Published on in Vol 27 (2025)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/60845, first published .
Effectiveness of Virtual Reality Technology Interventions in Improving the Social Skills of Children and Adolescents With Autism: Systematic Review

Effectiveness of Virtual Reality Technology Interventions in Improving the Social Skills of Children and Adolescents With Autism: Systematic Review

Effectiveness of Virtual Reality Technology Interventions in Improving the Social Skills of Children and Adolescents With Autism: Systematic Review

Review

1College of Physical Education, Shenzhen University, Shenzhen, China

2College of Physical Education, Southwest University, Chongqing, China

3School of Public Teaching, Shanwei Institute of Technology, Shanwei, China

4Department of Education, Shenzhen University, Shenzhen, China

*these authors contributed equally

Corresponding Author:

Zhanbing Ren, PhD

College of Physical Education

Shenzhen University

No. 3688,Nanhai Avenue Nanshan District

Shenzhen, 518000

China

Phone: 86 13318881919

Email: rzb@szu.edu.cn


Background: Virtual reality (VR) technology has shown significant potential in improving the social skills of children and adolescents with autism spectrum disorder (ASD).

Objective: This study aimed to systematically review the evidence supporting the effectiveness of VR technology in improving the social skills of children and adolescents with ASD.

Methods: The search for eligible studies encompassed 4 databases: PubMed, Web of Science, IEEE, and Scopus. Two (XY and JW) researchers independently assessed the extracted studies according to predefined criteria for inclusion and exclusion. These researchers also independently extracted information regarding gathered data on the sources, samples, measurement methods, primary results, and data related to the main results of the studies that met the inclusion criteria. The quality of the studies was further evaluated using the Physiotherapy Evidence Database scale.

Results: This review analyzed 14 studies on using VR technology interventions to improve social skills in children and adolescents with ASD. Our findings indicate that VR interventions have a positive effect on improving social skills in children and adolescents with ASD. Compared with individuals with low-functioning autism (LFA), those with high-functioning autism (HFA) benefited more from the intervention. The duration and frequency of the intervention may also influence its effectiveness. In addition, immersive VR is more suitable for training complex skills in individuals with HFA. At the same time, nonimmersive VR stands out in terms of lower cost and flexibility, making it more appropriate for basic skill interventions for people with LFA. Finally, while VR technology positively enhances social skills, some studies have reported potential adverse side effects. According to the quality assessment using the Physiotherapy Evidence Database scale, of the 14 studies, 6 (43%) were classified as high quality, 4 (29%) as moderate quality, and 4 (29%) as low quality.

Conclusions: This systematic review found that VR technology interventions positively impact social skills in children and adolescents with ASD, with particularly significant effects on the enhancement of complex social skills in individuals with HFA. For children and adolescents with LFA, progress was mainly observed in basic skills. Immersive VR interventions are more suitable for the development of complex skills. At the same time, nonimmersive VR, due to its lower cost and greater flexibility, also holds potential for application in specific contexts. However, the use of VR technology may lead to side effects such as dizziness, eye fatigue, and sensory overload, particularly in immersive settings. These potential issues should be carefully addressed in intervention designs to ensure user comfort and safety. Future research should focus on optimizing individualized interventions and further exploring the long-term effects of VR interventions.

Trial Registration: International Platform of Registered Systematic Review and Meta-analysis Protocols INPLASY202420079U1; https://inplasy.com/inplasy-2024-2-0079/

J Med Internet Res 2025;27:e60845

doi:10.2196/60845

Keywords



Background

Autism spectrum disorder (ASD) is a neurodevelopmental condition marked by challenges in social interaction and communication, as well as by the presence of repetitive and stereotyped interests and behaviors [First MB. Diagnostic and statistical manual of mental disorders, 5th edition, and clinical utility. J Nerv Ment Dis. 2013;201(9):727-729. [CrossRef] [Medline]1]. The precise etiology of ASD remains elusive; however, studies indicate that a combination of genetic, environmental, and neurodevelopmental factors may contribute to its development [Loomes R, Hull L, Mandy WPL. What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(6):466-474. [CrossRef] [Medline]2]. Statistics from the US Centers for Disease Control and Prevention have shown a marked rise in the prevalence of ASD diagnoses in recent decades, with 1 in 77 children currently being diagnosed [Pain O, Pocklington AJ, Holmans PA, Bray NJ, O'Brien HE, Hall LS, et al. Novel insight into the etiology of autism spectrum disorder gained by integrating expression data with genome-wide association statistics. Biol Psychiatry. 2019;86(4):265-273. [FREE Full text] [CrossRef] [Medline]3]. Social impairment is often characterized by difficulty interpreting social cues, including changes in facial expressions, body language, and tone of voice. This can lead to children and adolescents with ASD displaying a reduced interest in, or maladaptive responses to, social situations [Sandin S, Lichtenstein P, Kuja-Halkola R, Hultman C, Larsson H, Reichenberg A. The heritability of autism spectrum disorder. JAMA. 2017;318(12):1182-1184. [FREE Full text] [CrossRef] [Medline]4]. Currently, early intervention is an effective way to improve the social skills of children and adolescents with ASD [Ozonoff S, Young GS, Carter A, Messinger D, Yirmiya N, Zwaigenbaum L, et al. Recurrence risk for autism spectrum disorders: a baby siblings research consortium study. Pediatrics. 2011;128(3):e488-e495. [FREE Full text] [CrossRef] [Medline]5,Rogers S, Vismara LA. Evidence-based comprehensive treatments for early autism. J Clin Child Adolesc Psychol. 2008;37(1):8-38. [CrossRef] [Medline]6].

Individuals with ASD experience significant deficits in social skills. These deficits manifest as difficulties in understanding others’ emotions and intentions, establishing and maintaining social relationships, and lacking flexibility in social interactions [Mehling M, Tassé MJ. Severity of autism spectrum disorders: current conceptualization, and transition to DSM-5. J Autism Dev Disord. 2016;46(6):2000-2016. [CrossRef] [Medline]7]. Such challenges often lead to increased social isolation and a decreased quality of life for those with ASD [Hirota T, King BH. Autism spectrum disorder: a review. JAMA. 2023;329(2):157-168. [CrossRef] [Medline]8]. The severity of ASD symptoms varies; individuals with high-functioning autism (HFA) usually experience milder social impairments, while those with low-functioning autism (LFA) face more severe communication challenges [Aldred C, Green J, Adams C. A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry. 2004;45(8):1420-1430. [CrossRef] [Medline]9]. Various interventions have been developed to address social skill deficits in individuals with ASD, achieving varying levels of success. For example, applied behavior analysis (ABA) is a therapeutic approach designed to improve social skill acquisition and enhance social motivation among individuals with ASD. Research by Roane et al [Roane H, Fisher WW, Carr JE. Applied behavior analysis as treatment for autism spectrum disorder. J Pediatr. 2016;175:27-32. [CrossRef] [Medline]10] suggests that individualized, ABA-based interventions can significantly improve developmental outcomes for individuals with ASD, leading to progressive enhancements in social skills [Weiss MJ, Harris SL. Teaching social skills to people with autism. Behav Modif. 2001;25(5):785-802. [CrossRef] [Medline]11]. In addition, speech therapy offers personalized language and communication support, helping individuals gradually improve social communication skills. In the Social Communication Intervention Project (SCIP) led by Adams et al [Adams C, Lockton E, Freed J, Gaile J, Earl G, McBean K, et al. The social communication intervention project: a randomized controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. Int J Lang Commun Disord. 2012;47(3):233-244. [CrossRef] [Medline]12], it was found that speech therapy could enhance expressive language and comprehension, enabling individuals to gradually improve social skills by practicing conversations, learning communication techniques, and using assistive tools [Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev. 2004;2004(2):CD003466. [FREE Full text] [CrossRef] [Medline]13]. Cognitive behavioral therapy (CBT) is also widely used to address critical symptoms and socio-emotional challenges in children and adolescents with ASD. A meta-analysis by Wang et al [Wang X, Zhao J, Huang S, Chen S, Zhou T, Li Q, et al. Cognitive behavioral therapy for autism spectrum disorders: a systematic review. Pediatrics. 2021;147(5):e2020049880. [CrossRef] [Medline]14] revealed significant improvements in both autistic symptoms and socio-emotional issues following CBT. Despite the considerable benefits of these traditional interventions, they have certain limitations. The high costs and the need for specific therapeutic environments and specialized therapists make these services inaccessible for many families, limiting their reach and frequency [Sapiets SJ, Totsika V, Hastings RP. Factors influencing access to early intervention for families of children with developmental disabilities: a narrative review. J Appl Res Intellect Disabil. 2021;34(3):695-711. [FREE Full text] [CrossRef] [Medline]15,Maglione MA, Gans D, Das L, Timbie J, Kasari C, Technical Expert Panel, et al. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012;130 Suppl 2:S169-S178. [CrossRef] [Medline]16]. In addition, the lack of personalization in traditional methods may impact their effectiveness, especially for individuals with varying needs and responses [Lord C, Charman T, Havdahl A, Carbone P, Anagnostou E, Boyd B, et al. The Lancet Commission on the future of care and clinical research in autism. Lancet. 2022;399(10321):271-334. [CrossRef] [Medline]17]. These limitations underscore the importance of exploring alternative, more adaptable, individualized, and cost-effective intervention strategies.

