Virtual reality (VR) technologies allow for controlled simulations of affectively engaging background narratives. These virtual environments offer promise for enhancing emotionally relevant experiences and social interactions. Within this context, VR can allow instructors, therapists, neuropsychologists, and service providers to offer safe, repeatable, and diversifiable interventions that can benefit assessments and learning in both typically developing children and children with disabilities. Research has also pointed to VR’s capacity to reduce children’s experience of aversive stimuli and reduce anxiety levels. Although there are a number of purported advantages of VR technologies, challenges have emerged. One challenge for this field of study is the lack of consensus on how to do trials. A related issue is the need for establishing the psychometric properties of VR assessments and interventions. This review investigates the advantages and challenges inherent in the application of VR technologies to pediatric assessments and interventions.

Virtual reality (VR) is an emerging technology that can be considered the result of the evolution of existing communication interfaces toward various levels of immersion.1 An important difference between VR and other media or communication systems is the sense of presence, the “feeling of being there.”2 Through merging of educational and entertainment environments (eg, gamification, VR, and edutainment), coupling of immersive technologies (eg, head-mounted displays [HMDs]) with advanced input devices (eg, gloves, trackers, and brain-computer interfaces), and computer graphics, VR is able to immerse users in computer-generated environments that reflect real-world activities.3,5 Within this context, and within the field of VR more widely, there are many technologies that have been developed and used in educational and clinical settings. As such, there is a wide range of hardware available to researchers and practitioners. Table 1 provides a synthesis of currently available technology and highlights the various specifications, costs, and user interactions across a spectrum of devices. Although these VR technologies differ in their specification, size, and portability, the key affordances of VR (ie, immersion, presence, and ecological validity) remain. Therefore, it is likely some key findings (eg, acceptance, presence, immersion, limited negative effects) from previous work could be applicable across many current technologies.6 Although the quality, graphic fidelity, and refresh rates might vary across platforms (as highlighted in Table 1), the nature of the VR immersive environments and presentation of visual (and audio) stimuli help to ensure similar user experiences across all platforms.

TABLE 1

Comparison of VR Systems

PC-Based VRMobile-Based VRConsole-Based VRStand-alone
System Oculus Rift HTC VIVE Samsung Gear VR Google Cardboard Google Daydream PlayStation VR Allwinner VR Snapdragon 820 VR 
Cost, US$ 599 799 99 10–50 69–149 399 99–249 399–450 
Hardware requirements (US$) High-end PC (>1000) High-end PC (>1000) High-end Samsung phone (>600) Middle or high-end Android phone or iPhone (>299) High-end Android phone (>499) PS4 (299) or PS4 Pro (399) None None 
Resolution 2160 × 1200 2160 × 1200 2560 × 1440 Depends on the phone (minimum 1024 × 768) Depends on the phone (minimum 1920 × 1080) 1920 × 1080 1920 × 1080 2560 × 1440 
Refresh rate 90 Hz 90 Hz 60 Hz 60 Hz 90 Hz minimum 120 Hz 60 Hz 70 Hz 
Field of view 110° 110° 101° from 70° 96° 100° 90° 92° 
Body tracking Medium or high: head tracking (rotation) and positional tracking (forward and backward) High: head tracking (rotation) and volumetric tracking (full room size is 15 × 15 ft for movement) Medium: head tracking (rotation) Medium: head tracking (rotation) Medium: head tracking (rotation) Medium or high: head tracking (rotation) and positional tracking (forward and backward) Medium: head tracking (rotation) Medium or high: head tracking (rotation) and positional tracking (forward and backward) 
User interaction with VR High (by using a joystick or controllers) High (by using controllers) Medium (by using gaze, a built-in pad, or a joystick) Low (by using gaze or a button) Medium (by using gaze or a joystick) High (by using a joystick or controllers) Medium (by using gaze, a built-in pad, or a joystick) Medium (by using gaze, a built-in pad, or a joystick) 
Software availability Oculus store Steam store Oculus store Google Play or iOS store Google Play PlayStation store Google Play Google Play 
PC-Based VRMobile-Based VRConsole-Based VRStand-alone
System Oculus Rift HTC VIVE Samsung Gear VR Google Cardboard Google Daydream PlayStation VR Allwinner VR Snapdragon 820 VR 
Cost, US$ 599 799 99 10–50 69–149 399 99–249 399–450 
Hardware requirements (US$) High-end PC (>1000) High-end PC (>1000) High-end Samsung phone (>600) Middle or high-end Android phone or iPhone (>299) High-end Android phone (>499) PS4 (299) or PS4 Pro (399) None None 
Resolution 2160 × 1200 2160 × 1200 2560 × 1440 Depends on the phone (minimum 1024 × 768) Depends on the phone (minimum 1920 × 1080) 1920 × 1080 1920 × 1080 2560 × 1440 
Refresh rate 90 Hz 90 Hz 60 Hz 60 Hz 90 Hz minimum 120 Hz 60 Hz 70 Hz 
Field of view 110° 110° 101° from 70° 96° 100° 90° 92° 
Body tracking Medium or high: head tracking (rotation) and positional tracking (forward and backward) High: head tracking (rotation) and volumetric tracking (full room size is 15 × 15 ft for movement) Medium: head tracking (rotation) Medium: head tracking (rotation) Medium: head tracking (rotation) Medium or high: head tracking (rotation) and positional tracking (forward and backward) Medium: head tracking (rotation) Medium or high: head tracking (rotation) and positional tracking (forward and backward) 
User interaction with VR High (by using a joystick or controllers) High (by using controllers) Medium (by using gaze, a built-in pad, or a joystick) Low (by using gaze or a button) Medium (by using gaze or a joystick) High (by using a joystick or controllers) Medium (by using gaze, a built-in pad, or a joystick) Medium (by using gaze, a built-in pad, or a joystick) 
Software availability Oculus store Steam store Oculus store Google Play or iOS store Google Play PlayStation store Google Play Google Play 

