Using Virtual Reality Environments to Augment Cognitive Behavioral Therapy for Fears and Phobias in Autistic Adults

The Application of Extended Reality in Treating Children with Autism Spectrum Disorder

Autism Spectrum Disorder (ASD) is a common neurodevelopmental disorder in children, characterized by social interaction, communication difficulties, and repetitive and stereotyped behaviors. Existing intervention methods have limitations, such as requiring long treatment periods and needing to be more convenient to implement. Extended Reality (XR) technology offers a virtual environment to enhance children's social, communication, and self-regulation skills. This paper compares XR theoretical models, application examples, and intervention effects. The study reveals that XR intervention therapy is mainly based on cognitive rehabilitation, teaching, and social-emotional learning theories. It utilizes algorithms, models, artificial intelligence (AI), eye-tracking, and other technologies for interaction, achieving diverse intervention outcomes. Participants showed effective improvement in competency barriers using XR-based multimodal interactive platforms. However, Mixed Reality (MR) technology still requires further development. Future research should explore multimsodal interaction technologies combining XR and AI, optimize models, prioritize the development of MR intervention scenarios, and sustain an optimal intervention level.

A Pilot Randomised Control Trial Exploring the Feasibility and Acceptability of Delivering a Personalised Modular Psychological Intervention for Anxiety Experienced by Autistic Adults: Personalised Anxiety Treatment-Autism (PAT-A)

Anxiety is commonly experienced by autistic people and impacts on quality of life and social participation. New anxiety interventions are required to effectively meet the needs of autistic people. Personalised Anxiety Treatment-Autism (PAT-A©) is a bespoke, modular approach to treating anxiety in up to 12 sessions. This study explored the feasibility and acceptability of delivering PAT-A© in the UK National Health Service (NHS). A single-blind randomised controlled trial design. Thirty-four autistic adults were recruited via clinical services and randomised to receive either PAT-A© or enhanced treatment as usual (CCSP). Outcome assessments relating to anxiety, quality of life and related constructs were completed at baseline, immediately post intervention; and at 3 and 12 months. Seventy-one percent of the PAT-A© group and 65% of the CCSP met diagnostic threshold for at least three anxiety disorders. Retention was good across both groups, with 82% (N = 14/17) completing the full course of PAT-A© and 71% (N = 12/17) attending both psychoeducational sessions in CCSP. 94% in PAT-A© and 82% in CCSP completed some follow up assessment 3 months post-intervention. Thematic analysis of interview data revealed that many participants valued the personalised approach, developed transferable skills and experienced positive changes to their anxiety. Participants were willing to be recruited and randomised, PAT-A© was feasible to deliver in the NHS and the trial methods and materials were acceptable. Our findings indicate that a fully powered clinical and cost-effectiveness trial of PAT-A© is warranted.

Consensus statements on optimal adult post-autism diagnosis support and services: Delphi process following a UK survey of autistic adults, relatives and clinicians

LAY ABSTRACT

Research has identified types of support helpful to autistic people, for example, physical and mental health interventions, psycho-education, peer support, developing positive identities and affiliation with social groups. However, accessing suitable post-autism diagnosis support and services is extremely difficult. We asked autistic adults, relatives and clinicians about their experiences of receiving and delivering post-autism diagnosis support/services. In Stage 1, 343 autistic adults and 45 relatives completed a survey. They answered questions about their experiences of UK autism post-diagnosis support/services for adults within 12 months after receiving a diagnosis. Thirty-five clinicians completed a similar survey. Just over half of adults and relatives said there was a follow-up appointment or discussion about support after diagnosis. Fewer than 40% received any support/services in 12 months after diagnosis. We used information from the surveys to create 11 statements describing characteristics of appropriate adult post-autism diagnosis support/services. In Stage 2, we asked clinicians for their views on the statements - they agreed with all of them. For example, those adults are offered an additional follow-up meeting after diagnosis and have access to mental and physical health services. We shared results with autistic adults, relatives and clinicians at two events. Some autistic adults, relatives and clinicians were positive about post-autism diagnosis support/services. However, they described many areas for improvement. The study findings can be used to define, develop and improve the types of adult post-diagnosis support services.