Virtual reality (VR) technology, as a promising tool for promoting health, has gradually been applied in various fields, including gaming, education, health care, and psychotherapy. In gaming and entertainment, VR technology provides users with a highly immersive experience, allowing them to be fully immersed in a virtual world, which enhances interactivity and engagement [Wu J, Loprinzi PD, Ren Z. The rehabilitative effects of virtual reality games on balance performance among children with cerebral palsy: a meta-analysis of randomized controlled trials. Int J Environ Res Public Health. 2019;16(21):4161. [FREE Full text] [CrossRef] [Medline]18,Fodor L, Coteț CD, Cuijpers P, Szamoskozi Ș, David D, Cristea IA. The effectiveness of virtual reality based interventions for symptoms of anxiety and depression: a meta-analysis. Sci Rep. 2018;8(1):10323. [FREE Full text] [CrossRef] [Medline]19]. VR simulates laboratories and historical scenes in education, enabling students to engage in hands-on learning within a safe virtual environment, thereby promoting deeper understanding and knowledge retention [Wu J, Ma Y, Ren Z. Rehabilitative effects of virtual reality technology for mild cognitive impairment: a systematic review with meta-analysis. Front Psychol. 2020;11:1811. [FREE Full text] [CrossRef] [Medline]20]. VR has been widely used in health care for rehabilitation, pain management, and psychotherapy [Wu J, Sun Y, Zhang G, Zhou Z, Ren Z. Virtual reality-assisted cognitive behavioral therapy for anxiety disorders: a systematic review and meta-analysis. Front Psychiatry. 2021;12:575094. [FREE Full text] [CrossRef] [Medline]21,Beheshti J, Bilal D, Druin A, Large A. Testing children's information retrieval systems: Challenges in a new era. Proc. Am. Soc. Info. Sci. Tech. 2011;47(1):1-4. [FREE Full text] [CrossRef]22]. Research by Rizzo and Koenig [Rizzo AS, Koenig ST. Is clinical virtual reality ready for primetime? Neuropsychology. 2017;31(8):877-899. [CrossRef] [Medline]23] suggests that VR technology provides a highly personalized interactive environment for psychotherapy and cognitive rehabilitation, helping patients better engage in treatment. Moreover, VR aids motor rehabilitation, particularly for patients with Parkinson disease and children with balance disorders, significantly enhancing recovery outcomes [Wu J, Zhang H, Chen Z, Fu R, Yang H, Zeng H, et al. Benefits of virtual reality balance training for patients with parkinson disease: systematic review, meta-analysis, and meta-regression of a randomized controlled trial. JMIR Serious Games. 2022;10(1):e30882. [FREE Full text] [CrossRef] [Medline]24]. VR interventions can be categorized into immersive and nonimmersive types, depending on the realism of the simulated scenes [Bevilacqua R, Maranesi E, Riccardi GR, Donna VD, Pelliccioni P, Luzi R, et al. Non-immersive virtual reality for rehabilitation of the older people: a systematic review into efficacy and effectiveness. J Clin Med. 2019;8(11):1882. [FREE Full text] [CrossRef] [Medline]25]. Immersive VR typically uses head-mounted displays to fully engage the user’s senses, offering a highly realistic experience, thus making it particularly suitable for interventions requiring deep involvement [Horvat N, Martinec T, Perišić M, Škec S. Comparing design review outcomes in immersive and non-immersive collaborative virtual environments. Procedia CIRP. 2022;109:173-178. [FREE Full text] [CrossRef]26]. In contrast, nonimmersive VR is experienced through traditional computer displays, offering greater flexibility and accessibility, thus making it more appropriate for everyday educational settings [Smith C, Read JE, Bennie C, Hale L, Milosavljevic S. Can non-immersive virtual reality improve physical outcomes of rehabilitation? Physical Therapy Reviews. 2013;17(1):1-15. [FREE Full text] [CrossRef]27]. For ASD interventions, Parsons and Cobb [Parsons S, Cobb S. State-of-the-art of virtual reality technologies for children on the autism spectrum. Eur. J. Spec. Needs Educ. 2011;26(3):355-366. [FREE Full text] [CrossRef]28] conducted an in-depth study on the application of VR technology, noting that VR can provide a safe virtual environment for children with ASD to practice social skills without real-world pressures. Therefore, VR technology holds significant potential as an innovative and adaptable intervention for addressing social skill deficits in children and adolescents with ASD.

Objective

Although VR technology has shown great potential in the fields of education and therapy, especially in improving social skills in children and adolescents with ASD, empirical research remains limited. Therefore, this systematic review aims to evaluate the effects of VR interventions in ASD treatment and address the following key research questions: (1) What are the differences in the positive effects of VR interventions on the social skills of children and adolescents with HFA versus LFA? (2) How do different types of VR interventions impact the social skills of children and adolescents with ASD? and (3) Are there potential adverse effects of VR interventions on children and adolescents with ASD?

To answer these questions, this study aims to achieve the following objectives: (1) to compare the positive effects of VR interventions on the social skills of children and adolescents with HFA and LFA, (2) to analyze the impact of different types of VR interventions on the social skills of children and adolescents with ASD, and (3) to evaluate the potential adverse effects of VR interventions on children and adolescents with ASD.


Recruitment

Our research protocol was registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols (ID: INPLASY202420079U1). This study followed the PRISMA (Preferred Reporting Items for Systematic Evaluation) guidelines to ensure transparency in the research process [Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. [CrossRef] [Medline]29,Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. [FREE Full text] [CrossRef] [Medline]30].

Search Strategy

A comprehensive search was conducted across 4 electronic databases: PubMed, Web of Science, IEEE, and Scopus, as of April 11, 2024, to systematically identify pertinent studies concerning the impact of VR technology on improving the social abilities of children and adolescents with ASD. The search focused explicitly on peer-reviewed articles published in English. The search strategy incorporated keywords such as VR, ASD, social skills, communication skills, children, and adolescents.

Multimedia Appendix 1

Search research strategy.

DOCX File , 12 KBMultimedia Appendix 1 provides detailed information about the search terms used. Previous reviews have described the selection of search terms for VR interventions, social skills, and children and adolescents with ASD [Mesa-Gresa P, Gil-Gómez H, Lozano-Quilis J, Gil-Gómez J. Effectiveness of virtual reality for children and adolescents with autism spectrum disorder: an evidence-based systematic review. Sensors (Basel). 2018;18(8):2486. [FREE Full text] [CrossRef] [Medline]31]. In addition, researchers manually searched the included studies’ reference lists to identify relevant articles.

Eligibility Criteria

The criteria for inclusion in the study were developed using the PICOS (Population, Intervention, Comparison, Outcomes, and Study design) principles [Morgan R, Whaley P, Thayer KA, Schünemann HJ. Identifying the PECO: a framework for formulating good questions to explore the association of environmental and other exposures with health outcomes. Environ Int. 2018;121(Pt 1):1027-1031. [FREE Full text] [CrossRef] [Medline]32], as follows:

  • Population: The participants were children and adolescents aged 3-18 years, diagnosed by a physician or by a reliable ASD assessment tool. Mixed studies on children and adolescents with attention deficit/hyperactivity disorder, Down syndrome, or other neurodevelopmental disorders were excluded.
  • Intervention: This study investigated the implementation of VR technology as an intervention in clinical settings or clinical trials.
  • Comparison: No restrictions were placed on the control group.
  • Outcomes: All studies used a validated tool or methodology to assess the social competence of children and adolescents with ASD.
  • Study design: There were no restrictions on trial design, including randomized and nonrandomized controlled trials.

Study Selection and Data Extraction

Two researchers independently conducted a multistep search and assessed the studies based on the titles, abstracts, and full texts. To evaluate the risk of bias in the included studies, we used the Cochrane Risk of Bias tool [Minozzi S, Cinquini M, Gianola S, Gonzalez-Lorenzo M, Banzi R. The revised cochrane risk of bias tool for randomized trials (RoB 2) showed low interrater reliability and challenges in its application. J Clin Epidemiol. 2020;126:37-44. [CrossRef] [Medline]33]. This tool evaluates bias across several domains, including random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and other sources of bias. Two (XY and JW) researchers independently assessed each study, resolving disagreements through discussion or consulting a third researcher [Armijo-Olivo S, Ospina M, da Costa BR, Egger M, Saltaji H, Fuentes J, et al. Poor reliability between cochrane reviewers and blinded external reviewers when applying the Cochrane risk of bias tool in physical therapy trials. PLoS One. 2014;9(5):e96920. [FREE Full text] [CrossRef] [Medline]34].

The team created a data extraction form to collect information about each study’s characteristics, including details of the literature (authors and year), participant characteristics (sample size and age range), intervention components (location, intervention design, frequency, and duration), measurement instruments, and data related to primary outcomes. To increase transparency, we have included the PRISMA checklist in the

Multimedia Appendix 2

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

DOCX File , 22 KBMultimedia Appendix 2. This checklist provides a comprehensive overview of the methodology followed throughout the study, ensuring all relevant criteria are addressed and documented. This addition will allow readers to understand our research process better and replicate it.

Quality Assessment

The methodological quality of each included study was independently assessed by 2 researchers according to the Physiotherapy Evidence Database (PEDro) scale [Herbert R, Moseley A, Sherrington C. PEDro: a database of randomised controlled trials in physiotherapy. Health Inf Manag. 1998;28(4):186-188. [CrossRef] [Medline]35]. The decision to use the PEDro scale was based on its widespread use and recognition in assessing the quality of clinical trials, particularly in physiotherapy and rehabilitation [Herbert R, Moseley A, Sherrington C. PEDro: a database of randomised controlled trials in physiotherapy. Health Inf Manag. 1998;28(4):186-188. [CrossRef] [Medline]35]. Despite the challenges posed by VR studies, the PEDro scale remains a valuable tool due to its comprehensive assessment of key methodological aspects, such as randomization and allocation concealment, which are critical for reducing bias in clinical research [Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721. [Medline]36].