PC, personal computer.

The availability of much more affordable devices (as shown in Table 1) illustrates that VR hardware has the potential to become more accessible to a much wider demographic than before. Therefore, the extent to which the key affordance of presence is supported by the different VR technologies is a central research question for the field if we are to really understand what features supported by the different hardware are necessary and sufficient for supporting effective and authentic assessment and learning with VR for a much wider group of children. In other words, VR offers an important pathway for narrowing the digital gap nationally and internationally if we can establish how a sense of presence can be achieved in the most accessible and available technologies.

Recent advances in VR technology allow for improved efficiency in administration, presentation of stimuli, logging of responses, and data analyses.7 These features have allowed VR platforms to emerge as promising tools for pediatric cohorts in a number of domains. Examples from recent research and reviews (within the past 10 years) include the following:

  • Neurocognitive assessment8 

  • Psychotherapy9 

  • Rehabilitation10 

  • Pain management11 

  • Prevention and treatment of eating disorders12 

  • Communication training13 

  • Vocational readiness training14 

  • Social skills training15 

Within this context, VR technology can allow instructors, therapists, neuropsychologists, and service providers to offer safe, repeatable, and diversifiable interventions that can benefit assessments and learning in both typically developing children and children with disabilities.16 

VR and augmented reality platforms are rooted in gaming, simulation, and entertainment experiences. Augmented reality overlays virtual objects over a real environment, resulting in a mixed reality that can be used for student-centered learning scenarios. Given the merging of educational and entertainment environments, virtual environments (VEs) and augmented environments have the potential to be a “positive technology” that can improve the quality of children’s experiences.17,18 For example, Active Worlds, Second Life, and ecoMobile are platforms that have been advocated as promoting more active exploration, engagement, student-centered, hands-on learning; better understanding of complex subjects; and more authentic, collaborative, and experiential opportunities for solving real-life problems.19 

The Google Expeditions Pioneer Program20 is a good example of this emerging trend, which allows teachers to take their students on virtual journeys using an application installed on the students’ smartphones. In addition to being teaching and learning tools, VR allows for data capturing of learners’ attitudes, behavior changes, and “aha” moments. Such a portfolio of assessments helps serve as a foundation for educators to develop formative assessment loops, address individual needs, and design better learning opportunities.21 In higher education, VR technologies may help prepare students for future work places in science, technology, engineering, mathematics, business, and medicine. This is especially the case in training skills and performance that carry high risks (eg, driving, flying, conducting a surgery, managing investments).

Augmented reality, too, is an effective experiential learning tool.22 On 1 side, it uses virtual objects to provide nondirective but targeted suggestions that help learners to develop knowledge and skills effectively. On the other side, it allows real-time interactivity in an ecological setting. In particular, as demonstrated recently by the worldwide success of Pokémon Go, it also has the potential of improving public health by promoting physical activity.23 

A focus on positive technology also provides new ways of thinking about the locus and, therefore, solutions of the different challenges or problems faced by children with neurocognitive difficulties.24 For example, rather than developing VR to fix the impairments of the child, VR could be developed to provide better insights and awareness into the difficulties experienced by individuals so as to promote better understanding from the wider public. The “Too Much Information” project of the National Autistic Society in the United Kingdom is a good example of this kind of approach (http://www.autism.org.uk/VR).