Virtual reality in the diagnostic and therapy for mental disorders: A systematic review

BACKGROUND

Virtual reality (VR) technologies are playing an increasingly important role in the diagnostics and treatment of mental disorders.

OBJECTIVE

To systematically review the current evidence regarding the use of VR in the diagnostics and treatment of mental disorders.

DATA SOURCE

Systematic literature searches via PubMed (last literature update: 9^th of May 2022) were conducted for the following areas of psychopathology: Specific phobias, panic disorder and agoraphobia, social anxiety disorder, generalized anxiety disorder, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder, eating disorders, dementia disorders, attention-deficit/hyperactivity disorder, depression, autism spectrum disorder, schizophrenia spectrum disorders, and addiction disorders.

ELIGIBILITY CRITERIA

To be eligible, studies had to be published in English, to be peer-reviewed, to report original research data, to be VR-related, and to deal with one of the above-mentioned areas of psychopathology.

STUDY EVALUATION

For each study included, various study characteristics (including interventions and conditions, comparators, major outcomes and study designs) were retrieved and a risk of bias score was calculated based on predefined study quality criteria.

RESULTS

Across all areas of psychopathology, k = 9315 studies were inspected, of which k = 721 studies met the eligibility criteria. From these studies, 43.97% were considered assessment-related, 55.48% therapy-related, and 0.55% were mixed. The highest research activity was found for VR exposure therapy in anxiety disorders, PTSD and addiction disorders, where the most convincing evidence was found, as well as for cognitive trainings in dementia and social skill trainings in autism spectrum disorder.

CONCLUSION

While VR exposure therapy will likely find its way successively into regular patient care, there are also many other promising approaches, but most are not yet mature enough for clinical application.

REVIEW REGISTRATION

PROSPERO register CRD42020188436.

FUNDING

The review was funded by budgets from the University of Bonn. No third party funding was involved.

A Virtual Reality Based System for the Screening and Classification of Autism

Autism - also known as Autism Spectrum Disorders or Autism Spectrum Conditions - is a neurodevelopmental condition characterized by repetitive behaviours and differences in communication and social interaction. As a consequence, many autistic individuals may struggle in everyday life, which sometimes manifests in depression, unemployment, or addiction. One crucial problem in patient support and treatment is the long waiting time to diagnosis, which was approximated to thirteen months on average. Yet, the earlier an intervention can take place the better the patient can be supported, which was identified as a crucial factor. We propose a system to support the screening of Autism Spectrum Disorders based on a virtual reality social interaction, namely a shopping experience, with an embodied agent. During this everyday interaction, behavioral responses are tracked and recorded. We analyze this behavior with machine learning approaches to classify participants from an autistic participant sample in comparison to a typically developed individuals control sample with high accuracy, demonstrating the feasibility of the approach. We believe that such tools can strongly impact the way mental disorders are assessed and may help to further find objective criteria and categorization.

Virtual Reality in the Neurosciences: Current Practice and Future Directions

Virtual reality has made numerous advancements in recent years and is used with increasing frequency for education, diversion, and distraction. Beginning several years ago as a device that produced an image with only a few pixels, virtual reality is now able to generate detailed, three-dimensional, and interactive images. Furthermore, these images can be used to provide quantitative data when acting as a simulator or a rehabilitation device. In this article, we aim to draw attention to these areas, as well as highlight the current settings in which virtual reality (VR) is being actively studied and implemented within the field of neurosurgery and the neurosciences. Additionally, we discuss the current limitations of the applications of virtual reality within various settings. This article includes areas in which virtual reality has been used in applications both inside and outside of the operating room, such as pain control, patient education and counseling, and rehabilitation. Virtual reality's utility in neurosurgery and the neurosciences is widely growing, and its use is quickly becoming an integral part of patient care, surgical training, operative planning, navigation, and rehabilitation.