The PEDro scale consists of 11 scoring criteria: eligibility criteria (not scored), random allocation, concealed allocation, baseline comparability, blinding of subjects, blinding of therapists, blinding of assessors, sufficient follow-up, intention-to-treat analysis, between-group comparisons, and point estimates with variability [Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721. [Medline]36]. PEDro scores ranged from 0 to 10, with a median score of 5. However, scoring individuals and therapists participating in VR technology trials can be challenging, and blinding participants or therapists in VR studies is often not feasible due to the nature of the technology, as both parties are usually aware of the ongoing intervention [Sherrington C, Moseley AM, Herbert RD, Elkins MR, Maher CG. Ten years of evidence to guide physiotherapy interventions: Physiotherapy Evidence Database (PEDro). Br J Sports Med. 2010;44(12):836-837. [CrossRef] [Medline]37]. Therefore, considering the limitations of using VR technology, the scoring system can be categorized into 3 categories: high quality ≥6, appropriate quality=4-5, and low quality ≤3 [Armijo-Olivo S, da Costa BR, Cummings GG, Ha C, Fuentes J, Saltaji H, et al. PEDro or cochrane to assess the quality of clinical trials? A meta-epidemiological study. PLoS One. 2015;10(7):e0132634. [FREE Full text] [CrossRef] [Medline]38]. In total, 2 (XY and JW) researchers independently assessed the methodological quality of the included studies according to the 11 PEDro criteria and calculated a total score to determine the quality of the study [Cheung M, Vijayakumar R. A guide to conducting a meta-analysis. Neuropsychol Rev. 2016;26(2):121-128. [CrossRef] [Medline]39].

Disagreements regarding quality ratings should be deliberated until a consensus is achieved; if consensus proves elusive, a third researcher makes the final decision following a mutual discussion.


Search Results

Figure 1 illustrates the specific search process, during which we initially retrieved 724 relevant studies: 30 from PubMed, 236 from Web of Science, 262 from IEEE, 196 from Scopus, and 5 additional studies (manual screening of reference lists and consultations with experts in the field). After excluding duplicates, 532 studies were included in the final analysis. First, 396 irrelevant studies were excluded based on title and abstract screening. The researchers removed 91 incomplete studies, leaving 45 studies for analysis. The final exclusion of reports and abstracts, studies lacking trial data, books, patents, and non-English language studies resulted in the inclusion of 14 studies.

Figure 1. The flow chart of literature screening.

Research Characteristics

A total of 14 relevant studies were included in this review [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], with detailed characteristics of each study presented in Tables 1 and 2.

Table 1. Study characteristics.
AuthorCountry or regionAge range (year)Diagnostic methodsSample size, n (IGa and CGb)HFAc or LFAdSetting
Matsentidou and Poullis [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]Cyprus9-10NRe12HFAClinical
Cheng et al [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41]Taiwan10-13NR3HFASchool
Ip et al [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]Hong Kong6-12NR72 (36 and 36)HFASchool
Rosenfield et al [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43]United StatesNRNR2HFASchool
Junaidi et al [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]Indonesia13-18NR7LFAClinical
Yeh and Meng [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45]Taiwan7-14NR10HFASchool
Tsai et al [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46]Taiwan7-9DSM-5f3HFAClinical
Soltani Kouhbanani et al [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47]Iran6-12DSM-530 (15 and 15)HFA and LFAClinical
Moon and Ke [Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]United States10-14NR15HFASchool
Elkin et al [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]United States6-17DSM-510HFA and LFAClinical
Frolli et al [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]Italy9-10DSM-560 (30 and 30)HFAClinical
Ke et al [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]United States10-14NR7HFAClinical
Zhao et al [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]China3-5DSM-544 (22 and 22)HFA and LFAClinical
Moon and Ke [Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]United States12-13DSM-54HFA Clinical

aIG: intervention group.

bCG: control group.

cHFA: high-functioning autism.

dLFA: low-functioning autism.

eNR: not reported.

fDSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Table 2. Intervention information and main findings
ReferencesImmersive or nonimmersiveInterventionFrequency (length)TypeMeasuresMain findings
Matsentidou and Poullis [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]ImmersiveCAVEaNRbChronicBehavior observationResults are “encouraging”
Cheng et al [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41]Immersive3D-SUc6 wkChronicSocial events card; social behaviors scaleImproved nonverbal communication, social initiations, and social cognition behaviors
Ip et al [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]ImmersiveCAVE2/wk; 14 wkChronicPsychoeducational Profile (Third Edition)Social interactions (P<.05); emotional expression (P<.01)
Rosenfield et al [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43]ImmersiveVRdNRChronicBehavior observationTo help effectively
Junaidi et al [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]NonimmersiveVRNRAcuteBehavior observationSupports shopping skill development effectively
Yeh and Meng [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45]NonimmersiveVR-SSTe1/wk; 8 wkChronicSocial skills evaluation sheetAnswer speed (P<.05); conversation and expression (P<.05); the completeness of sentence-structure (P<.05); conversation etiquette (P<.05)
Tsai et al [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46]ImmersiveCAVE5 wkChronicSocial Skills Training ScalesTPP-RPGf system improved social skills (P<.01), maintained after intervention
Soltani Kouhbanani et al [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47]NonimmersiveVR7/wk; 12 wkChronicVineland Adaptive Behavior ScaleSocial skills (P<.01); behavioral symptoms (P<.01)
Moon and Ke [Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]NonimmersiveVR-SST8 wkChronicJaccard IndexTreatment integrity scores improved (P<.05)
Elkin et al [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]ImmersiveVR-SCg1 timeChronicBehavior observationEnhances propensity for social interaction through gaze behavior analysis
Frolli et al [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]Immersive3D projection of primary emotions3/wk; 12 wkChronicImage testingPrimary emotions (P=.25); emotions and situations for primary emotions (P<.05)
Ke et al [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]NonimmersiveVR-SST2/wk; 15 wkChronicSimulator Sickness Questionnaire; Social Communication QuestionnaireSimulator Sickness Questionnaire Self (P>.05); Simulator Sickness Questionnaire Parent (P>.05); Social Communication Questionnaire (P>.05)
Zhao et al [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]NonimmersiveVR3/wk; 12 wkChronicPsychoeducational Profile (Third Edition)Social interaction (P<.01); emotional expression (P<.01)
Moon and Ke [Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]NonimmersiveVR-SST3/wk; 8 wkChronicSimulator Sickness QuestionnaireSocial-interaction initiation (P<.05); responding to social interactions (P>.05); interpersonal negotiation (P<.05); self-identity (P>.05); Simulator Sickness Questionnaire Self (P>.05)

aCAVE: cave automatic virtual environment.

bNR: not reported.

c3D-SU: 3D Immersive Virtual Environment System to Enhance Social Understanding.

dVR: virtual reality.

eVR-SST: virtual reality social skills training.

fTPP-RPG: third-person perspective role-playing game.

gVR-SC: virtual reality safe course.

The 14 studies included 279 children and adolescents with ASD aged 3-18 years [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. Six studies used the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) to diagnose children and adolescents with ASD [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], while 8 studies had clinical diagnoses made by physicians (Table 1) [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51].

Of these 14 studies, 5 were from the United States [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]; 1 from Hong Kong [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]; 1 from Iran [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47]; 1 from Cyprus [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]; 1 from Indonesia [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]; 3 from Taiwan, China [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46]; 1 from Italy [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]; and 1 from China [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]. In terms of the trial design, 1 study used a single case trial [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]; 4 used a randomized controlled trial [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]; and 9 used a single-group, before-and-after controlled trial [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41,Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53] (Table 1).

Regarding trial sites, 9 studies were conducted in institutions or clinics [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], and 5 were conducted in homes or schools (Table 1) [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48].

In terms of intervention modalities, 3 studies used a cave automatic virtual environment [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46], 1 study used a 3D Immersive Virtual Environment System to Enhance Social Understanding [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41], 4 studies used VR Social Skills Training [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], 1 study used VR SAFE Course [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49], 1 study used a 3D projection of primary emotions [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50], and 5 studies did not report the specific VR technology and content used (Table 2) [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52].

The 14 studies had a minimum intervention period of 1 day [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49] and a maximum of 15 weeks [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]. Notably, 3 studies did not report detailed information on the duration of the intervention (Table 2) [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744].

To assess social competence, 2 studies used the Psychoeducational Profile (Third Edition) [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52], 2 used the Simulator Sickness Questionnaire [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], 1 used the Social Events Card and Social Behaviors Scale [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41], 1 used the Vineland Adaptive Behaviour Scale [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47], and 1 used the Jaccard Index scores [Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]. One study used image testing [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50], 1 study used the Social Communication Questionnaire [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51], 1 study used Social Skills Training scales and the Likert Scale [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46], 1 study used speech data mining [Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], 1 study used Social Skills Performance Evaluation Sheet [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45], and 4 studies used behavioral observation and analysis (Table 2) [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49].

Quality Evaluation

Details of the quality assessments of the included studies are presented in Table 3. The 14 studies had an average PEDro quality (overall study quality) score of 5.21, of which 6 had an overall study quality score of ≥7. All 14 studies met the eligibility criteria and point measures criteria, reflecting a general consistency in study design and a general focus on outcome assessment. Random allocation, concealed allocation, and between-group comparison were implemented in 6 studies each. In contrast, a similar-at-baseline comparison was implemented in 10 studies, demonstrating that a proportion of the studies attempted to adopt the methodological criteria of randomization and control in their design to enhance the validity and credibility of the findings.

No studies implemented subject blinding, therapist blinding, or assessor blinding simultaneously, suggesting that the use of blinding was very limited in these studies, which may be due to the specific design and implementation settings of the studies. Most studies (n=11) reported a participant attrition dropout rate. Still, they did not perform intention-to-treat analyses, which may have affected the interpretation and generalization of the findings.

Table 3. Methodological quality assessment of included studies.
ReferencesEligibility criteriaRandom allocationConcealed allocationSimilar at baselineSubject blindedTherapist blindedAssessor blindedDropout rateIntention-to-Treat analysisBetween-group comparisonPoint measuresTest of statistical significanceOverall study quality
Matsentidou and Poullis [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]1a0b00000000102
Cheng et al [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41]1000000100114
Ip et al [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]1111001101119
Rosenfield et al [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43]1000000000102
Junaidi et al [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]1001000100104
Yeh and Meng [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45]1111000101107
Tsai et al [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46]1001000000103
Soltani Kouhbanani et al [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47]1000000000102
Moon and Ke [Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]1111100101119
Elkin et al [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]1111010101108
Frolli et al [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]1111000101118
Ke et al [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]1111000101107
Zhao et al [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]1001000100104
Moon and Ke [Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]1001000100104

a1: Yes.

b0: No.

