by Patrick Lin
Illustration: “Augmented Reality” by Sushant Thomas
A healthy social life involves interactions with other people in different settings. In doing so, these individuals undergo a process of socialization, where they must recognize the norms and rules of an environment through ongoing interactions and behave accordingly in order to communicate and participate in that environment. Socialization helps an individual utilize different roles in accordance with a professional, educational, or casual setting. 1 Across various recognized studies, researchers have found that individuals with autism spectrum conditions (ASCs) often experience great difficulties with socialization, specifically when enacting executive functions, which include planning, attention, problem solving, and general social skills. These challenges are most noticeable in their emotional incapacity to maintain empathic relationships and to recognize emotions through social cues. Consequently, these deficits lead to a less complete comprehension of the rules of communication, resulting in a lesser ability to anticipate what others feel, do, or say. 2 For many individuals with ASCs, the transition into adulthood is particularly challenging. Social impairments, inherent in ASCs, interfere with relationship building, social and occupational functioning, and emotion recognition, all of which are aspects of social cognition and social functioning that take on a larger role during the transition to adulthood. Navigating these new social demands is an added challenge for many individuals with ASCs. 3 Recognition of these challenges led to the development of treatments for individuals with ASCs that aim to increase functioning by focusing on select social skills, which in turn improve social cognition and social functioning. Less common, however, are interventions that directly focus on social cognition and theory of mind. 2, 3 Successful socialization requires a person to know appropriate behaviors for acceptable social interactions and to carry out these behaviors based on social cognition, the thought processes of accurately integrating, interpreting, and responding to social cues. 4 Theory of mind, according to Carter et al., is the ability to recognize the mental state of others, which allows people to interpret and anticipate the actions of others, which in turn facilitate appropriate social interactions. In the absence of sufficient social cognition and theory of mind, an individual cannot adequately make inferences about the thoughts, emotions, or intentions of others. 1, 4 In essence, the lack of real-world training in traditional treatment and therapy methods may hinder the generalization of treatment effects. Fortunately, virtual reality (VR) is a useful platform that provides opportunities for individuals with ASCs to practice dynamic and real-life interactions.
II. Virtual Classroom
Traditionally, adult interventions have found mixed success when employing techniques that quantify social skills and cognition over time. While previous studies found improvements on measures of emotion recognition, other measures such as theory of mind, social cognition, and conversational skills did not exhibit any notable changes after the interventions. 3 Some adult group intervention studies employed observational techniques, such as conversational style during simulated scenarios of a party or a job interview, or observations of frequency and types of interactions. 5, 6 Another approach for measuring social skills improvement over time is through the use of social cognition performance measures. These interventions record performance measures while participants engage in social tasks and the accuracy of the response is quantified. For example, measures of emotion recognition in faces or voices are recorded while a participant is asked to label or match an emotion or emotion word. 7, 8 A majority of past interventions were social skills-based and group-based, which may limit the amount of time spent on practicing social skills and interacting with individuals outside of the autism spectrum. With a lack of real-world environments, researchers have turned to conducting real-time simulations of authentic social interactions with neurotypical adults. 3
For years, scientists and medical professionals have developed and implemented VR in ways that help train, diagnose, and treat in different situations. A VR platform, specifically a virtual reality social cognition training (VR-SCT) intervention, could be a place to practice, refine, and solidify learned social skills via role-play in safe and controlled simulated environments designed to mimic specific, realistic social situations in a comfortable and contained virtual environment (VE), without interference from extraneous variables such as fear or embarrassment. 9, 10 This unique advantage suggests that VR can be a promising and effective tool for improving social skills, cognition, and functioning for individuals with neurodevelopmental disorders and ASCs. 3, 9
Unlike traditional therapeutic approaches, VR’s utility is derived from representing real-life experiences in a safe, controllable environment that allows for repeated practice and exposure. VR also provides naturalistic VEs with unlimited social scenarios and can replicate social conditions. For instance, clinicians can control avatars in VR scenarios and software can alter the clinicians’ voice to match the avatar’s demographic. Perhaps the most imperative component responsible for the success of VR is that it allows those with ASCs to practice social interactions without high levels of stress or fears of mistakes or rejection. 3, 10
