Research | edtc

Background Research

Autism

Social Stories

Virual Reality

VR and Autism

References

Our project initially aimed to create a virtual reality (VR) video of a social story that trains autistic children in specific social interaction skills. From our initial interview and meetings with our client Ashley Carrick, the CEO and founder of TherapyOS, a start-up company trying to incorporate VR in autism therapy, we have determined the major requirements and key features desired of our prototype.

Our background research aims to deepen our understanding of

(1) autism in children and associated developmental disorders,

(2) VR as an industry and medical applications of VR,

(3) the latest research on the use of VR in autism therapy.

This research will prepare for user observation and further interviews.

What do we Need to Know?

More about VR

More about Autism

About TherapyOS

References

Autism Science Foundation. (2017). Treatment Options. Retrieved April 17, 2017, from http://autismsciencefoundation.org/what-is-autism/treatment-options/

Carpenter, L., PhD. (2013). DSM-5 Autism Spectrum Disorder. Retrieved April 17, 2017, from https://depts.washington.edu/dbpeds/Screening%20Tools/DSM-5%28ASD.Guidelines%29Feb2013.pdf

CDC, & NCHS. (n.d.). Distribution of children aged 3 to 17 years ever diagnosed with autism spectrum disorder (ASD) in the U.S. in 2011 to 2013 and 2014, by gender. In Statista - The Statistics Portal. Retrieved April 17, 2017, from https://www-statista-com.turing.library.northwestern.edu/statistics/676769/children-diagnosed-with-autism-spectrum-disorder-in-us-by-gender/.

CDC, & NCHS. (n.d.). Percentage of children diagnosed with autism spectrum disorder with select co-occurring conditions in the U.S. 2014. In Statista - The Statistics Portal. Retrieved April 17, 2017, from https://www-statista-com.turing.library.northwestern.edu/statistics/677019/co-occurring-conditions-among-children-with-autism-in-us/.

CDC. (n.d.). Prevalence of autism spectrum disorder in the U.S. from 2000 to 2012 (per 1,000 children). In Statista - The Statistics Portal. Retrieved April 17, 2017, from https://www-statista-com.turing.library.northwestern.edu/statistics/676303/autism-rate-among-children-us/.

Didehbani, N., Allen, T., Kandalaft, M., Krawczyk, D., & Chapman, S. (2016). Virtual Reality Social Cognition Training for children with high functioning autism. Computers in Human Behavior,62, 703-711. doi:10.1016/j.chb.2016.04.033

Gray, C. (2010). What are Social Stories?. In The Gray Centre. Retrieved April 17, 2017 from http://www.thegraycenter.org/social-stories/what-are-social-stories.

ImmersiveTouch Inc. (2017). Technology and Services. Retrieved April 17, 2017, from http://www.immersivetouch.com/

Kandalaft, M. R., Didehbani, N., Krawczyk, D. C., Allen, T. T., & Chapman, S. B. (2012). Virtual Reality Social Cognition Training for Young Adults with High-Functioning Autism. Journal of Autism and Developmental Disorders,43(1), 34-44. doi:10.1007/s10803-012-1544-6

Myers, K.M., Davis, M. (2007). “Mechanisms of Fear Extinction”. Molecular Psychiatry. 12(2): 120-150.

National Institute of Neurological Disorders and Stroke (NINDS). (2015, September). Autism Spectrum Disorder Fact Sheet. Retrieved April 17, 2017, from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Autism-Spectrum-Disorder-Fact-Sheet#3082_3

Nunatak. (n.d.). Forecast revenue for virtual reality products* worldwide from 2014 to 2018 (in million U.S. dollars). In Statista - The Statistics

Portal. Retrieved April 17, 2017, from https://www-statista-com.turing.library.northwestern.edu/statistics/426276/virtual-realiy-revenue-forecast-worldwide/.

Parsons, T. D., & Rizzo, A. A. (2008). Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: A meta-analysis. Journal of Behavior Therapy and Experimental Psychiatry,39(3), 250-261. doi:10.1016/j.jbtep.2007.07.007

Tager-Flusberg, H. (2007). Evaluating the Theory-of-Mind Hypothesis of Autism. Current Directions in Psychological Science, 16, 311-315. DOI: 10.1111/j.1467-8721.2007.00527.x

USC Institute for Creative Technologies (2017). Bravemind. Retrieved April 17, 2017, from http://medvr.ict.usc.edu/projects/bravemind/

Virtually Better Inc. (2017). Virtually Better Store. Retrieved April 17, 2017, from http://www.virtuallybetter.com/sales/

Firsthand Technology Inc. (n.d.). Products. Retrieved April 17, 2017, from http://firsthand.com/products/

Munster, G., Jakel, T., Clinton, D., & Murphy, E. (2015, May). Next Mega Tech Theme is Virtual Reality (Rep.). Piper Jaffray. Retrieved April 17, 2017, from https://piper2.bluematrix.com/sellside/EmailDocViewer?encrypt=052665f6-3484-40b7-b972-bf9f38a57149&mime=pdf&co=Piper&id=reseqonly@pjc.com&source=mail.