Main Findings

Impact of VR Interventions on the Social Skills of Children and Adolescents With ASD

Among the 14 studies included [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], 71% (n=10) of the participants were individuals with HFA [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], 21% (n=3) included both participants with HFA and LFA [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52], and 7% (1) involved only participants with LFA (Table 1) [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]. We found that VR interventions significantly improved the social skills of children and adolescents with HFA, while the improvements for participants with LFA were more limited (Table 4).

Table 4. The main results and conclusions of the included studies.
ReferencesMain resultsAdverse effectsConclusions
Matsentidou and Poullis [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]75% success in street crossingYesVRa improves social skills
Cheng et al [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41]Increases in initiation, cognition, non-verbalNRb3D-SUc enhances social initiation skills
Ip et al [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]Significant improvements in emotion and social interactionYesVR enhances emotional regulation and social skills
Rosenfield et al [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43]Reduced response time in conversationYesVR facilitates conversation practice
Junaidi et al [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]Moderate effectiveness; high readabilityYesVR moderately effective for clarity
Yeh and Meng [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45]Improved answer speed and conversation skillsNRVR enhances conversation etiquette
Tsai et al [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46]Increased correct social responsesYesTPP-RPGd improves social reciprocity
Soltani Kouhbanani et al [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47]Maintained social improvements at follow-upNRVR + risperidone enhances social behavior
Moon and Ke [Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]Enhanced initiation and negotiation skillsNREnhanced initiation and negotiation skills
Elkin et al [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]Gaze behavior varies with ASDe severityNRVR differentiates gaze behavior by severity
Frolli et al [Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]Faster emotion recognitionNRVR accelerates social skills acquisition
Ke et al [Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]Improved social initiation and flexibilityYesVR enhances social interaction
Zhao et al [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]Increased cognitive and social scoresNRVR + rehab boosts cognitive or social skills
Moon and Ke [Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]Improved social interaction scoresNRVR prompts improve social skills

aVR: virtual reality.

bNR: not reported.

c3D-SU: 3D Immersive Virtual Environment System to Enhance Social Understanding.

dTPP-RPG: Third-Person Perspective Role-Playing Game.

eASD: autism spectrum disorder.

Studies focusing on HFA consistently demonstrated that VR social skills training systems significantly improved the social skills of children and adolescents with HFA [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. Some studies also found that VR training effectively enhanced eye contact and the quality of social interactions in individuals with HFA [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]. Other research indicated that VR training helped HFA children and adolescents improve cognitive flexibility, social initiative, and conflict resolution skills [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. In comparison, the effects of VR interventions on children and adolescents with LFA were less pronounced [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. While VR-based shopping skills training was found to help individuals with LFA improve basic life skills to some extent, the overall progress was slower, and the degree of improvement was not as significant as in individuals with HFA [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]. Although some studies found that LFA participants did not perform as well as participants with HFA in VR settings, others still reported that VR interventions helped them progress in self-care skills [Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]. Furthermore, the research emphasized that continuous improvements in adaptive prompts and personalized training could offer more support for individuals with LFA [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52].

Impact of Different VR Intervention Approaches on the Social Skills of Children and Adolescents With ASD

Of the included studies, 64% (9/14) were conducted in institutional or clinical settings [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], while 36% (5/14) were conducted in-home or school environments (Table 1) [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]. We found that interventions conducted in institutional or clinical settings generally had greater control and professional oversight (Table 4) [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. These settings often had specialized equipment and supervision by therapists, resulting in more significant intervention effects, which were better suited for highly customized interventions for children and adolescents with ASD [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46]. However, the primary advantages of home- or school-based interventions were their convenience and real-world applicability [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45]. Although these interventions had relatively less control, they still demonstrated benefits in terms of flexibility and cost-effectiveness [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48].

Regarding intervention duration and frequency, 79% (11/14) of the studies reported this information [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41,Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53], while 21% (3/14) did not [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]. The intervention duration ranged from as short as 1 day to as long as 15 weeks (Table 2) [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]. Compared to short-term interventions, we found that long-term interventions led to more significant improvements in social skills and cognitive flexibility (Table 4) [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. In addition, higher-frequency interventions generally produced more noticeable improvements, while lower-frequency interventions, although beneficial, did not yield results as strong as high-frequency ones [Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. Lower-frequency interventions may not sufficiently reinforce the skills being taught, leading to weaker transfer effects [Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45]. Overall, the most effective intervention duration was found to be 6 to 15 weeks, with a frequency of at least 2-3 sessions per week [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. This high-frequency, long-term intervention model provided participants ample opportunities to practice, ensuring effective social skills development and long-term retention [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53].

Of the studies, 50% (7/14) used immersive VR technology [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50], while 50% (7/14) used nonimmersive VR systems (Table 2) [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. We found that immersive VR was more effective for complex social skills training, especially in participants with HFA (Table 4) [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]. Immersive VR technology, by providing rich multisensory stimulation, allowed participants to better grasp emotional expression and social interaction skills within simulated environments [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]. In more complex school scenarios, immersive VR better supports participants in practicing and transferring learned skills to real-life situations [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]. Finally, immersive VR training experiences received positive feedback, and no instances of motion sickness were reported [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43]. While nonimmersive VR systems, such as desktop-based VR, did not offer fully immersive experiences, they still demonstrated advantages in terms of flexibility, cost, and adaptability [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53].

Adverse Effects of VR Interventions on Children and Adolescents With ASD

Although VR technology significantly improved social skills, 6 studies reported adverse side effects associated with its use (Table 4) [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42-Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]. One study found that some children and adolescents with HFA experienced dizziness and nausea while using the cave automatic virtual environment system [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640]. Another study reported that 71% (10/14) of children and adolescents with LFA experienced anxiety and fear when using head-mounted displays for the first time, and most participants felt fatigued after using VR devices [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]. In addition, 2 other studies also reported anxiety-related issues [Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]. While overall, the use of VR technology for social skills training was positive, some children reported discomfort, although no cases of motion sickness were observed [Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43]. Another study indicated that children and adolescents with HFA experienced headaches and eye fatigue, particularly after prolonged use of VR devices [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42].


Principal Findings

This systematic review analyzed the effects of VR interventions on the social skills of children and adolescents with ASD. The results showed that VR interventions significantly impacted individuals with HFA, while the effects on those with LFA were more limited. The study also indicated that the duration and frequency of the interventions had a notable impact on their effectiveness. Moreover, immersive VR was found to be more suitable for training complex skills in individuals with HFA. At the same time, nonimmersive VR excelled in cost and flexibility, making it more appropriate for basic skill interventions in individuals with LFA. Finally, although VR interventions showed positive outcomes in improving social skills, some studies reported potential side effects, highlighting the need to account for individual differences when designing intervention programs and implementing measures to reduce adverse effects.

Impact of VR Interventions on the Social Skills of Children and Adolescents With ASD

The differences in the effectiveness of VR interventions for children and adolescents with HFA and LFA can be attributed to variations in cognitive, social, and sensory processing skills [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51,Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. Individuals with HFA generally have higher cognitive abilities and language skills, enabling them to understand better and adapt to complex social situations within VR environments [Levin L. Social and academic abilities in children with high-functioning autism spectrum disorders. Sch. Soc. Work J. 2014;39(1):96. [FREE Full text]54]. This finding aligns with earlier studies that highlighted the need for more personalized intervention strategies based on ASD symptom severity [Aldred C, Green J, Adams C. A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry. 2004;45(8):1420-1430. [CrossRef] [Medline]9-Weiss MJ, Harris SL. Teaching social skills to people with autism. Behav Modif. 2001;25(5):785-802. [CrossRef] [Medline]11]. These previous studies suggested that traditional interventions like ABA and CBT were more effective for high-functioning individuals due to their adaptability and cognitive skills, which is similarly observed in VR settings [Aldred C, Green J, Adams C. A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry. 2004;45(8):1420-1430. [CrossRef] [Medline]9-Weiss MJ, Harris SL. Teaching social skills to people with autism. Behav Modif. 2001;25(5):785-802. [CrossRef] [Medline]11]. The advantages demonstrated by children and adolescents with HFA in VR interventions are partly due to their stronger abstract thinking skills and higher sensory tolerance [Lai CLE, Lau Z, Lui SSY, Lok E, Tam V, Chan Q, et al. Meta-analysis of neuropsychological measures of executive functioning in children and adolescents with high-functioning autism spectrum disorder. Autism Res. 2017;10(5):911-939. [CrossRef] [Medline]55]. Multisensory stimuli, such as the combination of visual, auditory, and tactile inputs, activate key brain regions, including the mirror neuron system and the prefrontal cortex, further enhancing social interaction and emotional understanding [Fernández MS. Mirror neurons and its impact on neurological diseases. Universidad de Cantabria. 2016. URL: https://repositorio.unican.es/xmlui/handle/10902/8743 [accessed 2025-08-01] 56]. In addition, individuals with HFA are better at handling contextual changes within VR environments, adapting to feedback mechanisms in virtual scenarios, allowing them to quickly learn and transfer skills to real-life situations [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42]. This adaptability explains why children with HFA generally exhibit faster progress in VR interventions. In contrast, individuals with LFA’s slower cognitive and language development hinders their progress in VR interventions [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]. This limitation reflects findings from traditional interventions, where children with LFA often progressed more in structured, basic tasks than in complex social or emotional skills [Adams C, Lockton E, Freed J, Gaile J, Earl G, McBean K, et al. The social communication intervention project: a randomized controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. Int J Lang Commun Disord. 2012;47(3):233-244. [CrossRef] [Medline]12,Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev. 2004;2004(2):CD003466. [FREE Full text] [CrossRef] [Medline]13,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]. Children with LFA often struggle with processing multisensory stimuli in virtual environments, making them prone to discomfort, such as sensory overload or anxiety reactions [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Reichow B, Servili C, Yasamy MT, Barbui C, Saxena S. Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review. PLoS Med. 2013;10(12):e1001572; discussion e1001572. [FREE Full text] [CrossRef] [Medline]57]. This sensory sensitivity confuses complex social scenarios, making it difficult for them to keep pace with the intervention [Robertson CE, Baron-Cohen S. Sensory perception in autism. Nat Rev Neurosci. 2017;18(11):671-684. [CrossRef] [Medline]58]. Moreover, for individuals with LFA, cognitive and social difficulties limit their ability to master complex emotional expression or social interaction skills [Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49]. They tend to show progress in more structured, more straightforward tasks, such as life skills training or behavior management [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]52]. These limitations suggest that individuals with LFA require specialized support and simplified task designs to ensure gradual improvement in controlled settings.

