems to be far from being validated. Few controlled trials were found, with a small sample size, and a short training course. The short duration of training does not allow adequate examination of possible complications, especially the ocular and social isolation effects.
The risk of bias of included studies was performed according to standard scale and presented in Figure 2. [20]

List of Abbreviations:

ADHD: Attention deficit hyperactivity disorder
ASD: Autistic spectrum disorder
HMD: Head mounted device
VR: Virtual reality

Author Contributions

Conceptualization, AA, SAS; Methodology, AA, WAH, HAH; SAH, FAH, and SAS; software, AA, WAH, HAH; SAH, FAH, and SAS; investigation, AA, WAH, HAH; SAH, FAH, and SAS; resources, AA, WAH, HAH; SAH, FAH, and SAS, data curation, AA, WAH, HAH; SAH, FAH, and SAS; writing—original draft preparation, AA, WAH, HAH; SAH, FAH, and SAS; writing—review and editing, AA, WAH, HAH; SAH, FAH, and SAS; supervision, AA, WAH, SAS; project administration, AA, SAS; funding acquisition, (none). All authors have read and agreed to the published version of the manuscript.

Acknowledgments

I wanted, as a first author, to dedicate this work to anyone who is considered as a “black sheep” in his workplace, college or school environment, just because he is beautifully different. We all, through different stages of our life, have gone through similar, difficult times, where we felt alone and non-appreciated, but you should know that your personal worth is unrelated to others’ perception.

Conflicts of Interest

The authors declare no conflict of interest.

References

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  8. Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: A virtual reality enabled approach. Comput Educ [Internet]. 2018;117:1–15. Available from: https://doi.org/10.1016/j.compedu.2017.09.010. [CrossRef]
  9. Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the Autism Spectrum and the Use of Virtual Reality for Supporting Social Skills. Children [Internet]. 2022 Feb 1;9(2):181. Available from: https://www.mdpi.com/2227-9067/9/2/181.
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  15. Merkx C, Nawijn J. Virtual reality tourism experiences: Addiction and isolation. Tour Manag [Internet]. 2021;87(May):104394. Available from: https://doi.org/10.1016/j.tourman.2021.104394. [CrossRef]
  16. Naef AC, Jeitziner MM, Knobel SEJ, Exl MT, Müri RM, Jakob SM, et al. Investigating the role of auditory and visual sensory inputs for inducing relaxation during virtual reality stimulation. Sci Rep [Internet]. 2022;12(1):1–11. Available from: https://doi.org/10.1038/s41598-022-21575-9. [CrossRef]
  17. Turnbull PRK, Phillips JR. Ocular effects of virtual reality headset wear in young adults. Sci Rep [Internet]. 2017;7(1):1–9. Available from: http://dx.doi.org/10.1038/s41598-017-16320-6. [CrossRef]
  18. Yoon HJ, Moon HS, Sung MS, Park SW, Heo H. Effects of prolonged use of virtual reality smartphone-based head-mounted display on visual parameters: a randomised controlled trial. Sci Rep [Internet]. 2021;11(1):1–9. Available from: https://doi.org/10.1038/s41598-021-94680-w. [CrossRef]
  19. Farra SL, Gneuhs M, Hodgson E, Kawosa B, Miller ET, Simon A, et al. Comparative Cost of Virtual Reality Training and Live Exercises for Training Hospital Workers for Evacuation. Comput Inform Nurs [Internet]. 2019 Sep;37(9):446–54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/31166203.
  20. Viswanathan M, Patnode CD, Berkman ND, Bass EB, Chang S, Hartling L, et al. Recommendations for assessing the risk of bias in systematic reviews of health-care interventions. J Clin Epidemiol [Internet]. 2018 May;97:26–34. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0895435617310661.
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Figure 1. Prisma 2020 flow diagram for our systematic revuew to show study selection process.
Figure 1. Prisma 2020 flow diagram for our systematic revuew to show study selection process.
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Figure 2. Risk of Bias assessment of the included studies by their order of distribution in Table 1. (Study 1: Maresca et al, Study 2: Bioulac et al, Study 3: Frolli et al, Study 4: Ip et al).
Figure 2. Risk of Bias assessment of the included studies by their order of distribution in Table 1. (Study 1: Maresca et al, Study 2: Bioulac et al, Study 3: Frolli et al, Study 4: Ip et al).
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Table 1. Details of included studies.
Table 1. Details of included studies.
Citation number in the text Author name Year of the trial Disease age groups Sample size Duration of training Type of VR Scales used and main results
11 Maresca G et al

2022

Dyslexia
10-12 years 		28 72 sessions
Total: 24 weeks		 Virtual reality rehabilitation system (VRRS) Neuropsychological evaluation performed by (WISC-IV) showed a decline in all variables. WISC score:
Perceptual reasoning index and Processing speed index improved significantly
10 Bioulac 2020 ADHD 7-11 years 48 12 sessions (8 weeks) VR (HMD) vs. Psychotherapy vs. psychostimulant intervention Number of commission and omission errors
(CPT)		 Significant reduction in commission errors
8 Frolli 2022 Autism 6-16 60 36 sessions (12 weeks) VR (without HMD) The acquisition time of primary and secondary emotions Time group interaction is shorter in VR but there is no significant diff in acquired skills (At the level of primary emotions perception)
9 Ip 2017 Autism 7-11 72 28 sessions (14 weeks) VR without HMD Emotional recognition
Adaptive skills 		Emotional recognition and expression better in VR group
Adaptive skills better in control group
Abbreviations: ADHD: Attention deficit hyperactivity disorder, CPT: continuous performance test, HMD: Head-mounted device, VR: Virtual reality, WISC: Wechsler intelligence scale
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Copyright: This open access article is published under a Creative Commons CC BY 4.0 license, which permit the free download, distribution, and reuse, provided that the author and preprint are cited in any reuse.
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