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DEVELOPMENTAL NEUROREHABILITATION
https://doi.org/10.1080/17518423.2018.1432713

Comparing the effectiveness of virtual reality and video modeling as an

intervention strategy for individuals with Autism Spectrum Disorder: Brief report
Emily Fitzgerald a , Hui Kee Yapa , Charlotte Ashtona , Dennis W Moorea, Brett Furlongera , Angelika Andersona ,
Richard Kickbushb, James Donaldb, Margherita Busaccaa, and Derek L Englisha
the Faculty of Education, Monash University, Clayton, Australia;b Educational Psychology and Inclusive Education, MindSight VR, Melbourne, Australia

ABSTRACT ARTICLE HISTORY

The increasing numbers of individuals diagnosed with Autism Spectrum Disorder (ASD) has foresha Received 18 August 2017
dowed a greater need for effective intervention procedures to aid learning. Revised 19 January 2018
Purpose: This study compared the effectiveness of video modeling (VM) and virtual reality (VR) for Accepted 22 January 2018
teaching adults with ASD. KEYWORDS
Methods: Using an alternating treatments design without baseline two participants completed paper Adults; autism spectrum
folding projects of varying difficulty following exposure to either VM or VR task modeling. The rate of disorder; interventions;
learning (ROL) determined treatment effectiveness. video modeling; virtual
Results: One participant reached mastery criterion for the intermediate project on the 5th trial with both reality
VR and VM (ie equal ROL). The other achieved mastery by the 6th trial of VM, but did not attain mastery
in VR. Both participants enjoying reported both procedures.
Conclusions: The results suggest that VM was more effective than VR in facilitating learning.
Implications for future research are discussed.

Attempting to address the disabling impairments that persist
across the lifespan for those with Autism Spectrum Disorder
(ASD), researchers have focused on interventions for children
1.2
and young people typically with ASD. Indeed, of 150
recently examined ASD intervention studies, less than 2% were
3 This
conducted with individuals older than 20 years.
narrow focus has left a sizeable gap in the knowledge base
4.5 With the
concerning effective interventions for this group.
continuing rapid increase in the number of children diagnosed
with ASD, the number of adults with this condition can only rise.
3,4,6
This prospect has foreshadowed a greater
need for effective interventions and services for adults with 6.7
ASD.
Video modeling (VM) has been shown to be an effective and
8 intervention for children and adolescents with ASD , pro
mising for adults. 9.10 VM involves the participant viewing
videotaped demonstrations of a model performing a target
8
behavior and subsequent imitations. VM offers a range of
presentation formats wherein the type of model is the main
variable. 11 VM models can be peers, adults, siblings, or even
12 the learner themselves (video self-modeling). VM can also
be presented from the vantage point of the individual
demonstrating the behavior, this being referred to as point-of-
13
Working to reduce extraneous stimuli, this
view (POV) video modeling.
format directs the attention of the viewer to the relevant stimuli
11 and may be particularly suited to fine motor tasks. VM is
thought to be effective with this population because it capitalizes
on their relative strengths in visual processing, minimizes human
14
interaction, and, for many, is inherently reinforcing.
Virtual reality (VR) is a 3D simulation of real or imagined
environments 15 allowing users to explore the virtual space
15 The
and interact with objects and people in real time.
therapeutic application of VR has already been extensively
16
explored with non-autistic populations. For example, as a
mode for exposure therapy for specific phobias 17, to assist in
the safe mastery of wheelchair use for people with cerebral
palsy 18, and to assist in the restoration of motor skills in
19
children recovering from trauma. Although pilot studies
exploring the use of VR with ASD populations have reported
encouraging results, the evidence base for VR as an
20 A small number of
intervention to assist people with ASD is
limited. studies have provided preliminary evidence that VR
interventions successfully facilitate learning in children and adolescents
21–
24 cents. However, methodological weaknesses (eg poorly
operationalized independent and dependent variables,
inadequate statistical analyses, insufficient sample sizes, and
with parison conditions) have diminished the strength of this
body of research, justifying further experimentation.
Researchers have argued that VR is well matched to the
learning needs of those with ASD and potentially provides
15
unique advantages as an intervention for adults with ASD.
What sets VR apart from 2D VM is the degree to which users
feel present within the virtual environment (VE) 18, increasing
25 their attention to relevant stimuli. Another unique feature
15
of VR is the ability to interact with the VE. VR can provide
less hazardous and more forgiving environments for developing
daily living skills, which might otherwise be considered unsafe.
16
Hence VR has the potential to be more conducive to
learning than VM. However, the technology does not come