A concern for many researchers is whether ASC individuals can accept, use, and interpret VEs as representations of reality. It is well documented that individuals with ASCs often interpret situations and language literally, seemingly unaware of underlying meanings. An overly literal interpretation of a VE could limit its usefulness as a social skills teaching tool since participants may not understand that interactions and occurrences in a VE are not a literal representation of what may unfold in real-life. 10, 11 However, if participants understood VEs as representational, then they would be willing to make a non-literal interpretation about the behavior of some people in a virtual scene. Fortunately, various studies have shown that individuals with ASCs can interact with VEs with the understanding that VEs are representations of reality. 10, 12 Individuals with ASCs tend to accept VEs as copies of reality comparable to typically-developing controls; participants also demonstrated communication and executive functioning problems in VEs that resemble their difficulties in real-life. 9
III. Making the Grade: Case Studies
Across many VR-SCT studies, researchers were able to conclude that the intervention method’s safe, repeatable VEs provides adults with ASCs with a familiar and predictable environment, reducing their anxiety and increasing their confidence in social situations. 13 The research conducted by Yang et al. focused on neural connections and utilized functional magnetic resonance imaging (fMRI) to detect changes in brain activity before and after participants received VR-SCT treatment. After virtual reality training, young adults with autism showed increased activation in brain regions associated with social understanding (Figure 1). Furthermore, the researchers observed increased connectivity between brain regions that exchange information during effective social interactions (Figure 2). By changing the scripted dialogue of his virtual characters, Yang was able to simulate many different scenarios for the users of his VR-SCT. Situations included job interviews and first interactions with a new neighbor or a blind date, allowing participants to learn and train a diverse skill set.
One appeal of VR as a teaching tool is that it allows for social interaction without high levels of stress or fear of making mistakes or rejection. Without these inhibitors, participants were able to fully immerse themselves in conversation and were typically more confident following the study. 3 The study conducted by Parsons et al. was particularly successful because it allowed participants to navigate a series of connected social situations in a single session rather than a singular conversation or interaction. Participants begin the VR session outside of a building and must interact with various virtual objects and characters before making their way to a virtual café. The interactions are largely facilitated by virtual characters with pre-programmed responses or clinician-written scripts, allowing the participants to converse without external stressors, which were common in traditional role-playing and observational approaches. 10
The dynamism of VR coupled with its virtually limitless scenarios allows participants to practice their social skills across many different situations. The program designed in Lorenzo et al.’s study aimed to enhance the emotional competencies of children with ASCs by having researchers establish a set of behavior guidelines with participants. In the various designed social scenarios, researchers observed the student’s displayed emotional behaviors of joy, sadness, fear, or surprise. These designed scenarios ranged from participants playing with classmates in a park or attending a birthday party to waiting in line to enter the classroom or going on a field trip. The diverse social situations, which emphasized casual peer-to-peer interaction and the ability to show and recognize emotions, allowed participants to practice an emotional script. The researchers found that following the sessions, participants were able to transfer some of their learned skills to real-life scenarios that were similar to the ones experienced in the VR program. 2
All in all, across different studies, participants in VR social cognition programs appeared to benefit most from a higher level of comfort in a controlled VE and a diverse set of social scenarios, which tested specific interactions in social or professional settings.
IV. Closing Thoughts
Ultimately, the flexibility of VR environments, their removal of common stressors of face-to-face interactions, and their inherent appeal to many adults with ASCs all suggest that VR may prove to be a more effective platform for enhancing social skills and social cognition in ASC individuals than other therapeutic tools that are more constrained in their applications. 3 VR has been used previously and shown to be an effective intervention tool in treating various conditions such as anxiety, phobias such as fear of flying, stroke, and post-traumatic stress disorder. It would not be unprecedented to see this technology’s application expanded to include social cognition training for people living with ASCs. After sessions of virtual reality social cognition training intervention, participants exhibited increased understanding in some measures of verbal and non-verbal recognition and theory of mind. 3, 13 Findings across various VR-SCT studies support the potential benefits as well as the feasibility of implementing and further testing of a VR social skills training program to practice various social abilities in a relatively short period of time. Some studies have also found that VR interventions may enhance performance on emotion recognition from faces as well. While more controlled trial studies are needed to validate this alternative intervention method, the current findings in VR studies are promising. By providing people with autism a safe place to learn and practice without fear, VR social cognition training can do more than help its participants develop social skills. VR social cognition training can instill a greater sense of confidence as well.
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