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DawnHuizerBIS499Interdisciplinary Studies ProjectDr.

Joshua OlsbergJanuary5th, 2018WillVirtual Reality be employed as a future learning tool to improve socialinteraction performance, reduce phobias and help daily living skills, such asfacial recognition with children and adolescents with high and low functionautism?This research paper will cover the useof virtual reality with children that are diagnosed with Autism SpectrumDisorder and will determine whether or not virtual reality is an actualpowerful tool that may help an individual that suffer from this condition.AutismSpectrum Disorder (ASD) is a neurological condition. The traits of thiscondition are vast and are characterized by repetitive behaviors, impairednon-verbal and verbal communication, and challenged with social skills andinteraction. Individuals with ASD take longer than their peers to acquiresocial and self-care skills without assistance. One in eighty-eight children inthe United States falls under the Autism Spectrum Disorder.

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ASD patients arealso divided into two categories; High Functional Autism (HFA) and LowFunctional Autism (LFA). HFA appear to be similar to their peers as they cancommunicate by using a spoken language, are more aware of social conventionsand may even participate in a classroom setting, whereas LFA usuallycommunicate by using technology or picture boards instead of a spoken languageand their disability is more obvious and are less likely to be included in atypical classroom. Although ASD is divided into these categories, one mustalways bear in mind that individuals with this disability may react differentlyin different situations and both categories may be triggered if they are notfeeling in a safe environment.

In both cases “ASD has a significant economicand social impact due to its high prevalence, the absence of specifictherapeutic intervention, comorbidity, outcome, and impact on families.Discarding medical costs, intensive behavioral interventions for children withASD are estimated to cost between $40,000 to $60,000 for a year for each childin the United States, which is an economic burden for both parents and thegovernment. (17 marco) That is why virtual reality has gained a particularfocus because it will reduce therapy cost drastically. Virtual Reality (VR) addresses the possibilityof creating a computer simulation of real environments and provides saferlearning experiences for individuals with ASD. (marco). Treatment and Educationof Autistic and related Communication Handicapped Children (TEACCH) emphasis onhow important structure and repetition is during a therapy session, this alsoincludes a safe environment that does not overwhelm children with ASD. VirtualReality (VR) offers the potential for presenting learning tasks that arerealistic, but that is presented within a simplified and safe environment.

VRsettings offer a greater benefit to an individual with ASD as they canstimulate a real-world scenario in a controlled place. VR environments rangefrom three-dimensional environments that use a joystick and a home computerthrough to fully immersive environments with a headset display, body trackerand 3D hand controls which are now available for only several hundred dollarsper unit.  Virtual Reality therapystarted in 1990 and till today more advanced and sophisticated VR environmentsare created in order to allow the individual with autism to feel safe duringtherapy.During the research for this paper, theinterdisciplinary subject that covered this topic were Education, Engineering,Health Science, and Psychology. The following paragraphs in this research paperwill be a brief narrative on some authors that covered the interdisciplinaryfields mentioned above. Professor, Anastassios TassosMikropoulos is the Dean of the School of Education and Director of the EducationalApproaches to Virtual Reality Technologies. His discipline is focused mostly onInformation & Communication Technologies (ICT) and Virtual Reality inEducation. He wrote various research articles, eight books, participate inscientific talks and also created several educational software.

Dr. Wass gained a first-classundergraduate degree in Experimental Psychology at Oxford University. He didhis Ph.

D. at the Centre for Brain and Cognitive Development, Birkbeck, and hispostdoctoral research in Cambridge, at the Medical Research Council Cognitionand Brain Sciences Unit. He appears regularly on English television, such asBBC News and radio such as BBC Radio Live, and has given talks at the RoyalInstitution. His work also appears regularly in national newspapers in England.(https://www.sites.google.

com/site/samwass/about).            Dr.Marco Simoes is a Professor at the University Of Coimbra, Portugal in theDepartment of Informatics Engineering.

He wrote several articles and his mainfocus is on virtual reality, 3D and brain-computer interface.(https://www.researchgate.net/profile/Marco_Simoes)Yiju Cai is an Associate Professor withthe College of Engineering, Nanyang Technological University, Singapore. He hasa joint appointment with NTU’s Institute for Media Innovation.

