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Virtual Reality in Pediatric Psychology
Thomas D. Parsons, PhD,a Giuseppe Riva, PhD,b,c Sarah Parsons, PhD,d Fabrizia Mantovani,
PhD,e Nigel Newbutt, PhD,f Lin Lin, EdD,g Eva Venturini, PhD,e Trevor Hall, PsyDh
abstract Virtual reality (VR) technologies allow for controlled simulations of affectively engaging
background narratives. These virtual environments offer promise for enhancing
emotionally relevant experiences and social interactions. Within this context, VR can allow
instructors, therapists, neuropsychologists, and service providers to offer safe, repeatable,
and diversifiable interventions that can benefit assessments and learning in both typically
developing children and children with disabilities. Research has also pointed to VR’s
capacity to reduce children’s experience of aversive stimuli and reduce anxiety levels.
Although there are a number of purported advantages of VR technologies, challenges have
emerged. One challenge for this field of study is the lack of consensus on how to do trials.
A related issue is the need for establishing the psychometric properties of VR assessments
and interventions. This review investigates the advantages and challenges inherent in the
application of VR technologies to pediatric assessments and interventions.
Departments of aPsychology and gLearning Technologies, University of North Texas, Denton, Texas; bDepartment of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy; cApplied
Technology for Neuro-Psychology Laboratory, Istituto Auxologico Italiano, Milan, Italy; dSouthampton Education School, University of Southampton, Southampton, United Kingdom;
eDepartment of Human Sciences for Education, University of Milan, Milan, Italy; fDepartment of Arts and Cultural Industries, University of the West of England, Bristol, United Kingdom; and
hDepartment of Pediatrics, Oregon Health & Science University, Portland, Oregon
Dr T. Parsons conceived and developed the initial draft, contributed to the enhancement of the original draft, and participated in developing the final draft; Dr Riva,
Prof S. Parsons, and Drs Mantovani, Newbutt, Lin, Venturini, and Hall worked with Dr T. Parsons to enhance the original draft and develop it into the final draft; and
all authors have reviewed and approved the final manuscript as submitted.
The analysis, conclusions, and recommendations contained in each paper are solely a product of the individual workgroup and are not the policy or opinions of, nor
do they represent an endorsement by Children and Screens: Institute of Digital Media and Child Development or the American Academy of Pediatrics.
DOI: https://doi.org/10.1542/peds.2016-1758I
Accepted for publication Apr 19, 2017
Address correspondence to Thomas D. Parsons, PhD, Computational Neuropsychology and Simulation Laboratory, Department of Psychology, University of North
Texas, 1155 Union Circle #311280, Denton, TX 76203. E-mail: thomas.parsons@unt.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2017 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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Supplement Article PEDIATRICS Volume 140, number s2, November 2017:e20161758TABLE 1 Comparison of VR Systems
PC-Based VR Mobile-Based VR Console-Based Stand-alone
VR
System Oculus Rift HTC VIVE Samsung Google Google PlayStation VR Allwinner VR Snapdragon
Gear VR Cardboard Daydream 820 VR
Cost, US$ 599 799 99 10–50 69–149 399 99–249 399–450
Hardware High-end PC High-end PC High-end Middle or high- High-end PS4 (299) or None None
requirements (>1000) (>1000) Samsung end Android Android PS4 Pro
(US$) phone phone or phone (399)
(>600) iPhone (>499)
(>299)
Resolution 2160 × 1200 2160 × 1200 2560 × 1440 Depends on Depends on 1920 × 1080 1920 × 1080 2560 × 1440
the phone the phone
(minimum (minimum
1024 × 768) 1920 ×
1080)
Refresh rate 90 Hz 90 Hz 60 Hz 60 Hz 90 Hz minimum 120 Hz 60 Hz 70 Hz
Field of view 110° 110° 101° from 70° 96° 100° 90° 92°
Body tracking Medium or High: head Medium: Medium: head Medium: head Medium or Medium: head Medium or
high: head tracking head tracking tracking high: head tracking high: head
tracking (rotation) tracking (rotation) (rotation) tracking (rotation) tracking
(rotation) and (rotation) (rotation) (rotation)
and volumetric and and
positional tracking positional positional
tracking (full room tracking tracking
(forward size is 15 (forward (forward
and × 15 ft for and and
backward) movement) backward) backward)
User interaction High (by using High (by using Medium (by Low (by using Medium (by High (by using Medium (by Medium (by
with VR a joystick or controllers) using gaze or a using a joystick or using gaze, using gaze,
controllers) gaze, a button) gaze or a controllers) a built-in a built-in
built-in joystick) pad, or a pad, or a
pad, or a joystick) joystick)
joystick)
Software Oculus store Steam store Oculus store Google Play or Google Play PlayStation Google Play Google Play
availability iOS store store
PC, personal computer.