Ma, B., Nahal, S., & Tran, F. (2016, September 7). Future Reality: Virtual, Augmented, Mixed Reality (VR, AR, MR) Primer (pp. 1-148, Rep.). Bank of

America Merill Lynch . Retrieved April 17, 2017, from https://www.bofaml.com/content/dam/boamlimages/documents/articles/ID16_1099/virtual_reality_primer_short.pdf.

Virtual Reality Society. (2017, February 13). What is Virtual Reality? Retrieved April 17, 2017, from https://www.vrs.org.uk/virtual-reality/what-is-virtual-reality.html

Autism Speaks Inc. (2012). About Autism. Retrieved April 17, 2017, from https://www.autismspeaks.org/sites/default/files/sctk_about_autism.pdf

Bioflight VR. (2017). Portfolio. Retrieved April 17, 2017, from http://www.immersus.co/

Floreo Tech. (2016). Our Product. Retrieved April 17, 2017, from http://floreotech.com/our-product/

Medical Realities. (n.d.). Medical Realities . Retrieved April 17, 2017, from http://www.medicalrealities.com/

One Caring Team. (n.d.). Plans. Retrieved April 17, 2017, from https://onecaringteam.com/#faq

Literature Review about VR and Autism

We conducted a literature review of the use of VR for autism therapy and exposure therapy in general. Based on our literature review, there was evidence suggesting that VR has potential for autism therapy, and in some cases was as effective as conventional therapy. There was neither evidence proving that VR caused substantial improvements in social interaction for ASD individuals over conventional treatment, nor were there studies showing the use of VR will definitely bring about negative effects. The application of VR in autism therapy is still relatively new and niche and we did not find any published study that conducted long term VR autism therapy use for a large sample size.

A meta-study conducted by the Institute for Creative Technologies in 2007 analyzed 52 studies and found that virtual reality exposure therapy had statistically large effects and appears effective from a clinical psychology standpoint. This conclusion was limited by fact that most studies analyzed carefully select their patients, and thus this conclusion may not generalize to all patients (Parsons. et al, 2008).

In a 2012 study conducted by the University of Texas Southwestern, VR was used for social recognition training among young adults aged between 18 to 26 years. Eight participants completed 10 VR sessions over 5 weeks, and significant increases on social cognitive measures of theory of mind and emotion recognition were found. Given the small sample size of this study, however, it is difficult to generalize the effectives of VR social recognition training. Furthermore, the study only had high-functioning ASD individuals (autistic individuals who are mostly independent in daily activities), which further limits the strength of the conclusion (Kandalaft. et al, 2012).

A similar study conducted by the University of Texas at Dallas in 2016 focused on social recognition training for autistic children between the ages of 7-16. In terms of emotion recognition, social attribution, attention and executive function, the study found the use of VR as an effective treatment option. The study was similarly limited by the small sample size and short total trail period (Didehbani, 2016).

Direct Competitor

Medical Applications of VR

Medical training

Companies such as Immersive Touch, BioflightVR and Medical Realities have developed VR for training surgeons (ImmersiveTouch Inc, 2017; BioflightVR, 2017; Medical Realities). VR provides strong benefits to this sector as it allows medical students to train their surgery skills under complex, life-like environments at low risk. The same VR application can be used for doctors to rehearse complicated procedures, enabling them to improve precision and accuracy during the actual operation. Furthermore, the VR simulation of surgery can be useful in helping patients understand their medical conditions and treatment better.

Lifestyle and Wellness

Firsthand Technology focuses on producing VR software that “improves wellness and enhance mindfulness”. Their VR features games that incorporate biosensor feedback to help players relax, meditate and alleviate chronic pain and anxiety (Firsthand Technology).

One Caring Team uses VR to provide personalized and consistent human connections as psychological support for lonely elderly. Elderly using this platform are paired with a real listeners, who converse and interact with the elderly to keep them company, and relay observations and messages to the elderly’s loved ones (One Caring Team).