One area of future research that will be of interest to clinical scientists is the performance of large-scale randomized controlled trial (RCTs). Although quantitative reviews of VR interventions have revealed statistically large effects on a number of affective domains,25 future studies can increase the confidence in these findings through the inclusion of control groups and performing RCTs. Furthermore, there is need for future studies aimed specifically at establishing the ecological validity and other psychometric properties of VR assessments and interventions for clinical, social, and affective neuroscience research.26 

After the establishment of psychometric properties of VR protocols, future work will be assisted by adopting procedures for standardized reporting of RCT outcomes. This is especially important in the context of new designs and relatively untested features of technology. A potential aid for future research can be found in the Consolidated Standards of Reporting Trials guideline that ensures readers have the basic information necessary to evaluate the quality of a clinical trial.27 

Although VR-based neuropsychological assessments are often referenced for their promise of enhanced ecological validity,3,26 there are potential practical limitations that should be considered. Some VR-based assessments offer automated presentations that do not allow flexibility for clinical examiners to interrupt or test the limits during assessment. Future development of VEs should allow for flexible presentations, wherein clinicians may adjust graphics, stimuli, and task parameters via an interactive user interface. Moreover, the dearth of established guidelines for the development, administration, and interpretation of these assessments could lead to important psychometric pitfalls. Although these limitations are important to consider, advances in VR technology will allow for continued enhancements in approximations of real-world cognitive and affective processes.

There is also the potential for unintended negative effects of exposure to VEs; stimulus intensity, if taken too far, may exacerbate rather than ameliorate a deficit. Although this is an important concern, studies using VR with students diagnosed with neurodevelopmental disorders have been performed with no reported negative effects.5,8,28,29 As we adopt newer and more immersive technologies it is important that researchers continue to consider the potential negative effects (eg, dizziness, sickness, displacement) to ensure that wearable technologies (eg, HMDs) can provide an acceptable space for children to use them, especially children with disabilities. With this said, there is some evidence that suggests children do not experience HMDs any more negatively than screen-based media.5,8,28,29 Taken as a whole, the need to validate and confirm the acceptance of evolving and new technologies is evident, and there is need for more research in this domain.

With this in mind, there is a need, before we enter into VR RCTs, design, and intervention programs, to fully validate and understand users’ perspectives and ensure that ethical guidelines are established. This could be done in either laboratory-based or in situ settings; however, careful attention will need to be placed on developing protocols to ensure the voices of participants are always heard in any research endeavor involving VR technologies.

The introduction of affordable HMDs (eg, Oculus Rift, Samsung Gear VR, Google Cardboard) makes VR an increasingly popular entertainment and learning venue. However, the unmonitored use of VR for entertainment has raised concerns over the years. For example, Segovia and Bailenson30 conducted a study examining the use of VR in children. They found that children exposed to VEs do not always differentiate between VR-based memories and memories formed in the real world. Although these findings need to be replicated in additional studies, the implications demonstrate that unmonitored and entertainment-based VR platforms may not be appropriate for all children. Moreover, the merging of VR with gaming technologies will open VR to concerns that have been raised for gaming and entertainment technologies: sedentary lifestyle, cyber addiction, violence, social isolation, desensitization, and safety. Additional research is needed in these areas.

An important challenge in the design and development of VR technologies is the difficulty involved in putting together interdisciplinary research teams for developing appropriate interventions. Furthermore, there is increasing recognition that representatives of intended user groups should also be included to achieve a better fit between identified needs and proposed solutions. Although not without difficulties, such approaches also align with increasing awareness of the need to involve, for example, members from the clinical and educational communities in these research agendas more widely. Our main recommendation here is that policy makers, including funders, need to support and encourage more user-centered design approaches to VR development and evaluation to ensure that end users’ needs and priorities are more effectively met in research programs and projects.