Background computer-generated environments could be applicable across many
that reflect real-world activities.3–5
current technologies.6 Although the
Virtual Reality for Assessment and Within this context, and within the quality, graphic fidelity, and refresh
Training field of VR more widely, there are rates might vary across platforms (as
Virtual reality (VR) is an emerging many technologies that have been highlighted in Table 1), the nature of
technology that can be considered developed and used in educational the VR immersive environments and
the result of the evolution of existing and clinical settings. As such, there is presentation of visual (and audio)
communication interfaces toward a wide range of hardware available stimuli help to ensure similar user
various levels of immersion.1 An to researchers and practitioners. experiences across all platforms.
important difference between VR Table 1 provides a synthesis of
and other media or communication currently available technology and The availability of much more
systems is the sense of presence, highlights the various specifications, affordable devices (as shown in
the “feeling of being there.”2 costs, and user interactions across Table 1) illustrates that VR hardware
Through merging of educational and a spectrum of devices. Although has the potential to become
entertainment environments (eg, these VR technologies differ in their more accessible to a much wider
gamification, VR, and edutainment), specification, size, and portability, demographic than before. Therefore,
coupling of immersive technologies the key affordances of VR (ie, the extent to which the key
(eg, head-mounted displays [HMDs]) immersion, presence, and ecological affordance of presence is supported
with advanced input devices (eg, validity) remain. Therefore, it is likely by the different VR technologies is
gloves, trackers, and brain-computer some key findings (eg, acceptance, a central research question for the
interfaces), and computer graphics, presence, immersion, limited field if we are to really understand
VR is able to immerse users in negative effects) from previous work what features supported by the
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PEDIATRICS Volume 140, number s2, November 2017 S87different hardware are necessary and of educational and entertainment public health by promoting physical
sufficient for supporting effective and environments, virtual environments activity.23
authentic assessment and learning (VEs) and augmented environments
A focus on positive technology also
with VR for a much wider group of have the potential to be a “positive
provides new ways of thinking
children. In other words, VR offers technology” that can improve the
about the locus and, therefore,
an important pathway for narrowing quality of children’s experiences.17,18
solutions of the different challenges
the digital gap nationally and For example, Active Worlds, Second
or problems faced by children with
internationally if we can establish Life, and ecoMobile are platforms
neurocognitive difficulties.24 For
how a sense of presence can be that have been advocated as
example, rather than developing VR
achieved in the most accessible and promoting more active exploration,
to fix the impairments of the child,
available technologies. engagement, student-centered,
VR could be developed to provide
hands-on learning; better
Current State of the Science better insights and awareness into
understanding of complex subjects;
the difficulties experienced by
Recent advances in VR technology and more authentic, collaborative,
individuals so as to promote better
allow for improved efficiency in and experiential opportunities for
understanding from the wider
administration, presentation of solving real-life problems.19
public. The “Too Much Information”
stimuli, logging of responses, and project of the National Autistic
data analyses.7 These features have The Google Expeditions Pioneer Society in the United Kingdom
allowed VR platforms to emerge as Program20 is a good example of is a good example of this kind of
promising tools for pediatric cohorts this emerging trend, which allows approach (http://www.autism.org.
