Evaluating the Effectiveness of Using Virtual Reality Interventions on Children and Adolescents with Autism Spectrum Disorder: A Systematic Review

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Introduction
An umbrella term used to describe a variety of neurodevelopmental problems is autism spectrum disorder(ASD).These problems are specified through conversation and social interplay problems (1,2).Individuals with ASD frequently manifest limited, repetitious, and stereotyped signs and symptoms or behavior styles.This ailment initiates in early formative years and lasts for the duration of a person's life (3,4).ASD is observed in human beings everywhere in the world, irrespective of race, lifestyle or monetary background.Autism is more common in boys than girls, with a male to Evaluating the effectiveness of VR on ASD EBHPME 2023; 7(4) P a g e | 316 female ratio of 4 males and 1 female (5).There is evidence that ASD cases are on the rise.While the severity of signs varies greatly, there are usually problems of social interplay and verbal exchange skills, restrained interests, and repetitious behaviors (6)(7)(8).Various studies have demonstrated that technologies such as virtual reality can assist in the management of autism patients (2)(3)(4).Virtual reality (VR) has had many definitions in the literature since it was first acknowledged as useful in 1987 (7).In general, the concept of virtual reality (VR) in its simplest definition is the simulation of a world separate from reality that permits the user to enter a space different from his surroundings and engage in the desired experience (8)(9)(10)(11).In fact, virtual reality nowadays is described as computer-generated reality.A simulated reality is identified as an artificial world in which the user can place himself with the appropriate technical equipment.The user is given an experience as a result of how this technology operates.Users are interacting with a threedimensional world rather than the screen in front of them.(12)(13)(14).
VR has emerged as a novelty and effective therapeutic approach to various areas of healthcare including diagnosis, surgical training, improving emotional levels in patients and helping to treat mental disorders such as phobias, anxiety problems, obsessive-compulsive issues as well as ASD (15).Considering the two important features of VR, namely the experience of presence and immersion as well as the possibility of repetition and practice in a safe environment, this technology has greatly improved the conversation and social interaction of individuals with ASD by providing the possibility of training in a realistic environment (3,14,16).In recent years, research was performed at the efficacy of VR interventions in the field of autism (6,7,9,13,17).Recent studies indicate that the usage of virtual reality interventions, including computer emulations can assist persons with autism to create low-stress environments and improve their social interactions and communication.Further, these interventions reduce social anxiety by providing a virtual and dynamic environment for frequent practice of social exchanges (18,19).
The study by Cox et al. (20) exhibited that the utilization of virtual reality driving simulation intervention improved the performance of novice drivers and reduced their panic while driving (20).The Weston study found that virtual reality-based cognitive-behavioral therapies considerably progressed cognition, emotional communication, social skills, and perception of facial expressions in children with ASD (21).Moreover, a study conducted by smith et al. (22) In the field of occupation interview training in individuals with ASD and in which contributors were randomly segregated into two groups of job training intervention through virtual reality and the control group, demonstrated that the persons in the intervention group improved their performance in comparison with the control group (22).Mesa-Gresa et al. (7), after reviewing various articles, reported that VR interventions can enhance many benefits to the remedy of ASD symptoms, but more studies are needed to reveal that VR can efficaciously supplement conventional therapies.
This study aimed to evaluate the effectiveness of virtual reality technologies on children and adolescents with ASD through a systematic review of studies in this field.

Search Strategy
The systematic review executed a complete literature investigating PubMed, WoS, and Scopus.Regarding that technology is an crucial part of virtual reality studies, technology has progressed very rapidly in recent years, simplest, latest articles (from 1 January 2012 to 30 May 2021) had been taken into consideration in the systematic review.The search phrases were: (autism OR "autism spectrum disorder" OR ASD) AND ("virtual reality" OR VR).The related studies in the reference section of articles are manually added.Studies of this type were excluded: Review articles, letter papers, abstracts, editorial manuscripts, and notes.Studies were selected in which researchers evaluated the impact of an interventions based on virtual reality technologies on individuals with ASD, and only Englishlanguage studies were included.

Selection Criteria
Making the right questions to determine the selection criteria and associated clinical finding in the literature is extremely essential.Therefore, decision was made on the PICO model for this motive due to the fact an excellent query have to encompass four components that perceive the study population (P), Intervention performed (I), Comparison of participants (C), and outcomes of study (O) (7).The following PICO query became set up for the literature choice process: non-VR-based treatment, person's situation before VR-based treatment, without treatment.

Selection Process
In the PubMed, only studies that targeted on humans have been selected.Second, files belonging to the types of reviews articles, letter papers, study abstracts and editorial manuscripts have been excluded from the records acquired from every database.Third, a selection of the articles was accomplished based on titles and abstracts in every database; then the outcomes of the selection in the three indexes have been evaluated to dispose of duplicates.
Finally, the textual content of every article examined, and the contribution was ultimately decided on if: (1) The study covered individuals with ASD age limitation of 3-19 years (Children and adolescent); (2) the intervention hired treatments based on VR (3) intergroup or baseline evaluations have been performed; and (4) results on participants have been reported.Any discordance was resolved by the choice of the articles based on the authors of this work.

Data Extraction
Eligible articles were reviewed independently by 2 reviewers using a data extraction form that was developed for the purpose of this review and contain data about authors and year of publication, place of survey, objectives of the study, characteristics of the study population, tools used, type of intervention and results were extracted.Any disagreement between reviewers was resolved by team discussion to getting consensus.