Yiju Cai has aPh. D training in Engineering, MSc training in Computer Graphics -aided Geometry Design, and BSc training in Math. He has been doinginterdisciplinary research especially at the intersection of interactive anddigital media, and biomedical sciences.(https://biography.omicsonline.org/korea/korea-university/cai-yiyu-620864).

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

virginia.edu/psychiatry/faculty/daniel-j-cox-phd-ahpp/)  Dr. Morag Maskey currently works as aresearch assistant in the Institute of Neuroscience, at Newcastle University.Dr.

Maskey published two articles on autism however her professional exposurewas mostly made on the third eye neurotechnology which will be mentioned inthis research paper.(http://www.ncl.ac.uk/ion/staff/profile/moragmaskey.html#publications). Amy Swanson, M.

A., is a research andtraining coordinator at the Vanderbilt Kennedy Center. She received herbachelor’s degree in Psychology from Berea College and earned a Master’s degreein Social Science from the University of Chicago. She has ten years ofexperience focusing on technology-based intervention and training mechanisms toserve both pediatric health care providers and families of young children withautism spectrum disorder. In her current role, Swanson coordinates training onthe Screening Tool for Autism in Toddlers and Young Children (STAT), AutismDiagnostic Autism Schedule (ADOS-2). Dr.

Kwanguk Kim is a postdoctoral fellowat the M.I.N.D. Institute and a member of Dr.

Peter C. Mundy’s Social Attentionand Virtual-reality Laboratories. His previous and ongoing research centersaround the use of virtual reality as a tool to understand psychopathology suchas autism, schizophrenia, obsessive-compulsive disorder, and personalitydisorder, the human-computer interaction (HCI), and the treatment of childrenwith autism spectrum disorder. (http://mindbrain.ucdavis.edu/people/kukkim)Children with ASD both HFA and LFA havedifficulty in recognizing facial emotional expression such as happy, anger,sad, disgust, surprised. Amy Swanson and her colleagues developed an innovativeVR-based facial emotional expression presentation system that allows monitoringof eye gaze and physiological signals related to emotion identification in asynchronous manner. The major objectives of their work were “to develop aninnovative VR-based facial emotional recognition system that allows monitoringof eye gaze and physiological signal, perform a usability study to demonstratethe benefit of such a system in understanding the fundamental mechanism ofemotion recognition.

” (Swanson et al). The eye gaze apparatus measured thedilation of the pupil, the fixation duration and the rate of blinking, whereasthe physiological was monitored by electrocardiogram, pulse plethysmograph,skin temperature and galvanic response. Apart from the skin temperaturemonitoring, all other are associated with the sympathetic response of theautonomic nervous system. Thus when an individual is exposed to an externalfactor such as stress the sympathetic nervous system will automaticallyincrease the heart rate, raises blood pressure and skin temperature.

Duringtheir investigation, the emotional expressions were “enjoyment, surprise,contempt, sadness, fear, disgust and anger and all emotions had four levels ofarousal. All children participating in this research were HFA with average toabove average intelligence and were all drafted through other clinicalprograms. When the HFA subject was shown the emotional expression through anavatar, the gaze pattern concluded that HFA focused more on the forehead areaand less to the mouth area and had an abnormal eye blink and lower pupil diameterthan the control group. From this experiment, the results did not indicate alarge difference between the HFA and the control group as they did recognizethe facial expression, however, the results of the eye gaze were significantlydifferent because the HFA focused more on the forehead area, paid lessattention to the eye area than on the whole face. This research concluded thatchildren with ASD spent more time examining the facial expression prior toresponding and they were often less confident in their rating (Bekele et al).

Using this VR system, the findings were “useful in understanding heterogeneousdeficits individuals with ASD often display in processing and responding to thenonverbal communication of others”. (Bekele et al). Another similar research tostudy emotional responses and social motivation in children with ASD wasconducted by Dr. Kim.

“The paradigm used in this study provided a measure ofpreference for interpersonal distance exhibited by children with higherfunctioning HF ASD in a task involving their ability to recognize differenttypes and intensities of emotion expressed by an avatar”. (Kim et.al) Allparticipants, same as the research mentioned above had already received aclinical diagnosis of HFA. The facial emotions and the intensity level thatthis research had were very similar to the research above. The facial emotionswere happy, fear, anger, disgust, sadness, and surprise.