A survey of autistic adults, relatives and clinical teams in the United Kingdom: And Delphi process consensus statements on optimal autism diagnostic assessment for adults

Accessing adult autism diagnostic pathways can be difficult. This study explored perspectives of UK autistic adults, relatives and clinicians regarding the characteristics of optimal adult autism assessment and diagnostic services. In stage 1, three key stakeholder groups were surveyed about experiences of adult autism diagnostic services (pre-assessment/assessment): 343 autistic adults, 45 relatives and 35 clinicians completed parallel surveys. Information from stage 1 surveys was used to devise statements for a modified Delphi process in stage 2 seeking consensus among clinicians on optimal diagnostic service characteristics. Data analyses were non-parametric and descriptive. Over half of adults were in contact with mental health services prior to autism diagnosis. Clinicians reported that multidisciplinary diagnostic teams lacked key professionals. Thirteen statements describing optimal autism diagnostic service provision were developed. There was consensus from clinicians on 11 statements relating to clear assessment pathways, updates for people while waiting, pre-assessment information gathering/provision, co-occurring condition identification and training/networking. Some autistic adults, relatives and clinicians were positive about services, all stakeholders identified improvements were needed. The findings describing optimal service provision are relevant for UK clinicians, managers and commissioners to improve diagnostic assessments for autistic adults, and have international relevance for similar health systems.

Implementation of virtual reality for patient distraction during diagnostic cardiac catheterisation

Until now, the application of virtual reality as a distraction model has been widely described in the medical field, showing different benefits offered on patient's perception, particularly related to pain and anxiety. Previous clinical experience of virtual reality applications on surgical intervention has shown how during procedures with local anaesthesia, this modality improves patients' experience without changing times, costs, and clinical outcomes. Herein, we report our experience with three patients during diagnostic cardiac catheterisation, showing the effect of this technology on patients' perception and metrics during the procedure.

Virtual-reality-based social cognition and interaction training for patients with schizophrenia: A preliminary efficacy study

BACKGROUND

Social cognition and interaction training (SCIT) is a psychosocial intervention program for patients with psychosis, designed to improve their social functioning by improving social cognition. Although the feasibility and efficacy of SCIT have been verified, patients with schizophrenia tend to suffer from motivational deficits and low treatment adherence. It has been suggested that using virtual reality (VR) technology might be effective in addressing these issues. In this study, we aimed to develop a VR-based SCIT and compare its efficacy with that of traditional SCIT.

MATERIALS AND METHODS

We developed a novel VR-based social cognition and interaction training (VR-SCIT) that combines traditional SCIT (TR-SCIT) intervention with VR technology. Participants were randomly assigned in a 1:1:1 ratio to the VR-SCIT (n = 28), TR-SCIT (n = 30), or waiting-list groups (n = 29). All treatments were combined with treatment-as-usual. Assessments of social cognition (i.e., Chinese version of Face-Affective Identification Task, Chinese version of Social Cognition Screening Questionnaire) and social functioning (i.e., Chinese version of Personal and Social Performance Scale) were administered from baseline to post-intervention.

RESULTS

Patients receiving VR-SCIT and TR-SCIT showed a significantly greater improvement on the assessments of emotion perception (Cohen's d was 1.66, 0.55, and 0.10 for VR-SCIT, TR-SCIT, and Waiting-list, respectively), hostile attributional bias (Cohen's d was 0.48, 0.44, and 0.05 for VR-SCIT, TR-SCIT, and Waiting-list, respectively), metacognition (Cohen's d was 1.66, 0.76, and 0.06 for VR-SCIT, TR-SCIT, and waiting-list, respectively), and social functioning (Cohen's d was 1.09, 0.90, and 0.20 for VR-SCIT, TR-SCIT, and waiting-list, respectively) from baseline to post-intervention, compared to those in waiting-list group. Additionally, VR-SCIT showed an advantage over TR-SCIT in improving emotion perception and metacognition with higher treatment compliance.

CONCLUSION

These preliminary findings indicate that VR-SCIT is a feasible and promising method for improving social cognition and social functioning in patients with schizophrenia.

The use of virtual reality and augmented reality in psychosocial rehabilitation for adults with neurodevelopmental disorders: A systematic review

OBJECTIVES

Virtual reality and augmented reality have been used in psychosocial rehabilitation for adults with neurodevelopmental disorders in recent years, to provide functional training in a scaffolded and appealing manner. This systematic review attempted to evaluate (1) how virtual reality or augmented reality technology was deployed, when used as an intervention for adults with neurodevelopmental disorders; and (2) how virtual or augmented reality-assisted psychosocial rehabilitation programs impacted on the functional domains of community living, employment and social participation.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was adopted and a search of publications between June 2012 and June 2022 was carried out. The target groups were adults with schizophrenia/schizoaffective disorders, autism spectrum disorder, intellectual disabilities and attention deficit hyperactivity disorder. Interventions that targeted at least one functional domain were included.