As mentioned earlier, VR offers great potentials for teaching, learning, assessment, and interventions. Although VR can provide a safe environment for students to gain skills, it usually requires actual experiences to fully master a skill. Poorly designed VR environments may lead to misunderstanding or faulty training results. In addition, VR can provide authentic assessments and interventions in schools, where children and adolescents spend most of their time. The potential for VR technologies to be deployed in schools and used for distance learning is encouraging even if it is challenging. Its potential will be deepened by the diffusion of VR on smartphones.

It is the working group’s consensus that investigations into these future research endeavors have the potential to inform policy, theory, and praxes. Specifically, the addition of VR platforms to pediatric assessments and interventions offers an opportunity for advancing our understanding of the cognitive, affective, psychosocial, and neural aspects of children as they take part in real-world activities.

     
  • HMD

    head-mounted display

  •  
  • RCT

    randomized controlled trial

  •  
  • VE

    virtual environment

  •  
  • VR

    virtual reality

Dr T. Parsons conceived and developed the initial draft, contributed to the enhancement of the original draft, and participated in developing the final draft; Dr Riva, Prof S. Parsons, and Drs Mantovani, Newbutt, Lin, Venturini, and Hall worked with Dr T. Parsons to enhance the original draft and develop it into the final draft; and all authors have reviewed and approved the final manuscript as submitted.

The analysis, conclusions, and recommendations contained in each paper are solely a product of the individual workgroup and are not the policy or opinions of, nor do they represent an endorsement by Children and Screens: Institute of Digital Media and Child Development or the American Academy of Pediatrics.

FUNDING: This special supplement, “Children, Adolescents, and Screens: What We Know and What We Need to Learn,” was made possible through the financial support of Children and Screens: Institute of Digital Media and Child Development.