Exposure therapy

Exposure therapy is a form of psychological therapy where the patient is introduced and slowly exposed to traumatic stimuli so that he can manage his fear, stress and anxiety better and potentially overcome the trauma (Myers, K.M. et al, 2007). The use of VR in exposure therapy brings immense benefits as the patient can safely interact in a stress-inducing environment. Furthermore, VR allows greater flexibility and control in customizing the progressivity and features of the stimuli the patient experiences. Since TherapyOS, our client, intends to use VR as social interaction training tool, the form of VR it uses will be heavily similar to those used for exposure therapy. Hence, exposure therapy VR products can be seen as model products, as they content can be modified for progressive social interaction training with social stories.

Companies such as Virtually Better develops a variety of VR software for phobias, Post-Traumatic Stress Disorder (PTSD), childhood anxiety and sleep disorders (Virtually Better Inc, 2017). Other companies specialize in one particular exposure therapy. Bravemind, for instance, is specifically designed to treat PTSD for veterans and uses advanced brain imaging techniques to monitor the intensity of patients’ stress responses (USC Institute for Creative Technologies, 2017).

Floreotech is a direct competitor of TherapyOS. Floreotech produces VR software that helps autistic children practice skills to foster social interactions while having fun. A parent or therapist can follow the VR video and monitor the child’s progress on a separate device. Furthermore Floreo (name of product) employs analytics to help families and therapists effectively measure the child’s improvement over time. The company was founded at least as early as Oct 16, 2016 and has partnered with Celebrate the Children, a school for autism, and the Autism/Intellectual and Developmental Disabilities (IDD) Outreach Unit of Montgomery County Police Department (Floreo Tech, 2016).

More information on the product is currently unavailable as it has not officially launched for mass market consumers. It is difficult to compare Floreo and TherapyOS’s prototypes because both companies are at early stages. However, based on the images of Floreo, and the fact that Floreo started out early and has two established partners in autism education, it is highly likely that Floreo is more market ready compared to our client.

Figure R6. Forecast revenue for virtual reality products worldwide from 2014 to 2018 (in million USD)

Source: https://www-statista-com.turing.library.northwestern.edu/statistics/426276/virtual-realiy-revenue-forecast-worldwide/.

Augmented reality (AR), which superimposes virtual images into the user’s real and current perspective, is expected to outgrow the VR market, as shown in figure 7 below.

Figure R7. Augmented/Virtual Reality Revenue Forecast

Source: https://www.bofaml.com/content/dam/boamlimages/documents/articles/ID16_1099/virtual_reality_primer_short.pdf.

Figure 8 below summarizes predictions for the VR/AR market by application.

Virtual Reality

Virtual Reality refers to a three dimensional, computer generated environment which can be explored and interacted with. A VR interface must include the ability to track user’s head and eye movements and correspondingly adjust images the user’s display to reflect changes in perspective. (Virtual Reality Society, 2017)

Current VR technology requires the user to put on a headset (or look through a pair of googles) to view a stereoscopic 360 degree video. Depending on the complexity of the headset, it may include sensors that track head and eye movements. Users’ interaction within the VR environment depends on the hard and software employed. For maximum interaction with the VR environment, motion capture systems that can accurately provide the position, orientation of the body and map these body movements onto the virtual character (avatar) in real time are required (Ma, B. et al, 2016). The Virtuix Omini, for instance, is an omni-directional treadmill that allows users to walk around naturally and fully immerse in VR (Munster,G. et al, 2015). Interaction with the VR environment may be aided with the use of hand-held controllers, such as those produced by Samsung for Gear VR. Current VR systems are either based on personal computer (PC)/gaming consoles platform or mobile platforms. With more computing power, PC and gaming console based VR systems can achieve higher VR immersion and interaction, while mobile VR platforms offer greater convenience and affordability.

The VR market is projected to increase in the next few years, as shown in the figure 6 below.

Figure R8. VR/AR Market projections by applications

Source: https://www.bofaml.com/content/dam/boamlimages/documents/articles/ID16_1099/virtual_reality_primer_short.pdf.

In particular, we focused our research on the healthcare industry. VR in healthcare span a variety of applications such as medical surgical training.

Social Stories

An important tool used in autism treatment focused on improving social skills is the use of social stories. Social stories are written or visual guides describing social interactions, behaviors, skills or concepts in terms of social cues, perspectives and common responses in a specifically defined style and format (Gray, C., 2010). Each story describe clearly and concisely describes a specific social and points out what people do, why they do it, and the common appropriate responses.

The theory of mind suggests that people with autism do not understand that others might have a different opinion to them, or that others may want to do something different to what they want to do (Tager-Flusberg, H., 2007). Social stories addresses this by giving autistic individuals some perspective on the thoughts, emotions and behaviors of others. This method was developed by Carol Grey in 1994.