in a number of domains. Examples teachers to take their students uk/VR).
from recent research and reviews on virtual journeys using an
(within the past 10 years) include the application installed on the students’
following: smartphones. In addition to being Future Research
•• Neurocognitive assessment8 teaching and learning tools, VR
allows for data capturing of learners’ One area of future research that
•• Psychotherapy9 attitudes, behavior changes, and will be of interest to clinical
scientists is the performance of
•• Rehabilitation10 “aha” moments. Such a portfolio
of assessments helps serve as a large-scale randomized controlled
•• Pain management11 trial (RCTs). Although quantitative
foundation for educators to develop
•• Prevention and treatment of eating formative assessment loops, address reviews of VR interventions have
disorders12 individual needs, and design better revealed statistically large effects on
a number of affective domains,25
•• Communication training13 learning opportunities.21 In higher
education, VR technologies may future studies can increase the
•• Vocational readiness training14 confidence in these findings through
help prepare students for future
•• Social skills training15 work places in science, technology, the inclusion of control groups and
engineering, mathematics, business, performing RCTs. Furthermore,
Within this context, VR technology
and medicine. This is especially there is need for future studies
can allow instructors, therapists,
the case in training skills and aimed specifically at establishing
neuropsychologists, and service
performance that carry high risks (eg, the ecological validity and other
providers to offer safe, repeatable,
driving, flying, conducting a surgery, psychometric properties of VR
and diversifiable interventions that
managing investments). assessments and interventions
can benefit assessments and learning
for clinical, social, and affective
in both typically developing children
neuroscience research.26
and children with disabilities.16 Augmented reality, too, is an effective
experiential learning tool.22 On After the establishment of
Entertainment and Educational 1 side, it uses virtual objects to psychometric properties of VR
Environments provide nondirective but targeted protocols, future work will be
VR and augmented reality platforms suggestions that help learners assisted by adopting procedures
are rooted in gaming, simulation, to develop knowledge and skills for standardized reporting of
and entertainment experiences. effectively. On the other side, it RCT outcomes. This is especially
Augmented reality overlays virtual allows real-time interactivity in important in the context of new
objects over a real environment, an ecological setting. In particular, designs and relatively untested
resulting in a mixed reality that as demonstrated recently by the features of technology. A potential
can be used for student-centered worldwide success of Pokémon Go, aid for future research can be found
learning scenarios. Given the merging it also has the potential of improving in the Consolidated Standards of
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S88 Parsons et alReporting Trials guideline that can provide an acceptable space safety. Additional research is
ensures readers have the basic for children to use them, especially needed in these areas.
information necessary to evaluate the children with disabilities. With this
quality of a clinical trial.27 said, there is some evidence that Policy Makers
suggests children do not experience
An important challenge in the
HMDs any more negatively than
Recommendations design and development of VR
screen-based media.5,8,
28,
29
Taken
technologies is the difficulty
Clinicians and Providers as a whole, the need to validate and
involved in putting together
confirm the acceptance of evolving
Although VR-based interdisciplinary research teams
and new technologies is evident, and
neuropsychological assessments are for developing appropriate
there is need for more research in
often referenced for their promise of interventions. Furthermore, there
this domain.
enhanced ecological validity,3,26
is increasing recognition that
there are potential practical With this in mind, there is a need, representatives of intended user
limitations that should be before we enter into VR RCTs, groups should also be included
considered. Some VR-based design, and intervention programs, to achieve a better fit between
assessments offer automated to fully validate and understand identified needs and proposed
presentations that do not allow users’ perspectives and ensure that solutions. Although not without
flexibility for clinical examiners to ethical guidelines are established. difficulties, such approaches also
interrupt or test the limits during This could be done in either align with increasing awareness of
assessment. Future development laboratory-based or in situ settings; the need to involve, for example,
of VEs should allow for flexible however, careful attention will members from the clinical and
presentations, wherein clinicians need to be placed on developing educational communities in these
may adjust graphics, stimuli, and protocols to ensure the voices of research agendas more widely. Our
task parameters via an interactive participants are always heard in main recommendation here is that
user interface. Moreover, the any research endeavor involving VR policy makers, including funders,
dearth of established guidelines for technologies. need to support and encourage
the development, administration, more user-centered design
The introduction of affordable approaches to VR development
and interpretation of these HMDs (eg, Oculus Rift, Samsung
assessments could lead to important and evaluation to ensure that end
Gear VR, Google Cardboard) users’ needs and priorities are
psychometric pitfalls. Although makes VR an increasingly popular
these limitations are important more effectively met in research
entertainment and learning venue. programs and projects.