1
Riva
G
,
Botella
C
,
Baños
R
, et al
. Presence-inducing media for mental health applications. In:
Lombard
M
,
Biocca
F
,
Freeman
J
,
Ijsselsteijn
W
,
Schaevitz
RJ
, eds.
Immersed in Media: Telepresence Theory, Measurement & Technology
.
New York, NY
:
Springer International Publishing
;
2015
:
283
332
2
Waterworth
J
,
Riva
G
. The importance of feeling present. In:
Feeling Present in The Physical World and in Computer-Mediated Environments
.
Houndmills, Basingstoke, Hampshire
:
Palgrave Macmillan
;
2014
:
1
9
3
Parsons
TD
,
Carlew
AR
,
Magtoto
J
,
Stonecipher
K
.
The potential of function-led virtual environments for ecologically valid measures of executive function in experimental and clinical neuropsychology.
Neuropsychol Rehabil
.
2017
;
27
(
5
):
777
807
[PubMed]
4
Bohil
CJ
,
Alicea
B
,
Biocca
FA
.
Virtual reality in neuroscience research and therapy.
Nat Rev Neurosci
.
2011
;
12
(
12
):
752
762
[PubMed]
5
Iriarte
Y
,
Diaz-Orueta
U
,
Cueto
E
,
Irazustabarrena
P
,
Banterla
F
,
Climent
G
.
AULA-advanced virtual reality tool for the assessment of attention: normative study in Spain.
J Atten Disord
.
2016
;
20
(
6
):
542
568
[PubMed]
6
Newbutt
N
,
Sung
C
,
Kuo
H-J
,
Leahy
MJ
,
Lin
C-C
,
Tong
B
.
Brief report: a pilot study of the use of a virtual reality headset in autism populations.
J Autism Dev Disord
.
2016
;
46
(
9
):
3166
3176
[PubMed]
7
Parsey
CM
,
Schmitter-Edgecombe
M
.
Applications of technology in neuropsychological assessment.
Clin Neuropsychol
.
2013
;
27
(
8
):
1328
1361
[PubMed]
8
Parsons
TD
,
Bowerly
T
,
Buckwalter
JG
,
Rizzo
AA
.
A controlled clinical comparison of attention performance in children with ADHD in a virtual reality classroom compared to standard neuropsychological methods.
Child Neuropsychol
.
2007
;
13
(
4
):
363
381
[PubMed]
9
Gorini
A
,
Riva
G
.
The potential of virtual reality as anxiety management tool: a randomized controlled study in a sample of patients affected by generalized anxiety disorder.
Trials
.
2008
;
9
(
1
):
25
[PubMed]
10
Parsons
TD
,
Rizzo
AA
,
Rogers
S
,
York
P
.
Virtual reality in paediatric rehabilitation: a review.
Dev Neurorehabil
.
2009
;
12
(
4
):
224
238
[PubMed]
11
Gold
JI
,
Mahrer
NE
,
Yee
J
,
Palermo
TM
.
Pain, fatigue, and health-related quality of life in children and adolescents with chronic pain.
Clin J Pain
.
2009
;
25
(
5
):
407
412
[PubMed]
12
Riva
G
.
Out of my real body: cognitive neuroscience meets eating disorders.
Front Hum Neurosci
.
2014
;
8
:
236
[PubMed]
13
Cobb
S
.
Virtual environments supporting learning and communication in special needs education.
Top Lang Disord
.
2007
;
27
(
3
):
211
225
14
Smith
MJ
,
Fleming
MF
,
Wright
MA
, et al
.
Brief report: vocational outcomes for young adults with autism spectrum disorders at six months after virtual reality job interview training.
J Autism Dev Disord
.
2015
;
45
(
10
):
3364
3369
[PubMed]
15
Ke
F
,
Im
T
.
Virtual-reality-based social interaction training for children with high-functioning autism.
J Educ Res
.
2013
;
106
(
6
):
441
461
16
Parsons
S
,
Mitchell
P
,
Leonard
A
.
The use and understanding of virtual environments by adolescents with autistic spectrum disorders.
J Autism Dev Disord
.
2004
;
34
(
4
):
449
466
[PubMed]
17
Botella
C
,
Riva
G
,
Gaggioli
A
,
Wiederhold
BK
,
Alcaniz
M
,
Baños
RM
.
The present and future of positive technologies.
Cyberpsychol Behav Soc Netw
.
2012
;
15
(
2
):
78
84
[PubMed]
18
Riva
G
,
Baños
RM
,
Botella
C
,
Wiederhold
BK
,
Gaggioli
A
.
Positive technology: using interactive technologies to promote positive functioning.
Cyberpsychol Behav Soc Netw
.
2012
;
15
(
2
):
69
77
[PubMed]
19
Code
J
,
Clark-Midura
J
,
Zap
N
,
Dede
C
.
The utility of using immersive virtual environments for the assessment of science inquiry learning.
J Interact Learn Res
.
2013
;
24
(
4
):
371
396
20
Google
. Expeditions pioneer program - Google. Available at: https://www.google.com/edu/expeditions/. Accessed December 10, 2016
21
Loh
CS
,
Sheng
Y
,
Ifenthaler
D
, eds.
Serious Games Analytics: Methodologies for Performance Measurement, Assessment, and Improvement
.
Berlin, Germany
:
Springer
;
2015
22
Riva
G
,
Baños
RM
,
Botella
C
,
Mantovani
F
,
Gaggioli
A
.
Transforming experience: the potential of augmented reality and virtual reality for enhancing personal and clinical change.
Front Psychiatry
.
2016
;
7
:
164
[PubMed]
23
McCartney
M
.
Margaret McCartney: game on for Pokémon Go.
BMJ
.
2016
;
354
:
i4306
[PubMed]
24
Parsons
S
.
Authenticity in virtual reality for assessment and intervention in Autism: a conceptual review.
Educ Res Rev
.
2016
;
19
:
138
157
25
Parsons
TD
,
Rizzo
AA
.
Affective outcomes of virtual reality exposure therapy for anxiety and specific phobias: a meta-analysis.
J Behav Ther Exp Psychiatry
.
2008
;
39
(
3
):
250
261
[PubMed]
26
Parsons
TD
.
Virtual reality for enhanced ecological validity and experimental control in the clinical, affective and social neurosciences.
Front Hum Neurosci
.
2015
;
9
:
660
[PubMed]
27
Moher
D
,
Schulz
KF
,
Altman
D
;
CONSORT Group (Consolidated Standards of Reporting Trials)
.
The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials.
JAMA
.
2001
;
285
(
15
):
1987
1991
[PubMed]
28
Wallace
S
,
Parsons
S
,
Westbury
A
,
White
K
,
White
K
,
Bailey
A
.
Sense of presence and atypical social judgments in immersive virtual environments. Responses of adolescents with autism spectrum disorders.
Autism
.
2010
;
14
(
3
):
199
213
[PubMed]
29
Peli
E
.
The visual effects of head-mounted display (HMD) are not distinguishable from those of desk-top computer display.
Vision Res
.
1998
;
38
(
13
):
2053
2066
[PubMed]
30
Segovia
K
,
Bailenson
J
.
Virtually true: children’s acquisition of false memories in virtual reality.
Media Psychol
.
2009
;
12
(
4
):
371
393

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.