However, unlike theother experiment, the research had two avatars with both genders. The participantswere not monitored using the eye gaze and physiological signals. The HFAparticipants were instructed to select the best emotional word from a list thatmatches the avatar expression.

Also, the HFA participants were instructed “touse a joystick to move close to, or far from, the avatar as they would if thesituation was occurring in real life. (Kim et al). This research concluded thatthe child with HFA did not have a tendency to move towards someone that ishappy or to move away from some that are angry when compared to the controlgroup. On the other hand, both HFA and the control group recognized the happyemotion. Kim et al concluded that “children with HFA may not experience thesame level of rewards and approach behavior in response to positive affect orthe opportunity to share positive effect with other people”. In her researchpaper, Olga Mantzios et al. mentioned a different experiment which includedavatars in teaching and assessing of facial emotional expressions. The game shementioned in her research developed by Miranda et al.

is known as “Life isGame” and it is designed for children with ASD. This game encourages thechildren with ASD to “identify a specific expression from a set of presentedexpressions regarding full faces, half faces or mixed faces of avatars in comiccartons format, to construct a facial expression in order to match the emotionand to modify the expression of an avatar according to instructions given.”(Mantziou et al). The children suffering from ASD had a positive relationshipbetween the use of the game and the development of facial emotion recognitionskills in real life. (Mantziou et al). However, one must also mention that thetest subjects had HAF and not LAF.

In fact in another case study of 30 childrenwith HFA and four with LFA that also used a single computer with an avatar thathad four facial expression happy, sad, angry and frightened, the children withHAF managed to use the game at a level higher, whereas the children with LAFhad 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 onlyface to face interaction. (Mantziou et al).Virtual Reality is also used to treatand reduce specific Phobias in young children with ASD through a VRintervention.  In her research Maskey etal developed and evaluated a unique treatment combing cognitive behavior withgraduated exposure in a Virtual reality environment (VRE). During a research onfear in ASD children, 41% of the children were scared and had an unusual phobiasuch as toilets, buses, cars etcetera.

 As explained previously, the cost to take care of a child with ASD isfairly expensive and time-consuming. Also, not enough therapists are availablefor dealing with ASD children that suffer from anxiety. Therefore, “there hasbeen interesting in adapting treatments for anxiety for people with ASD, withmuch of this work based on the principles of cognitive behavior therapy(CBT)…which is particularly important given doubts about whether ASD specificsocial and cognitive impairments would render CBT inaccessible”. (Maskey etal). Virtual Reality Environment will increase the accessibility of specificfear in a controlled environment, which will then help people with ASD toovercome their phobia. Also “newly learned skills can be rehearsed andreinforced in a safe and controlled setting” (Maskey et al). With thecollaboration of the staff at Third Eye Technologies Maskey et al developed aVRE called “the blue room”.

“The blue room uses audiovisual images projectedonto the walls and ceilings of a 360 degree seamless screened room.Participants are not required to wear a headset or googles and can move aroundthe room freely, interacting and navigating through the scenario at their owndiscretion. (Masket et al). The selected candidates were screened by Masket anda psychology assistant. Masket and the psychology assistant met with the ASDchild and their parents in the comfort of their house, where they discussed thespecific phobia of the child.

The psychology assistant “explored with the ASDchild the possible steps to full exposure, including starting with short blueVRE sessions and increasing the length of exposure or increasing aspects of thescene.” (Maskey et al). During these home visits, the psychology also preparedthe ASD child and introduced relaxation techniques such as deep breathing, andhow to use positive coping when experience anxiety. These 45 min session were agood foundation before introducing the ASD child to the blue room as theymentally prepared the child. The Blue Room therapy sessions were delivered bythe psychology assistant, overseen by a consultant clinical psychologist.

(Maskey et al). Unlike other VR mentioned in the above research, this researchmentally prepared the ASD child. In the first steps when entering the room, thechild is not immersed directly in his phobia virtual reality environment. Onthe contrary, the trial starts with relaxing sounds with the therapist coachingthe ASD child through breathing and stretching exercises. The VRE will onlystart when the ASD child is ready to proceed.