to consider, advances in VR However, the unmonitored use of
technology will allow for continued VR for entertainment has raised
enhancements in approximations of Educators
concerns over the years. For
real-world cognitive and affective example, Segovia and Bailenson30 As mentioned earlier, VR offers great
processes. conducted a study examining potentials for teaching, learning,
There is also the potential for the use of VR in children. They assessment, and interventions.
unintended negative effects found that children exposed to Although VR can provide a safe
of exposure to VEs; stimulus VEs do not always differentiate environment for students to gain
intensity, if taken too far, may between VR-based memories and skills, it usually requires actual
exacerbate rather than ameliorate memories formed in the real world. experiences to fully master a skill.
a deficit. Although this is an Although these findings need to Poorly designed VR environments
important concern, studies using be replicated in additional studies, may lead to misunderstanding or
VR with students diagnosed with the implications demonstrate that faulty training results. In addition, VR
neurodevelopmental disorders have unmonitored and entertainment- can provide authentic assessments
been performed with no reported based VR platforms may not and interventions in schools, where
negative effects.5,8,
28,
29
be appropriate for all children. children and adolescents spend
As we adopt newer and more Moreover, the merging of VR with most of their time. The potential
immersive technologies it is gaming technologies will open VR for VR technologies to be deployed
important that researchers continue to concerns that have been raised in schools and used for distance
to consider the potential negative for gaming and entertainment learning is encouraging even if it
effects (eg, dizziness, sickness, technologies: sedentary lifestyle, is challenging. Its potential will be
displacement) to ensure that cyber addiction, violence, social deepened by the diffusion of VR on
wearable technologies (eg, HMDs) isolation, desensitization, and smartphones.
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PEDIATRICS Volume 140, number s2, November 2017 S89It is the working group’s consensus assessments and interventions
Abbreviations
that investigations into these offers an opportunity for advancing
future research endeavors have our understanding of the cognitive, HMD: h ead-mounted display
the potential to inform policy, affective, psychosocial, and neural RCT: r andomized controlled trial
VE: v
irtual environment
theory, and praxes. Specifically, the aspects of children as they take part
VR: v irtual reality
addition of VR platforms to pediatric in real-world activities.
FUNDING: This special supplement, “Children, Adolescents, and Screens: What We Know and What We Need to Learn,” was made possible through the financial
support of Children and Screens: Institute of Digital Media and Child Development.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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PEDIATRICS Volume 140, number s2, November 2017 S91Virtual Reality in Pediatric Psychology
Thomas D. Parsons, Giuseppe Riva, Sarah Parsons, Fabrizia Mantovani, Nigel
Newbutt, Lin Lin, Eva Venturini and Trevor Hall
Pediatrics 2017;140;S86
DOI: 10.1542/peds.2016-1758I
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/140/Supplement_2/S86
References This article cites 26 articles, 1 of which you can access for free at:
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Downloaded from www.aappublications.org/news by guest on February 21, 2021Virtual Reality in Pediatric Psychology
Thomas D. Parsons, Giuseppe Riva, Sarah Parsons, Fabrizia Mantovani, Nigel
Newbutt, Lin Lin, Eva Venturini and Trevor Hall
Pediatrics 2017;140;S86
DOI: 10.1542/peds.2016-1758I
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/140/Supplement_2/S86
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