Results
A search of selected databases yielded 808 initial studies, 460 records in WoS, 176 records in Scopus and 172 records in PubMed.63 records from the Wos index and 41 records from the Scopus index were excluded since they were abstracts, notes or reports.Out of a total of 532 records obtained from Wos and Scopus, duplication was reviewed and 296 duplicate articles were reviewed.Abstract of the remaining 236 articles was reviewed and 57 articles were selected to read the full text.With regard to 172 articles extracted from the PubMed index, 29 records were omitted because they failed to perform on humans.Out of the remaining 143 records, the screening of abstracts eliminated 81 articles.After this stage, 62 records remained.After merging the remaining articles from the WoS and Scopus indexes (57 records) and the remaining articles from the PubMed index (62 records), 35 articles were excluded due to duplication.Records that were deleted due to duplication were articles that were exactly the same (for example, the same title, authors and publications, etc.).The flowchart of the selection of articles is shown in Figure 1.Ultimately, the remaining 84 articles were study of their entirety to select articles that have all the selection criteria.The 15 records that met all the selection criteria are shown in Table 1.A total of 359 subjects participated in these studies, 221 individuals in the group of intervention and 138 participants in the group of control.In total, only 5 studies compared the group of intervention with the group of control, and in 10 other articles, the effect of the intervention was investigated only on the intervention group.The sex distribution for ASD participants in the intervention group was as follows: 73.45% of the participants were boys and 26.55% of the participants were girls.With regard to the effectiveness of the studies, all of them reported that VR-based therapies improved at least one of their goals.However, only 3 studies reported that these improvements were significant statistically.Most of the studies were conducted in the United States, with 10 of the studies belonging to the United States, and each of the following countries had one study: Italy, Australia, the United Kingdom, Hong Kong, and Canada.
In most studies, medical attention focused on social and/or emotional skills (40%), as well as emotion recognition, social interaction, and collaborative tasks.A total of three studies (20%) developed children's communication skills.Two studies (13.33%) try to improve daily living skills, especially driving and crossing the street.Two studies (13.33%) were designed to reduce a specific phobia or fear.One study (6.66%) was targeted to improve physical activities, and one study (6.66%) was focused on attention.Figure 2 displays the percentage of studies that concentrated on each clinical target.

Communication Ability
This category contained three articles.In two of these articles, a detailed description of the instances was provided and it was noted that the age range of the participants was between 6 and 18 years with an average age of 11.75 years.However, only the sex of the participants with 9 boys was specified in another article.The used technologies in these interventions included AR and VR elements and CVE games.

Daily Living Skills
In this category, interventions were performed based on training in tasks and skills pertinent to daily life, such as crossing the street or driving.There were two studies in this group in which the age range of participants was between 8 and 19 years and the mean age was 15.5 years.The samples in these studies consisted of 43 boys and 11 girls.The utilized technologies in these studies contained VR driving modules and VR scenarios.

Phobia or fear
Technologies for psychological interventions of fear in children with autism were included in two studies in this category.The participants in this study were all boys and ranged in age from 7 to 16 years with a mean age of 10 years.In this intervention, the virtual reality environment and the Blue Room with unique sensors were used.

Physical Activity
This category included an article that sought to boost motivation in physical activity.The age range of the samples was 4 to 8 years (with a mean age of 6.5 years).In these interventions, stereoscopic screens were applied to immerse individuals as VR technology.

Attention
There was only one article in this category that was selected according to Attention Training.Only a sixteen-year-old person participated in this study.The employed technologies in these interventions included virtual reality scenarios and a mobile object recognition system.

Discussion
This systematic study aimed to review and report the effectiveness of VR interventions in the treatment processes of children and adolescents with ASD.Fifteen published research papers between 2012 and 2021 in the WoS, Scopus and PubMed databases were analyzed for this systematic review.The age range of study participants was 4-19 years and their mean age was 10.5.
According to reports, the findings rightly claim that the use of virtual reality technologies not only improves the social and communication skills of children with ASD, but also provides them with an engaging and enjoyable experience.Additionally, parents revealed high satisfaction with VR applications (25,26,29,31).Most studies have concentrated on promoting emotional communication, social interaction, and daily activities such as driving and shopping due to the opportunities that VR provides.The crucial disadvantage in children with ASD is social skills, and most studies in this field have performed interventions (7,32).Furthermore, interventions in the field of daily life skills, physical activity, and fears have been frequently considered in studies; which improved participants' performance by creating repetitive, stress-free interactive and participatory virtual environments (33,34).Articles that offered emotional interventions basically used avatars and games to learn and regulate emotional reactions.Different studies have applied various tools to implement virtual reality interventions.Some studies have utilized mobile devices, which is regarded as an advantage since it can be used anywhere (7,17,30).
The results of the studies indicated the positive effects of VR intervention on ASD patients.However, it is momentous to note that the outcomes were obtained from small instances and in most papers, no accurate comparison was made between the intervention and control groups, and also another issue that could overshadow the results.One of the main criticisms in this regard is the absence of physisions and therapists from studies intended to educate and train autistic populations.(16,35).Lack of long-term studies to determine whether these technologies actually assist ASD patients in enhancing their social and communication skills is another limitation of the results.(31).

Conclusion
The results of the study manifest that there is not enough evidence to express that VR is significantly effective in ASD patients.However, the promising advantages of VR can motivate the community to use VR-based therapies and the implementation of studies with appropriate population design and homogenized samples with a large number, with the participation of therapists and families of children with ASD and for a long time, is recommended in the future; In order to apply its numerous possible positive results to improve the performance of these patients.

Figure 1 .
Figure 1.Flowchart of the selection of articles

Table 1 .
Final Studies selected for review

Table 1 .
Final Studies selected for review

Table 1 .
Final Studies selected for review

Table 1 .
Final Studies selected for review

Table 1 .
Final Studies selected for review