RESULTS

The database search generated 1,267 records and 38 studies met the inclusion criteria. Three studies utilized augmented reality while the rest utilized virtual reality. The virtual scenarios were displayed in various ways, such as head-mounted displays, computer screens, mobile devices and cave rooms. A few studies also used features such as speech recognition, eye tracking and motion-capture device to provide real-time feedback to participants during rehabilitation. Eleven studies reported interventions that addressed community living, 15 studies addressed vocational skills and nine studies trained participants in social skills or social cognition. Three studies sought to improve quality of life using virtual scenarios to expose participants to various situations. Majority of these studies reported preliminary promising results, with improvement in the functional domains addressed. However, several studies had small sample sizes and many single-arm pretest-posttest studies were assessed to be of serious or critical risk of bias.

CONCLUSION

Virtual reality and augmented reality are deployed in various ways to augment psychosocial rehabilitation for adults with neurodevelopmental disorders. Most interventions target skills training or strategy learning in the areas of community living, work and social participation. Preliminary positive findings of their effects on functional performance were reported. Larger and robust studies using ecologically valid outcome measures will be needed to establish their effects on real-world functional outcomes.

SYSTEMATIC REVIEW REGISTRATION

identifier: CRD42022335443.

Technology-Based Assessments and Treatments of Anxiety in Autistic Individuals: Systematic Review and Narrative Synthesis

This systematic review (Prospero Registration Number: CRD42019142910) aimed to narratively synthesise technology-aided assessments and treatments of anxiety in individuals with autism spectrum disorder (ASD) for the first time. Sixteen studies were identified: 5 assessment studies and 11 treatment studies. Assessment studies targeted state anxiety using ecological momentary assessment, wearables, or computerised tasks. Treatment studies targeted specific fears/phobias using electronic screen media or transdiagnostic anxiety using telemedicine. Broadly, results indicated technology-aided assessments and treatments may be feasible and effective at targeting anxiety in ASD, except treatments involving social scripts or peer modelling. Assessment results further indicated that state anxiety in ASD has a distinct psychophysiological signature and is evoked by idiosyncratic triggers. However, larger scale studies with representative samples are needed.

Effectiveness of Virtual/Augmented Reality-Based Therapeutic Interventions on Individuals With Autism Spectrum Disorder: A Comprehensive Meta-Analysis

In recent years, the application of virtual reality (VR) for therapeutic purposes has escalated dramatically. Favorable properties of VR for engaging patients with autism, in particular, have motivated an enormous body of investigations targeting autism-related disabilities with this technology. This study aims to provide a comprehensive meta-analysis for evaluating the effectiveness of VR on the rehabilitation and training of individuals diagnosed with an autism spectrum disorder. Accordingly, we conducted a systematic search of related databases and, after screening for inclusion criteria, reviewed 33 studies for more detailed analysis. Results revealed that individuals undergoing VR training have remarkable improvements with a relatively large effect size with Hedges g of 0.74. Furthermore, the results of the analysis of different skills indicated diverse effectiveness. The strongest effect was observed for daily living skills (g = 1.15). This effect was moderate for other skills: g = 0.45 for cognitive skills, g = 0.46 for emotion regulation and recognition skills, and g = 0.69 for social and communication skills. Moreover, five studies that had used augmented reality also showed promising efficacy (g = 0.92) that calls for more research on this tool. In conclusion, the application of VR-based settings in clinical practice is highly encouraged, although their standardization and customization need more research.

A Cognitive Behavioral Intervention for Driving for Autistic Teens and Adults: A Pilot Study

Background

For many autistic individuals approaching adulthood, interventions to promote skills toward independence are lacking. Driving is an important ability to cultivate as it may be a critical step to attaining independence, securing and maintaining work, and fostering relationships. Only about one third of able autistic individuals drive independently, and fear to drive is a common reason for not driving.