When the ASD child is mentallyprepared to start the exercise, the VRE scene that will appear will be on a lowanxiety level. For example, if the ASD child is scared to ride a crowded busthe scene would start with just a bus stop and an empty bus. The level willincrease after the ASD child is confident enough to proceed to the secondlevel. The psychologist is in the blue room too and is also evaluating the bodylanguage and response of the ASD child to proceed further. Most importantly theparents were also able to watch their child from another room and monitoredtheir improvement and even learn the techniques that the psychologist used.

Nine ASD children were chosen for this experiment and only one did not improvehis phobia condition. Four of the ASD children completely overcame their phobiaand normalized and these effects were maintained six months, a year and a yearand a half post-treatment (Maskey et al). “The major change for the majority of the children in this study wastheir functional ability to handle the real-life situation they were previouslyafraid of”. (Maskey et al). Maskey et al concluded that modified CBT can beeffective for young people with ASD and high anxiety…CBT techniques deliveredby a therapist in an immersive VRE has potential to be developed as a widelyavailable treatment for phobias in children with ASD. This is because the VREwith CBT offers a greater degree of control over the stimuli than with CBTalone…the therapist and child have a common point of reference for therapeuticwork, without the need for verbal exchange and because VRE taps into a numberof strengths and characteristics, and interest of those with ASD.Apart from the above VRE, the otherresearch that I found interesting was the design and development of a virtualdolphinarium for children with autism. This research was done by Yiyu Cai etal.

In his research Cai et al also emphasis that “intervention and treatmentmethods for children with autism are rare and costly and often involving atrained therapist to work one-on-one or small group sessions for a 40 hour perweek therapy”. The dolphin-assisted therapy is not always available and notaffordable to many. Only thirty-two ASD children attended this therapy in aspan of four years. This therapy consists of the child with ASD to interact inthe pool with a real pink dolphin.

There are steps before the child with ASDcan enter the pool. The child same as the VRE blue room mentioned above ismentally being prepared using the following procedures. The ASD child watchesvarious dolphin videos and listen to dolphin sounds and feels a model dolphinmade of fiberglass. “Claims of benefits from this form of autism therapyinclude better attention, increased somatic awareness of the surroundingenvironment, improvement in gross and fine motor skills and nonverbalcommunication, especially in using hand gestures”. (Cai et al). However, thistherapy also includes a degree of risks, because at the end of the day thedolphin is a very strong animal and even though these dolphins are well trainedthey can snap at any point in time during the therapy.

Therefore Cai and histeam decided to “design and development a virtual dolphinarium to assistchildren with autism to learn nonverbally communication through gesturing. Thedifference 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 butrather is the dolphin’s trainer, which will improve their motor skills andlearn nonverbal communication through hand gesture control. This VDI wasdeveloped inside an immersive room in Singapore. This immersive room is “aninfrastructure design for all NTU researchers to visualize and simulate anyobjects or purposes” (Cai et al.

) Same as the other research in the immersiveroom conducted by Maskey, “a video of the real dolphin training performance isshown to the ASD children before they are invited to the immersive room. (Caiet al.)  To allow the child with autismto do gesturing at poolside, they had to stand close to the screen wearing apair of 3-D shutter glasses to enable an active stereographic view during theinteractive program. (Cai et al.

) When they successfully command the dolphin todo a command, several affects where activated such as water and dolphin sounds.The initial study involved of randomly selecting fifteen children with autismfrom the thirty-two children with autism that participated in the real dolphintherapy. However, unfortunately, from this study out of the fifteenparticipants, only eight participated without any problems and easily learned handgestures, whereas the other participants encounter a problem with the immersiveroom and the 3D google, because they were not feeling in a safe environmenteven though they were accompanied by their parents.In conclusion from the above researchfrom different fields, one may conclude that the main goal, irrelevant of thefield is to find a better way to help children with autism spectrum disorder byusing virtual technology.

Virtual technology is capable of providing a widerange of situations and scenarios that can be used to teach and help childrenwith HFA and LFA in a safe environment where the child will feel at ease. Notall the results of the above research were a success, yet I firmly believe thatvirtual reality will help children with autism to improve their condition andwill be used as a future learning tool to improve social interactionperformance, reduce phobias and help daily living skills, such as facialrecognition. However, although some results were promising, further studiesneed to be performed especially for children with LFA because from the aboveresearch the greatest result was achieved by children with HFA.        Reference

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