Future interventions should be more personalized to bridge the gap in VR intervention outcomes between individuals with HFA and LFA [Serret S, Hun S, Iakimova G, Lozada J, Anastassova M, Santos A, et al. Facing the challenge of teaching emotions to individuals with low- and high-functioning autism using a new serious game: a pilot study. Mol Autism. 2014;5:37. [FREE Full text] [CrossRef] [Medline]59]. For individuals with HFA, continued focus on complex social scenario training is essential. For individuals with LFA, interventions should emphasize managing sensory stimuli, reducing the risk of sensory overload, simplifying social interaction tasks, and offering more structured and incremental training content. The effectiveness of VR interventions is also significantly influenced by the setting in which they are conducted. Institutional and clinical environments generally offer specialized equipment and supervision by therapists, providing participants with highly customized support and real-time feedback [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. These settings help ensure the quality and consistency of interventions, especially in emotional regulation and complex social skills training [Mazon C, Fage C, Sauzéon H. Effectiveness and usability of technology-based interventions for children and adolescents with ASD: a systematic review of reliability, consistency, generalization and durability related to the effects of intervention. Comput. Hum. Behav. 2019;93:235-251. [FREE Full text] [CrossRef]60]. However, the limitations of institutional and clinical environments include high costs and limited scalability [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47]. In contrast, home and school environments, although lacking immediate professional supervision, offer convenience and real-world applicability advantages, making them more suitable for skill transfer to everyday activities [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]. In addition, home and school settings reduce participants’ anxiety, as children are more relaxed and receptive to interventions in familiar environments [McLoone JK, Rapee RM. Comparison of an anxiety management program for children implemented at home and school: lessons learned. Sch. Ment. Health. J. Multidiscip. Res. 2012;4(4):231-242. [FREE Full text] [CrossRef]61]. The flexibility and accessibility of these environments make them suitable for long-term interventions, though they may compromise the depth and complexity of the intervention [McLoone JK, Rapee RM. Comparison of an anxiety management program for children implemented at home and school: lessons learned. Sch. Ment. Health. J. Multidiscip. Res. 2012;4(4):231-242. [FREE Full text] [CrossRef]61]. Future research should explore how to incorporate more professional support into home and school environments to ensure the effectiveness of interventions is not compromised.

Impact of Different VR Intervention Approaches on the Social Skills of Children and Adolescents With ASD

The duration and frequency of interventions significantly impact the effectiveness of VR interventions. Longer intervention durations and higher frequencies generally have more significant and lasting effects, particularly in social skills and emotional regulation [Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]41,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46-Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48]. This observation is consistent with the findings in traditional therapies, where prolonged and frequent sessions in interventions like ABA and CBT have been linked to more sustainable outcomes in social skills improvement [Weiss MJ, Harris SL. Teaching social skills to people with autism. Behav Modif. 2001;25(5):785-802. [CrossRef] [Medline]11,Wang X, Zhao J, Huang S, Chen S, Zhou T, Li Q, et al. Cognitive behavioral therapy for autism spectrum disorders: a systematic review. Pediatrics. 2021;147(5):e2020049880. [CrossRef] [Medline]14]. Shorter intervention durations or lower frequencies may not be sufficient to consolidate the skills learned, limiting the maintenance of intervention effects [Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. Long-term, high-frequency interventions provide more practice opportunities, helping participants gradually master and transfer these skills [Howard SJ, Vasseleu E, Batterham M, Neilsen-Hewett C. Everyday practices and activities to improve pre-school self-regulation: cluster RCT evaluation of the PRSIST program. Front Psychol. 2020;11:137. [FREE Full text] [CrossRef] [Medline]62]. However, high-frequency and long-term interventions may also lead to fatigue, particularly in individuals with LFA who are more sensitive to sensory overload [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744]. Therefore, future intervention designs should balance the duration and frequency of interventions, ensuring sufficient practice opportunities while avoiding sensory fatigue and overstimulation in participants. Further research should explore the combination of optimal intervention duration and frequency to ensure both effectiveness and sustainability.

The differences in the effectiveness of immersive and nonimmersive VR interventions stem from their varying levels of sensory stimulation and interaction methods [Wu B, Yu X, Gu X. Effectiveness of immersive virtual reality using head‐mounted displays on learning performance: a meta‐analysis. Brit J Educational Tech. 2020;51(6):1991-2005. [FREE Full text] [CrossRef]63]. Immersive VR, with its multisensory stimulation and highly realistic virtual environments, is particularly effective for children with HFA, enhancing their adaptability in complex social interactions [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640-Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]43,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]49,Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]50]. However, its intense sensory input may pose challenges for individuals with LFA, potentially causing anxiety or sensory overload [Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]45,Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]47,Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]48,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51-Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]53]. As a lower-stimulus alternative, nonimmersive VR supports adaptive training for children with LFA, focusing on basic skills and behavior management [Panerai S, Gelardi D, Catania V, Rundo F, Tasca D, Musso S, et al. Functional living skills: a non-immersive virtual reality training for individuals with major neurocognitive disorders. Sensors (Basel). 2021;21(17):5751. [FREE Full text] [CrossRef] [Medline]64]. Its ease of use and scalability make it suitable for broader and long-term applications, particularly in educational settings where lower-stimulus environments are often preferable [Sapiets SJ, Totsika V, Hastings RP. Factors influencing access to early intervention for families of children with developmental disabilities: a narrative review. J Appl Res Intellect Disabil. 2021;34(3):695-711. [FREE Full text] [CrossRef] [Medline]15,Lord C, Charman T, Havdahl A, Carbone P, Anagnostou E, Boyd B, et al. The Lancet Commission on the future of care and clinical research in autism. Lancet. 2022;399(10321):271-334. [CrossRef] [Medline]17]. Future research should prioritize integrating the strengths of immersive and nonimmersive VR to balance engagement and usability, ensuring interventions can address the diverse needs of individuals with ASD effectively.

Practical Implications and Adverse Effects

VR technology interventions hold significant potential for clinical and educational applications in children and adolescents with ASD [Dailey-Hebert A, Estes JS, Choi DH. This history and evolution of virtual reality. In: Choi DH, Dailey-Hebert A, Estes JS, editors. Current and Prospective Applications of Virtual Reality in Higher Education. Beijing, China. Information Science Reference/IGI Global; 2021:1-20.65]. In clinical practice, VR can serve as a complementary tool to traditional interventions, providing therapists with a flexible and engaging means to meet the diverse needs of individuals with ASD [Tan B, Shi J, Yang S, Loh H, Ng D, Choo C, et al. The use of virtual reality and augmented reality in psychosocial rehabilitation for adults with neurodevelopmental disorders: a systematic review. Front Psychiatry. 2022;13:1055204. [FREE Full text] [CrossRef] [Medline]66]. For instance, the benefits of VR as an adjunct to speech therapy align with findings from the SCIP intervention in traditional therapy, where tailored approaches proved beneficial for improving social communication skills in children with ASD [Adams C, Lockton E, Freed J, Gaile J, Earl G, McBean K, et al. The social communication intervention project: a randomized controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. Int J Lang Commun Disord. 2012;47(3):233-244. [CrossRef] [Medline]12]. For instance, traditional speech therapy interventions, such as SCIP, have been shown to effectively improve social communication skills in children with ASD [Adams C, Lockton E, Freed J, Gaile J, Earl G, McBean K, et al. The social communication intervention project: a randomized controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. Int J Lang Commun Disord. 2012;47(3):233-244. [CrossRef] [Medline]12]. Integrating VR into these interventions could enhance the effects of traditional speech therapy, offering more engaging and personalized treatment sessions [Picard RW, Lane JK, El Kaliouby R, Goodwin M, Hoque ME. Exploring speech therapy games with children on the autism spectrum. Antwerp, Belgium. International Speech Communication Association; 2009. Presented at: 10th Annual Conference of the International Speech Communication Association; September 6-10, 2009; Brighton, United Kingdom. URL: https://hdl.handle.net/1721.1/5658067]. In addition, a meta-analysis of CBT’s effectiveness in addressing social-emotional challenges in children with ASD has shown significant improvements in core symptoms following CBT [Wang X, Zhao J, Huang S, Chen S, Zhou T, Li Q, et al. Cognitive behavioral therapy for autism spectrum disorders: a systematic review. Pediatrics. 2021;147(5):e2020049880. [CrossRef] [Medline]14]. By incorporating VR into CBT, children can practice coping strategies in simulated real-life emotional and social scenarios, potentially enhancing outcomes [Lindner P. Better, virtually: the past, present, and future of virtual reality cognitive behavior therapy. J Cogn Ther. 2020;14(1):23-46. [FREE Full text] [CrossRef]68]. Finally, VR could be combined with ABA to create personalized social scenarios, allowing therapists to offer more dynamic and adaptable intervention plans while children practice social behaviors in realistic but controlled environments [Weiss MJ, Harris SL. Teaching social skills to people with autism. Behav Modif. 2001;25(5):785-802. [CrossRef] [Medline]11,Leaf JB, Cihon JH, Leaf R, McEachin J, Liu N, Russell N, et al. Concerns about ABA-based intervention: an evaluation and recommendations. J Autism Dev Disord. 2022;52(6):2838-2853. [FREE Full text] [CrossRef] [Medline]69].