Methods

This initial pilot study was a 3-month open trial to investigate the feasibility, acceptability, and initial estimates of outcomes for the newly developed Cognitive Behavioral Intervention for Driving (CBID) intervention, a manualized curriculum to enhance executive functioning (EF) and emotional regulation (ER) skill development for driving, combined with individualized commentary-based driving simulator practice, in autistic teens and adults within a community research environment. Nineteen participants received the CBID intervention in 1.5-hour group sessions for 10 weeks, across two cohorts, with approximately five individualized driving simulator sessions. Data were collected on anxiety symptoms, driving cognitions, driving attitudes, and simulated driving performance at pre- and post-intervention assessments.

Results

Program completion rate was 81%. Participants and parents rated both the intervention and simulator practice sessions with high satisfaction. All the participants (100%) reported both a positive attitude change (interest toward driving) and a desire to drive in the future at the post-intervention assessment. Significant changes occurred for driving cognitions, attitudes, and behaviors, and 47% of participants obtained a driver's permit or license by 2 months post-intervention.

Conclusions

For autistic individuals, the CBID intervention appeared to directly impact the pursuit toward driving goals by both increasing driving attitudes and behaviors and reducing anxiety/apprehension. This highlights the need for driving intervention programs designed specific to autistic teens/adults that focus on EF and ER skills coupled with individualized simulator practice. CBID could be provided in community services to increase the number of autistic individuals driving.

Lay summary

Why was this study done?: Driving contributes greatly to independence in many teens and adults. Anxiety can act as a barrier to that independence by affecting driving attitudes, ability and performance. Autistic individuals are often affected by anxiety, executive functioning, and emotion regulation challenges. Previous studies show that virtual reality training and Cognitive Behavioral Therapy (CBT), separately, can reduce driving anxiety in autistic individuals and support driving skills. However, to date, no studies have developed and tested a manualized intervention specific to driving that combines such methods.What was the purpose of this study?: The goal of this study was to develop and test a group intervention, called Cognitive Behavioral Intervention for Driving (CBID), combined with individualized, coached driving simulator practice to help reduce fears and increase cognitions, attitudes and performance towards driving. The study examined the following questions: 1) Do autistic individuals actively participate in CBID? 2) Do autistic participants like CBID? and 3) Are autistic participants more prepared to drive after taking part in CBID than they were before they participated in the program?What did the researchers do?: After developing the CBID intervention with community member involvement, the researchers ran 2 intervention groups and individualized driving simulator sessions to a total of 19 enrolled participants. The group intervention focused on strengthening executive functioning and emotion regulation skills in 1.5 hour sessions over 10 weeks and 5, 1 hour driving simulator sessions. Researchers compared data on participant anxiety levels, driving cognitions, attitudes, and performance before and after the intervention.What were the results of the study?: Most of the participants completed the program (81%) and all (100%) rated satisfaction with the group and simulator practice. All (100%) of the participants changed attitudes towards driving. Participants had higher levels of positive thoughts about driving, better attitudes towards wanting to drive and less driving errors (like speeding, collisions, crossing lanes) on the driving simulator after completing CBID. Almost half (47%) of participants obtained a driver's permit or license by 2 months after the intervention.What do these findings add to what was already known?: This study adds a new option of an integrated approach, CBID, for addressing driving anxiety or apprehension. It provides initial findings of the value of incorporating executive functioning skills with traditional cognitive behavior therapy for enhancing driving readiness.What are the potential weaknesses in the study?: This study contained a small sample size that was mostly white male participants. This limits generalizing the results to a representative diverse population. It also did not have a control group or use randomization which means that results can't be interpreted as causal at this time. There was no information about participants obtaining permit/licensure later than 2 months after CBID so it is unclear if some participants require more time to pursue a license. There was no follow up to understand if participants continued to feel comfortable driving overtime.How will these findings help autistic adults now or in the future?: This study showed that it's possible to combine virtual reality training and Cognitive Behavioral Therapy into one driving readiness program. The new CBID program may help autistic adults by addressing multiple aspects of what they need to be ready to drive. Since the study used previously tested strategies, enrolled a community sample, manualized the program, and used a services approach, it was designed for broad distribution to other community settings.