Figure R5. Social Story depicting father’s death and funeral (read left to right, top to bottom)

Source: http://www.haringey.gov.uk/sites/haringeygovuk/files/what_are_social_stories.pdf

Social stories provide a prompt from socially appropriate behavior and help a person familiarize with a situation in order to respond appropriately. They also facilitate positive feedback so that individuals can recognize their own appropriate behavior, and prevents extreme reactions in new situations due to lack of social understanding. Figure 5 shows an example of a social story that prepares an autistic individual for a funeral.

Other Medical Issues and Challenges with ASD

ASD is also associated with other health issues that autistic individuals are more likely to face. Epilepsy, for instance, affects over a third of people diagnosed with ASD. Other medical issues include genetic disorders such as Fragile X syndrome, allergies, sleep dysfunction, and pain.

Moreover, development delays and learning disorders may also accompany autism. The majority of autistic individuals show some degree of cognitive impairment. The specific disability is characteristic to the individual. For example, some students with autism could perform well in abstract problem solving, but do poorly in language and verbal communication. Figure 4 below shows the prevalence of selected disabilities occurring alongside ASD.

Figure R4. Percentage of children diagnosed with autism spectrum disorder with select co-occurring conditions in the U.S. 2014
Source: https://www-statista-com.turing.library.northwestern.edu/statistics/677019/co-occurring-conditions-among-children-with-autism-in-us/

Autism Treatment

ASD cannot be cured and there is no medication that treats the core symptoms. However, medication is used to alleviate some behavioural symptoms such as irritability, aggression, and self-injurious behaviour. For example, Risperidone and Ariprirazole are used to treat irritability in children and adolescents (Autism Science Foundation, 2017).

Autism treatment is primarily focused on educational and behavioral interventions. The most effective treatment currently is Applied Behavior Analysis, which works to systematically change behavior by encouraging positive ones and discouraging negative ones (Autism Science Foundation, 2017). ABA also teaches new skills and their applications to new situations. The various forms of ABA include:

Early Intensive Behavioral Intervention, for young children typically under the age of five
Pivotal Response Training, which works to increase the child’s own motivation to learn, monitor own behavior, and initiate communication with others
Discrete trial teaching, which teaches social skills and positive behavior in small steps using prompts and rewards over each step. These prompts and rewards are gradually phased out.

In addition, occupational therapy (OT) is often used to treat sensory integration issues associated with ASD. OT teaches essential life skills involving fine movements, such as using utensils and writing. The purpose of OT is to improve the individual’s ability to participate fully in daily activities. OT for young children focuses primarily on improving sensory integration, while OT for older children focuses on improving social behavior and independence (Autism Science Foundation, 2017).

Physical therapy (PT) can often be an important aspect of autism treatment. PT improves gross motor skills and handle sensory integration issues such as walking, sitting, coordination and balance. Similar to OT, PT aims to improve the individual’s ability to participate in daily activities (Autism Science Foundation, 2017).

According to the National Institute of Neurological Disorders and Strokes (NINDS), “Autism spectrum disorder (ASD) refers to a group of complex neurodevelopment disorders characterized by repetitive and characteristic patterns of behavior and difficulties with social communication and interaction (NINDS, 2015)”.

ASD is characterized by difficulties in social interaction, verbal and nonverbal communication and repetitive behaviors. (Autism Speaks Inc., 2012). The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies Asperger syndrome, Rett syndrome, childhood disintegrative disorder, and pervasive development disorders under ASD (Carpenter, 2013). The fact that autism is a spectrum disorder implies that autistic individuals have a wide range of symptoms, skills, and levels of disability in functioning. Some children are able to perform daily tasks fully independently while others may require much more support.

About 1 in 68 children have autism, and ASD is more prevalent in males than females (NINDS, 2015). Figure 1 below shows the prevalence of ASD in the United States from 2000 to 2012. Figure 2 shows the distribution of children with ASD by gender.

While the symptoms of autism can vary greatly between individuals depending on type and severity, there are some indicators which are common to most autistic individuals. Early indicators (infant to toddler age) include, but are not limited to (NINDS, 2015):

No babbling or pointing by the age of 1
No single words by age 16 months
Poor eye contact
No smiling or social responsiveness

Later indicators include, but not limited to:

Impaired ability to make friends
Impaired ability to initiate or sustain conversations
Absence or impairment of imaginative and social play
Preoccupation with certain objects or subjects

The diagnosis of ASD is complex, and requires a complex of evaluation of the child’s development and behavior. The criteria for ASD diagnosis specified by DSM-5 are broadly classified under two categories: 1) Persistent deficits in social communication and social interaction 2) Restricted, repetitive patterns of behavior, interests or activities (Carpenter, 2013). Figure 3 below is a table relating severity of ASD and descriptions of behavior under the aforementioned categories.