Despite the many advantages of VR interventions, there are challenges to its widespread application, particularly regarding accessibility, cost, and the training required for educators and therapists to implement these technologies [Zhao W, Xu S, Zhang Y, Li D, Zhu C, Wang K. The application of extended reality in treating children with autism spectrum disorder. Neurosci Bull. 2024;40(8):1189-1204. [CrossRef] [Medline]70,Pirker J, Dengel A. The potential of 360° virtual reality videos and real VR for education-a literature review. IEEE Comput Graph Appl. 2021;41(4):76-89. [CrossRef] [Medline]71] effectively. Previous studies on traditional therapy have also highlighted these issues, where high costs and professional training needs limit scalability [Sapiets SJ, Totsika V, Hastings RP. Factors influencing access to early intervention for families of children with developmental disabilities: a narrative review. J Appl Res Intellect Disabil. 2021;34(3):695-711. [FREE Full text] [CrossRef] [Medline]15,Maglione MA, Gans D, Das L, Timbie J, Kasari C, Technical Expert Panel, et al. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012;130 Suppl 2:S169-S178. [CrossRef] [Medline]16]. Adequate training for therapists and educators is crucial to maximizing the potential of VR interventions [Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, et al. Virtual reality in the diagnostic and therapy for mental disorders: a systematic review. Clin Psychol Rev. 2022;98:102213. [FREE Full text] [CrossRef] [Medline]72]. Research has highlighted that while immersive VR offers powerful therapeutic effects, there are challenges related to user comfort and sensory overload, especially for children with ASD. It is essential to carefully manage symptoms such as dizziness, nausea, and sensory overload, emphasizing the importance of gradual exposure in VR-based interventions [Didehbani N, Allen T, Kandalaft M, Krawczyk D, Chapman S. Virtual reality social cognition training for children with high functioning autism. Comput. Hum. Behav. 2016;62:703-711. [FREE Full text] [CrossRef]73]. In addition, studies have reported adverse effects such as eye fatigue, headaches, anxiety, and disorientation during VR use [Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/000468000230023640,Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]42-Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.927660744,Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]46,Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]51]. These reactions are particularly concerning for children with ASD, who may exhibit heightened sensitivity to sensory stimuli [Posar A, Visconti P. Sensory abnormalities in children with autism spectrum disorder. Jornal de Pediatria. 2018;94(4):342-350. [CrossRef]74]. For instance, immersive VR systems with complex visual and auditory elements have been found to increase the risk of dizziness and nausea in approximately 15% of users [Conner NO, Freeman HR, Jones JA, Luczak T, Carruth D, Knight AC, et al. Virtual reality induced symptoms and effects: concerns, causes, assessment and mitigation. Virtual Worlds. 2022;1(2):130-146. [FREE Full text] [CrossRef]75]. Such adverse effects may reduce engagement and limit VR interventions’ scalability [Torous J, Bucci S, Bell IH, Kessing LV, Faurholt-Jepsen M, Whelan P, et al. The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. World Psychiatry. 2021;20(3):318-335. [FREE Full text] [CrossRef] [Medline]76]. To address these challenges, intervention designs must incorporate strategies to minimize adverse effects. These include shortening session durations, integrating regular breaks, and adapting VR content to reduce sensory overload [Indovina P, Barone D, Gallo L, Chirico A, de Pietro G, Giordano A. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review. Clin J Pain. 2018;34(9):858-877. [CrossRef] [Medline]77]. For example, designing environments with simpler visual elements or offering less immersive options for highly sensitive children could significantly mitigate these effects [Leekam S, Prior MR, Uljarevic M. Restricted and repetitive behaviors in autism spectrum disorders: a review of research in the last decade. Psychol Bull. 2011;137(4):562-593. [CrossRef] [Medline]78]. Furthermore, providing psychological support during interventions, such as teaching coping mechanisms for anxiety, may enhance user comfort and overall feasibility [Bernaerts S, Bonroy B, Daems J, Sels R, Struyf D, Gies I, et al. Virtual reality for distraction and relaxation in a pediatric hospital setting: an interventional study with a mixed-methods design. Front Digit Health. 2022;4:866119. [FREE Full text] [CrossRef] [Medline]79]. Future research should also systematically evaluate the prevalence and impact of these adverse effects, offering data-driven recommendations for optimizing VR-based interventions.

Moving forward, research should focus on improving the affordability and user-friendliness of VR interventions, ensuring that they are not limited to professional settings but can be widely applied in both clinical and educational environments [Zhang M, Ding H, Naumceska M, Zhang Y. Virtual reality technology as an educational and intervention tool for children with autism spectrum disorder: current perspectives and future directions. Behav Sci (Basel). 2022;12(5):138. [FREE Full text] [CrossRef] [Medline]80].

Limitations

Despite the many strengths of this study, several limitations require further discussion. The sample size of this systematic review is relatively small, including only 14 studies, which may limit the generalizability of the findings. The included studies used various scales and tools to assess the social skills of children and adolescents with ASD, and this diversity in assessment tools may have led to inconsistencies in the pooled results. Due to differences in evaluation tools and reported data types, this study could not provide a quantitative summary. There was significant heterogeneity in intervention protocols, including variations in VR content, session length, and frequency. This lack of standardization limits comparisons between studies and highlights the need for uniform intervention protocols in future research. Many of the included studies had small sample sizes, which reduced statistical power and increased the likelihood of underestimating the effects of VR interventions. Future research should recruit larger and more diverse samples to enhance the reliability and generalizability of findings. Finally, some studies lacked detailed reporting of key methodological elements, such as randomization and blinding, which increases the potential for bias. Adopting rigorous designs and transparent reporting practices, guided by frameworks such as PRISMA or CONSORT (Consolidated Standards of Reporting Trials), will help strengthen the evidence base for future studies. By addressing these limitations, this study underscores the importance of more robust and standardized research to advance the field of VR interventions for ASD.

Conclusion

This systematic review highlights the significant potential of VR technology interventions in enhancing social skills for children and adolescents with ASD (Textbox 1).

In conclusion, long-term, high-frequency VR interventions (especially those lasting 6 to 15 weeks with 2-3 sessions per week) demonstrate the most effectiveness. Future research should focus on optimizing VR interventions to meet the personalized needs of different subgroups of patients with ASD and conduct large-scale longitudinal studies to validate their long-term impact.

Textbox 1. Key insights on virtual reality (VR) interventions for children and adolescents with autism spectrum disorder (ASD).
  • Differences in VR intervention effects for individuals with high-functioning autism (HFA) and low-functioning autism (LFA): VR interventions show considerable improvements in complex emotional regulation and social interaction skills for children and adolescents with HFA. In contrast, improvements for individuals with LFA have been relatively limited, primarily supporting basic life skills. This suggests the need for more tailored VR approaches for different ASD subgroups.
  • Impact of different VR intervention types: Immersive VR proves more effective for enhancing complex social skills, particularly in children with HFA, as it provides a deeply engaging experience. Meanwhile, due to its flexibility and lower cost, nonimmersive VR offers valuable benefits in specific contexts, particularly in home or school settings. Institutional and clinical settings have shown more specialized and effective results, whereas interventions in home or school environments provide greater adaptability.
  • Potential adverse effects of VR interventions: Although VR technology holds promise, adverse effects such as dizziness and fatigue may arise, especially during immersive VR sessions. These potential issues should be carefully addressed in the design of VR-based interventions.
  • Practical recommendations for stakeholders: Therapists, educators, and developers should collaborate to optimize VR interventions for children with ASD. Therapists can integrate VR as a complementary tool to traditional therapies, tailoring interventions and gradually increasing exposure to reduce sensory overload. Educators can use VR for social skills training in controlled environments with proper training. Developers should focus on creating cost-effective, user-friendly VR platforms with customizable features to ensure accessibility in clinical and educational settings. These efforts will enhance the scalability and impact of VR interventions.

Acknowledgments

This research was supported by the Special Funding for Key Areas in Biomedicine and Health of Ordinary Colleges and Universities in Guangdong Province (2022ZDZX2086; 2024ZDZX2108) and the Humanities and Social Sciences Project of the Chinese Ministry of Education (24YJAZH106). Meanwhile, we express our sincere gratitude to Dr Zhongtang Wu, who serves in the College of Physical Education at Shenzhen University, for his invaluable technical expertise and assistance, which was paramount to the success of our research.

Data Availability

All data generated or analyzed during this study are included in this published paper (and Multimedia Appendices 1 and Loomes R, Hull L, Mandy WPL. What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(6):466-474. [CrossRef] [Medline]2).

Authors' Contributions

ZR was responsible for the research protocol and critically redrafted the paper. XY and JW performed literature searches. XY and JW performed study identification and screening. XY, JW, YM, and YT extracted and analyzed the data from the included journals. XY and JW wrote the first draft of the paper. JY, HC, AZ, and RF, contributed to refining the ideas, carrying out additional analyses, and finalizing this paper. All authors read and approved the final manuscript.

Conflicts of Interest

None declared.

Multimedia Appendix 1

Search research strategy.

DOCX File , 12 KB

Multimedia Appendix 2

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.