Memory for a virtual reality experience in children and adults according to image quality, emotion, and sense of presence

Numerous studies have explored the effects of virtual reality (VR) on adults' cognition. Little is known, however, of these effects in children. The aim of this study was to explore, in both children and adults, the respective roles of the specific factors of VR, such as immersion, sense of presence and emotion, on memory performance. To do so, we used a head-mounted display to present a VR experience in which we manipulated immersion by varying 3D asset quality (High and Low) and emotion by presenting negative, neutral and positive stimuli. 48 adults (M _age = 20.65) and 40 children (M _age = 11.63) were both divided into two experimental groups (High vs. Low 3D model quality). Valence, arousal, and sense of presence were self-assessed by means of questionnaires, while memory of the presented stimuli was assessed using a free recall task. We also performed physiological measurements to provide objective support for our data. Results showed that memory performance was better for emotional than for neutral stimuli regardless of age group, even though children seemed to avoid looking at negative stimuli compared to neutral ones. Memory was predicted by arousal and presence in adults and only by arousal in children. Memory was not impaired by using poor image quality when highly arousing content was displayed. This study revealed that, contrary to adults, the use of poor image quality did not protect children from strong emotional experiences in VR. The roles of familiarity and arousal are discussed to help explain these results.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s10055-021-00537-y.

Incorporating Virtual Reality to Improve Otolaryngology Resident Wellness: One Institution's Experience

OBJECTIVE

Burnout is defined as work-related emotional exhaustion, depersonalization, and decreased sense of accomplishment. Virtual reality (VR) has emerged as an effective treatment modality for various conditions related to anxiety, however, few studies have assessed its role for stress management in residents. We hypothesize that VR-based mindfulness meditation can reduce resident burnout in real-world settings.

STUDY DESIGN

Prospective randomized crossover trial.

METHODS

Resident participants completed the validated Maslach Burnout Inventory (MBI). One group used a VR-based meditation app; the second group received no intervention. After a 2-month rotation, all subjects completed an MBI and crossed over to the other arm. Wilcoxon rank-sum tests were used to compare MBI scores before and after intervention, and to compare results by gender and postgraduate year. Mann-Whitney U tests were used to assess qualitative differences between participants.

RESULTS

Eighteen residents completed the study. Five participants were female and 13 were male. Weekly use of VR-guided meditation and paced breathing was associated with a significant decrease in emotional exhaustion (P = .009), and on subgroup analysis, male gender specifically was associated with a decrease in emotional exhaustion (P = .027). In the post-intervention survey, 42.9% subjects reported that VR encouraged them to employ paced breathing techniques, 71.4% reported that they would use the technology if regularly available, and 21.4% reported they would use paced breathing in the future.

CONCLUSION

VR-based therapy may serve as a successful tool in stress management and reduce the rate of burnout among otolaryngology residents.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:1972-1976, 2021.

Virtual Reality Air Travel Training Using Apple iPhone X and Google Cardboard: A Feasibility Report with Autistic Adolescents and Adults

Rapid rises in autism diagnoses are increasing the demand for effective services and straining service providers. When individuals on the autism spectrum turn 18, they are faced with even greater barriers to services, since many services are delivered in school settings. Thus, there is a need for more accessible tools that teach daily life and communication skills to autistic adolescents and young adults. The current project reports findings from a pilot study using virtual reality (VR) to teach air travel skills to autistic young adults. The authors repurposed a virtual airport environment previously used to treat fear of flying for this study. Seven participants on the autism spectrum viewed a 5-minute virtual airport simulation with an overlaid narrative script using an iPhone X^® and Google Cardboard^® device once per week for 3 weeks. Researchers collected measures of attentiveness, language function, activity comprehension, and clinical observations on how participants interacted with the technology. Analyses revealed improvements in attentiveness, certain language functions such as labeling vocabulary, and activity comprehension in most participants. Clinical observations revealed acceptability of this technology and its capability to serve as an appealing media to deliver interventions. Thus, it is feasible to apply mobile VR trainings with autistic adolescents and young adults. We discuss ways to improve the pedagogical approach of VR-enhanced interventions in light of these findings. In the future, we plan to develop and test more virtual environments that address the needs of young adults on the autism spectrum, such as interview training and independent living skills.

Lay summary

Why was this virtual reality air travel training program developed?: Each year, more and more people travel via airplane. Long lines, unexpected changes and other stressors can make air travel overwhelming and difficult, particularly for autistic people. Our goal was to develop and pilot test a program to help autistic adults learn air travel skills without needing to physically enter an airport.What does the virtual reality air travel training program do?: Our virtual reality air travel training (VR-ATT) program presents a virtual simulation of the steps that travelers go through in an airport. It guides users through entering, checking in, navigating security, waiting at the departure gate, and boarding. VR-ATT also contains a narrative to guide users by highlighting important information such as: "Look, there's the ticket counter. Let's check in with the attendant." This script was based on social stories, which are often used to help individuals on the autism spectrum learn communication and social interaction strategies. Seven autistic adolescents and adults participated in our program. They watched the VR-ATT simulation on an iPhone X^® and Google Cardboard^® two to three times over the course of 3 weeks. Google Cardboard is an inexpensive virtual reality (VR) headset.How did the researchers evaluate the VR-ATT program?: We evaluated the program in three ways. First, we asked each participant to retell the sequence of events of the simulation. In other research studies, participants who retold what they watched showed a greater ability to apply the skill to the real world. Second, we tracked how and what types of language participants used. Third, we measured if participants could independently view the VR-ATT simulation without side effects such as dizziness or cybersickness (common side effects of VR viewing). This helps us understand the feasibility and acceptability of using VR with autistic individuals.What were the early findings?: Early findings suggest that autistic individuals are accepting of the iPhone and Google Cardboard VR viewing method. They also provide preliminary support for the ability of the program to promote improvements in functional language skills such as labeling vocabulary, which helps individuals interact and navigate busy environments, such as an airport. Finally, the findings suggest that participants can accurately retell the sequence of events in the virtual simulation.What were the weaknesses of this project?: One weakness was that researchers could not test how participants transferred the skills they learned in the virtual training to a real-world airport. Another weakness is the small sample of participants. Finally, not every participant completed all three training sessions, making it difficult to draw precise conclusions about the program's acceptability and success.What are the next steps?: Future studies should include a larger number of participants, a real-world test, changes to the virtual simulation to encourage more language use and interaction with virtual characters, and use more accurate measurement materials.How will this work help autistic adults now or in the future?: This air travel program may someday help autistic people learn what to expect and how to communicate in a busy airport setting. This program also highlights that new technology, such as VR, could potentially improve access to services and help more people in need in the future.

Treating anxiety in autistic adults: study protocol for the Personalised Anxiety Treatment-Autism (PAT-A©) pilot randomised controlled feasibility trial

BACKGROUND

Anxiety is common in autistic adults and significantly limits everyday opportunities and quality of life. Evidence-based psychological therapies offered by mental health services often fail to meet the needs of autistic adults. The development of appropriate treatments for mental health conditions and, in particular, anxiety has been identified as a key priority by the autism community. The Personalised Anxiety Treatment-Autism (PAT-A©) trial aims to address this need by investigating the feasibility and acceptability of delivering an individualised psychological treatment for anxiety experienced by autistic adults.

METHODS/DESIGN

This is a pilot randomised controlled feasibility trial. Up to 40 autistic adults with clinically diagnosed anxiety will be randomised into one of two groups (either the PAT-A© intervention or Current Clinical Services Plus two emotional literacy skills sessions). Before randomisation, participants will receive a detailed clinical assessment to inform formulation and guide anxiety treatment. As part of the baseline assessment participants will also identify two personally important 'target situations' that cause significant anxiety and impact upon their daily life. Based upon the formulation and identified target situations, participants randomised to the PAT-A© intervention will receive up to 12 individualised, one-to-one therapy sessions. Initial emotional literacy training sessions will be followed by a bespoke, modular, needs-based treatment approach utilising one or more of the following approaches: Mindfulness, Coping with Uncertainty in Everyday Situations (CUES), social anxiety and graded exposure within Virtual Reality Environments. Participants in the control arm will receive two psycho-educational sessions focussing on understanding and describing emotions and be signposted to healthcare provision as required. Data will be collected through quantitative and qualitative methods.

DISCUSSION

This feasibility pilot trial serves as the first stage in the development and evaluation of a manualised personalised, evidence-based psychological therapy treatment for anxiety in autistic adults. Study outcomes will be used to inform an application for a fully powered multi-site intervention trial of adults and young people.

TRIAL REGISTRATION

ISRCTN, ID: 15881562. Retrospectively registered on 9 August 2019.