DOCX File , 22 KB

  1. First MB. Diagnostic and statistical manual of mental disorders, 5th edition, and clinical utility. J Nerv Ment Dis. 2013;201(9):727-729. [CrossRef] [Medline]
  2. Loomes R, Hull L, Mandy WPL. What is the male-to-female ratio in autism spectrum disorder? A systematic review and meta-analysis. J Am Acad Child Adolesc Psychiatry. 2017;56(6):466-474. [CrossRef] [Medline]
  3. Pain O, Pocklington AJ, Holmans PA, Bray NJ, O'Brien HE, Hall LS, et al. Novel insight into the etiology of autism spectrum disorder gained by integrating expression data with genome-wide association statistics. Biol Psychiatry. 2019;86(4):265-273. [FREE Full text] [CrossRef] [Medline]
  4. Sandin S, Lichtenstein P, Kuja-Halkola R, Hultman C, Larsson H, Reichenberg A. The heritability of autism spectrum disorder. JAMA. 2017;318(12):1182-1184. [FREE Full text] [CrossRef] [Medline]
  5. Ozonoff S, Young GS, Carter A, Messinger D, Yirmiya N, Zwaigenbaum L, et al. Recurrence risk for autism spectrum disorders: a baby siblings research consortium study. Pediatrics. 2011;128(3):e488-e495. [FREE Full text] [CrossRef] [Medline]
  6. Rogers S, Vismara LA. Evidence-based comprehensive treatments for early autism. J Clin Child Adolesc Psychol. 2008;37(1):8-38. [CrossRef] [Medline]
  7. Mehling M, Tassé MJ. Severity of autism spectrum disorders: current conceptualization, and transition to DSM-5. J Autism Dev Disord. 2016;46(6):2000-2016. [CrossRef] [Medline]
  8. Hirota T, King BH. Autism spectrum disorder: a review. JAMA. 2023;329(2):157-168. [CrossRef] [Medline]
  9. Aldred C, Green J, Adams C. A new social communication intervention for children with autism: pilot randomised controlled treatment study suggesting effectiveness. J Child Psychol Psychiatry. 2004;45(8):1420-1430. [CrossRef] [Medline]
  10. Roane H, Fisher WW, Carr JE. Applied behavior analysis as treatment for autism spectrum disorder. J Pediatr. 2016;175:27-32. [CrossRef] [Medline]
  11. Weiss MJ, Harris SL. Teaching social skills to people with autism. Behav Modif. 2001;25(5):785-802. [CrossRef] [Medline]
  12. Adams C, Lockton E, Freed J, Gaile J, Earl G, McBean K, et al. The social communication intervention project: a randomized controlled trial of the effectiveness of speech and language therapy for school-age children who have pragmatic and social communication problems with or without autism spectrum disorder. Int J Lang Commun Disord. 2012;47(3):233-244. [CrossRef] [Medline]
  13. Pennington L, Goldbart J, Marshall J. Speech and language therapy to improve the communication skills of children with cerebral palsy. Cochrane Database Syst Rev. 2004;2004(2):CD003466. [FREE Full text] [CrossRef] [Medline]
  14. Wang X, Zhao J, Huang S, Chen S, Zhou T, Li Q, et al. Cognitive behavioral therapy for autism spectrum disorders: a systematic review. Pediatrics. 2021;147(5):e2020049880. [CrossRef] [Medline]
  15. Sapiets SJ, Totsika V, Hastings RP. Factors influencing access to early intervention for families of children with developmental disabilities: a narrative review. J Appl Res Intellect Disabil. 2021;34(3):695-711. [FREE Full text] [CrossRef] [Medline]
  16. Maglione MA, Gans D, Das L, Timbie J, Kasari C, Technical Expert Panel, et al. Nonmedical interventions for children with ASD: recommended guidelines and further research needs. Pediatrics. 2012;130 Suppl 2:S169-S178. [CrossRef] [Medline]
  17. Lord C, Charman T, Havdahl A, Carbone P, Anagnostou E, Boyd B, et al. The Lancet Commission on the future of care and clinical research in autism. Lancet. 2022;399(10321):271-334. [CrossRef] [Medline]
  18. Wu J, Loprinzi PD, Ren Z. The rehabilitative effects of virtual reality games on balance performance among children with cerebral palsy: a meta-analysis of randomized controlled trials. Int J Environ Res Public Health. 2019;16(21):4161. [FREE Full text] [CrossRef] [Medline]
  19. Fodor L, Coteț CD, Cuijpers P, Szamoskozi Ș, David D, Cristea IA. The effectiveness of virtual reality based interventions for symptoms of anxiety and depression: a meta-analysis. Sci Rep. 2018;8(1):10323. [FREE Full text] [CrossRef] [Medline]
  20. Wu J, Ma Y, Ren Z. Rehabilitative effects of virtual reality technology for mild cognitive impairment: a systematic review with meta-analysis. Front Psychol. 2020;11:1811. [FREE Full text] [CrossRef] [Medline]
  21. Wu J, Sun Y, Zhang G, Zhou Z, Ren Z. Virtual reality-assisted cognitive behavioral therapy for anxiety disorders: a systematic review and meta-analysis. Front Psychiatry. 2021;12:575094. [FREE Full text] [CrossRef] [Medline]
  22. Beheshti J, Bilal D, Druin A, Large A. Testing children's information retrieval systems: Challenges in a new era. Proc. Am. Soc. Info. Sci. Tech. 2011;47(1):1-4. [FREE Full text] [CrossRef]
  23. Rizzo AS, Koenig ST. Is clinical virtual reality ready for primetime? Neuropsychology. 2017;31(8):877-899. [CrossRef] [Medline]
  24. Wu J, Zhang H, Chen Z, Fu R, Yang H, Zeng H, et al. Benefits of virtual reality balance training for patients with parkinson disease: systematic review, meta-analysis, and meta-regression of a randomized controlled trial. JMIR Serious Games. 2022;10(1):e30882. [FREE Full text] [CrossRef] [Medline]
  25. Bevilacqua R, Maranesi E, Riccardi GR, Donna VD, Pelliccioni P, Luzi R, et al. Non-immersive virtual reality for rehabilitation of the older people: a systematic review into efficacy and effectiveness. J Clin Med. 2019;8(11):1882. [FREE Full text] [CrossRef] [Medline]
  26. Horvat N, Martinec T, Perišić M, Škec S. Comparing design review outcomes in immersive and non-immersive collaborative virtual environments. Procedia CIRP. 2022;109:173-178. [FREE Full text] [CrossRef]
  27. Smith C, Read JE, Bennie C, Hale L, Milosavljevic S. Can non-immersive virtual reality improve physical outcomes of rehabilitation? Physical Therapy Reviews. 2013;17(1):1-15. [FREE Full text] [CrossRef]
  28. Parsons S, Cobb S. State-of-the-art of virtual reality technologies for children on the autism spectrum. Eur. J. Spec. Needs Educ. 2011;26(3):355-366. [FREE Full text] [CrossRef]
  29. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. [CrossRef] [Medline]
  30. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700. [FREE Full text] [CrossRef] [Medline]
  31. Mesa-Gresa P, Gil-Gómez H, Lozano-Quilis J, Gil-Gómez J. Effectiveness of virtual reality for children and adolescents with autism spectrum disorder: an evidence-based systematic review. Sensors (Basel). 2018;18(8):2486. [FREE Full text] [CrossRef] [Medline]
  32. Morgan R, Whaley P, Thayer KA, Schünemann HJ. Identifying the PECO: a framework for formulating good questions to explore the association of environmental and other exposures with health outcomes. Environ Int. 2018;121(Pt 1):1027-1031. [FREE Full text] [CrossRef] [Medline]
  33. Minozzi S, Cinquini M, Gianola S, Gonzalez-Lorenzo M, Banzi R. The revised cochrane risk of bias tool for randomized trials (RoB 2) showed low interrater reliability and challenges in its application. J Clin Epidemiol. 2020;126:37-44. [CrossRef] [Medline]
  34. Armijo-Olivo S, Ospina M, da Costa BR, Egger M, Saltaji H, Fuentes J, et al. Poor reliability between cochrane reviewers and blinded external reviewers when applying the Cochrane risk of bias tool in physical therapy trials. PLoS One. 2014;9(5):e96920. [FREE Full text] [CrossRef] [Medline]
  35. Herbert R, Moseley A, Sherrington C. PEDro: a database of randomised controlled trials in physiotherapy. Health Inf Manag. 1998;28(4):186-188. [CrossRef] [Medline]
  36. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721. [Medline]
  37. Sherrington C, Moseley AM, Herbert RD, Elkins MR, Maher CG. Ten years of evidence to guide physiotherapy interventions: Physiotherapy Evidence Database (PEDro). Br J Sports Med. 2010;44(12):836-837. [CrossRef] [Medline]
  38. Armijo-Olivo S, da Costa BR, Cummings GG, Ha C, Fuentes J, Saltaji H, et al. PEDro or cochrane to assess the quality of clinical trials? A meta-epidemiological study. PLoS One. 2015;10(7):e0132634. [FREE Full text] [CrossRef] [Medline]
  39. Cheung M, Vijayakumar R. A guide to conducting a meta-analysis. Neuropsychol Rev. 2016;26(2):121-128. [CrossRef] [Medline]
  40. Matsentidou S, Poullis C. Immersive visualizations in a VR Cave environment for the training and enhancement of social skills for children with autism. 2014. Presented at: International Conference on Computer Vision Theory and Applications (VISAPP); January 5-8, 2014:230-236; Lisbon, Portugal. URL: https://doi.org/10.5220/0004680002300236
  41. Cheng Y, Huang C-L, Yang C-S. Using a 3D immersive virtual environment system to enhance social understanding and social skills for children with autism spectrum disorders. Focus Autism Other Dev Disabl. 2015;30(4):222-236. [FREE Full text] [CrossRef]
  42. Ip HHS, Wong SWL, Chan DFY, Byrne J, Li C, Yuan VSN, et al. Enhance emotional and social adaptation skills for children with autism spectrum disorder: a virtual reality enabled approach. Comput. Educ. 2018;117:1-15. [FREE Full text] [CrossRef]
  43. Rosenfield N, Lamkin K, Re J, Day K, Boyd L, Linstead E. A virtual reality system for practicing conversation skills for children with autism. Multimodal Technol. Interact. 2019;3(2):28. [FREE Full text] [CrossRef]
  44. Junaidi AR, Alamsyah Y, Hidayah O, Mulyawati NW. Development of virtual reality content to improve social skills in children with low function autism. 2020. Presented at: 6th International Conference on Education and Technology (ICET); October 17, 2020:115-119; Malang, Indonesia. URL: https://doi.org/10.1109/ICET51153.2020.9276607
  45. Yeh C-C, Meng Y-R. Preliminary study on the application of virtual reality social skills course to improve the abilities of social skills for elementary and junior high school students with high functional autism. Commun. Comput. Inf. Sci. 2020:183-193. [FREE Full text]
  46. Tsai W-T, Lee I-J, Chen C. Inclusion of third-person perspective in CAVE-like immersive 3D virtual reality role-playing games for social reciprocity training of children with an autism spectrum disorder. Univ Access Inf Soc. 2020;20(2):375-389. [FREE Full text] [CrossRef]
  47. Soltani Kouhbanani S, Khosrorad R, Zarenezhad S, Arabi SM. Comparing the effect of risperidone, virtual reality and risperidone on social skills, and behavioral problems in children with autism: a follow-up randomized clinical trial. Arch Iran Med. 2021;24(7):534-541. [FREE Full text] [CrossRef] [Medline]
  48. Moon J, Ke F. Exploring the treatment integrity of virtual reality-based social skills training for children with high-functioning autism. Interact. Learn. Environ. 2019;29(6):939-953. [FREE Full text] [CrossRef]
  49. Elkin TD, Zhang Y, Reneker JC. Gaze fixation and visual searching behaviors during an immersive virtual reality social skills training experience for children and youth with autism spectrum disorder: a pilot study. Brain Sci. 2022;12(11):1568. [FREE Full text] [CrossRef] [Medline]
  50. Frolli A, Savarese G, Di Carmine F, Bosco A, Saviano E, Rega A, et al. Children on the autism spectrum and the use of virtual reality for supporting social skills. Children (Basel). 2022;9(2):181. [FREE Full text] [CrossRef] [Medline]
  51. Ke F, Moon J, Sokolikj Z. Virtual reality–based social skills training for children with autism spectrum disorder. J Spec Educ Technol. 2020;37(1):49-62. [FREE Full text] [CrossRef]
  52. Zhao J, Zhang X, Lu Y, Wu X, Zhou F, Yang S, et al. Virtual reality technology enhances the cognitive and social communication of children with autism spectrum disorder. Front Public Health. 2022;10:1029392. [FREE Full text] [CrossRef] [Medline]
  53. Moon J, Ke F. Effects of adaptive prompts in virtual reality-based social skills training for children with autism. J Autism Dev Disord. 2024;54(8):2826-2846. [CrossRef] [Medline]
  54. Levin L. Social and academic abilities in children with high-functioning autism spectrum disorders. Sch. Soc. Work J. 2014;39(1):96. [FREE Full text]
  55. Lai CLE, Lau Z, Lui SSY, Lok E, Tam V, Chan Q, et al. Meta-analysis of neuropsychological measures of executive functioning in children and adolescents with high-functioning autism spectrum disorder. Autism Res. 2017;10(5):911-939. [CrossRef] [Medline]
  56. Fernández MS. Mirror neurons and its impact on neurological diseases. Universidad de Cantabria. 2016. URL: https://repositorio.unican.es/xmlui/handle/10902/8743 [accessed 2025-08-01]
  57. Reichow B, Servili C, Yasamy MT, Barbui C, Saxena S. Non-specialist psychosocial interventions for children and adolescents with intellectual disability or lower-functioning autism spectrum disorders: a systematic review. PLoS Med. 2013;10(12):e1001572; discussion e1001572. [FREE Full text] [CrossRef] [Medline]
  58. Robertson CE, Baron-Cohen S. Sensory perception in autism. Nat Rev Neurosci. 2017;18(11):671-684. [CrossRef] [Medline]
  59. Serret S, Hun S, Iakimova G, Lozada J, Anastassova M, Santos A, et al. Facing the challenge of teaching emotions to individuals with low- and high-functioning autism using a new serious game: a pilot study. Mol Autism. 2014;5:37. [FREE Full text] [CrossRef] [Medline]
  60. Mazon C, Fage C, Sauzéon H. Effectiveness and usability of technology-based interventions for children and adolescents with ASD: a systematic review of reliability, consistency, generalization and durability related to the effects of intervention. Comput. Hum. Behav. 2019;93:235-251. [FREE Full text] [CrossRef]
  61. McLoone JK, Rapee RM. Comparison of an anxiety management program for children implemented at home and school: lessons learned. Sch. Ment. Health. J. Multidiscip. Res. 2012;4(4):231-242. [FREE Full text] [CrossRef]
  62. Howard SJ, Vasseleu E, Batterham M, Neilsen-Hewett C. Everyday practices and activities to improve pre-school self-regulation: cluster RCT evaluation of the PRSIST program. Front Psychol. 2020;11:137. [FREE Full text] [CrossRef] [Medline]
  63. Wu B, Yu X, Gu X. Effectiveness of immersive virtual reality using head‐mounted displays on learning performance: a meta‐analysis. Brit J Educational Tech. 2020;51(6):1991-2005. [FREE Full text] [CrossRef]
  64. Panerai S, Gelardi D, Catania V, Rundo F, Tasca D, Musso S, et al. Functional living skills: a non-immersive virtual reality training for individuals with major neurocognitive disorders. Sensors (Basel). 2021;21(17):5751. [FREE Full text] [CrossRef] [Medline]
  65. Dailey-Hebert A, Estes JS, Choi DH. This history and evolution of virtual reality. In: Choi DH, Dailey-Hebert A, Estes JS, editors. Current and Prospective Applications of Virtual Reality in Higher Education. Beijing, China. Information Science Reference/IGI Global; 2021:1-20.
  66. Tan B, Shi J, Yang S, Loh H, Ng D, Choo C, et al. The use of virtual reality and augmented reality in psychosocial rehabilitation for adults with neurodevelopmental disorders: a systematic review. Front Psychiatry. 2022;13:1055204. [FREE Full text] [CrossRef] [Medline]
  67. Picard RW, Lane JK, El Kaliouby R, Goodwin M, Hoque ME. Exploring speech therapy games with children on the autism spectrum. Antwerp, Belgium. International Speech Communication Association; 2009. Presented at: 10th Annual Conference of the International Speech Communication Association; September 6-10, 2009; Brighton, United Kingdom. URL: https://hdl.handle.net/1721.1/56580
  68. Lindner P. Better, virtually: the past, present, and future of virtual reality cognitive behavior therapy. J Cogn Ther. 2020;14(1):23-46. [FREE Full text] [CrossRef]
  69. Leaf JB, Cihon JH, Leaf R, McEachin J, Liu N, Russell N, et al. Concerns about ABA-based intervention: an evaluation and recommendations. J Autism Dev Disord. 2022;52(6):2838-2853. [FREE Full text] [CrossRef] [Medline]
  70. Zhao W, Xu S, Zhang Y, Li D, Zhu C, Wang K. The application of extended reality in treating children with autism spectrum disorder. Neurosci Bull. 2024;40(8):1189-1204. [CrossRef] [Medline]
  71. Pirker J, Dengel A. The potential of 360° virtual reality videos and real VR for education-a literature review. IEEE Comput Graph Appl. 2021;41(4):76-89. [CrossRef] [Medline]
  72. Wiebe A, Kannen K, Selaskowski B, Mehren A, Thöne AK, Pramme L, et al. Virtual reality in the diagnostic and therapy for mental disorders: a systematic review. Clin Psychol Rev. 2022;98:102213. [FREE Full text] [CrossRef] [Medline]
  73. Didehbani N, Allen T, Kandalaft M, Krawczyk D, Chapman S. Virtual reality social cognition training for children with high functioning autism. Comput. Hum. Behav. 2016;62:703-711. [FREE Full text] [CrossRef]
  74. Posar A, Visconti P. Sensory abnormalities in children with autism spectrum disorder. Jornal de Pediatria. 2018;94(4):342-350. [CrossRef]
  75. Conner NO, Freeman HR, Jones JA, Luczak T, Carruth D, Knight AC, et al. Virtual reality induced symptoms and effects: concerns, causes, assessment and mitigation. Virtual Worlds. 2022;1(2):130-146. [FREE Full text] [CrossRef]
  76. Torous J, Bucci S, Bell IH, Kessing LV, Faurholt-Jepsen M, Whelan P, et al. The growing field of digital psychiatry: current evidence and the future of apps, social media, chatbots, and virtual reality. World Psychiatry. 2021;20(3):318-335. [FREE Full text] [CrossRef] [Medline]
  77. Indovina P, Barone D, Gallo L, Chirico A, de Pietro G, Giordano A. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures: a comprehensive literature review. Clin J Pain. 2018;34(9):858-877. [CrossRef] [Medline]
  78. Leekam S, Prior MR, Uljarevic M. Restricted and repetitive behaviors in autism spectrum disorders: a review of research in the last decade. Psychol Bull. 2011;137(4):562-593. [CrossRef] [Medline]
  79. Bernaerts S, Bonroy B, Daems J, Sels R, Struyf D, Gies I, et al. Virtual reality for distraction and relaxation in a pediatric hospital setting: an interventional study with a mixed-methods design. Front Digit Health. 2022;4:866119. [FREE Full text] [CrossRef] [Medline]
  80. Zhang M, Ding H, Naumceska M, Zhang Y. Virtual reality technology as an educational and intervention tool for children with autism spectrum disorder: current perspectives and future directions. Behav Sci (Basel). 2022;12(5):138. [FREE Full text] [CrossRef] [Medline]


ABA: applied behavior analysis
ASD: autism spectrum disorder
CBT: cognitive behavioral therapy
CONSORT: Consolidated Standards of Reporting Trials
DSM-5: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
HFA: high-functioning autism
LFA: low-functioning autism
PEDro: Physiotherapy Evidence Database
PICOS: Population, Intervention, Comparison, Outcomes, and Study design
PRISMA: Preferred Reporting Items for Systematic Evaluation
SCIP: Social Communication Intervention Project
VR: virtual reality


Edited by F Xie; submitted 23.05.24; peer-reviewed by F Jorge, N Luke , X Ding, P Li; comments to author 25.08.24; revised version received 10.09.24; accepted 20.12.24; published 05.02.25.

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©Xipeng Yang, Jinlong Wu, Yudan Ma, Jingxuan Yu, Hong Cao, Aihua Zeng, Rui Fu, Yucheng Tang, Zhanbing Ren. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 05.02.2025.

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