CONTACT Emily Fitzgerald esfitz24@gmail.com Monash University, 19 Ancora Imparo Way, Clayton, VIC Australia 3800
© 2018 Taylor & Francis
Machine Translated by Google
two
E. FITZGERALD ET AL.
without cost as the production of the 3D imagery remains
technically demanding and time consuming.
No study to date has compared the relative effects of these
two interventions. Considering the demand for and importance
of effective interventions for adults with ASD, examining the
differential effects of VM and VR may yield important information
regarding effective practices for researchers, families, and
health-care practitioners. Therefore, the aim in this proof-of-
concept-study was to assess and compare the relative
effectiveness of VM and VR as instructional proce dures for
adults with ASD. Further to this, a leisure activity was selected
as the intervention task to demonstrate the utility of these two
interventions because of the benefits it confers.
Leisure skills and activities are of high priority for individuals
26
with developmental disabilities as they promote the opment of
social and communication skills as well as improve the overall
27
quality of life for individuals with ASD.
Methods
Participants and setting
Two maladies, both diagnosed with ASD, participated. Jackson
(pseudonym) was a 31-year-old male. He was diagnosed with
ASD at approximately age of 27 years by an independent
clinician. He spoke English, had completed tertiary level
education and was employed as a laboratory technician at the
time of the study. His interests included horror novels and video
games. Jackson had no previous experience with VM or VR
and very limited experience with paper folding.
Luke (pseudonym) was an unemployed 25-year-old male
who used spoken English as his primary form of communication.
He was diagnosed with ASD at age 11 by a psychologist who
administered the High Functioning Autism Spectrum the WISC-
Questionnaire, Childhood
28 29
III, and the Screening
30 At the time of
Autism Rating Scale (CARS).
diagnosis, his full-scale IQ was 87, falling within the low average
range. Luke's interests include gardening, watching Anime, and
origami. Luke had previous experience with VM having
participated in an earlier university study. However, he had no
experience with VR technology.
Neither participant was color blind or had any major vision or
hearing impairments. All experiments were conducted at a
University office.
Materials
intervention tasks
We selected purposeful paper folding as a task as it has an
emphasis on problem-solving, creativity, and developing robust
31–33
knowledge and technical skills. Paper folding
offers a practical, purposeful activity assisting in the under
standing of symmetry and fractions and leads naturally onto
mathematical reasoning. 34.35 It involves the integration of
visual information with purposeful hand movements. Both
participants were willing to learn about paper folding.
Consequently, four Projects were selected to assess rates of
learning. Project 1 and 2 involved making a sailing boat, and a
pig's face. Both were categorized as easy, comprising 15 and
17 steps respectively. Project 3 involved making a crane (bird)
and Project 4 was a jumping frog. These were rated inter
mediate, involving 27 and 24 steps, respectively.
Virtual reality/video modeling filming and equipment All
videos were filmed using two GoPro 4 HERO Black with custom
194-degree fisheye lenses, and then edited using Kolar and
Adobe software. The VM video was produced from images
captured from a single GoPro lens. An ambisonic binaural in-
ear microphone array was used to record the voice narration
and ambient sounds. An Oculus RiftTM Consumer Version 1
(CV1) head mounted display (HMD) was used to view the VR
clips. An Apple 13-inch MacbookPro using QuickTime Media
Player was used to show the VM clips.
Task-analysis scoring sheets
Four scoring sheets were created (one per project), each based
on our task analyses.
social validity
On completion of the intervention, social validity interviews were
conducted with participants regarding the appropriate ness and
overall experience of both interventions.
Independent variable and dependent measures
The independent variable was the two different interventions:
VM and VR. The dependent variable was percentage of correctly
completed steps per trial, using event recording for correctly
completed steps within each trial. The mastery criterion was set
to 100% correct for two consecutive trials. To achieve this,
participants had to complete all steps in the correct sequence.
Both participants were given the easy projects at the first trial.
If participants completed these with 100% mastery after the first
or second trial, they were presented with the intermediate
projects.
experimental design
An alternating treatments design without baseline was used.
Intervention presentation order was randomized (coin toss),
except that each condition could not occur more than twice in
succession.
procedure
Ethics and pre-intervention data collection
Approval was obtained from the institutional review board.
Informed consent and demographic information was obtained
from both participants.
VR/VM production
Four full-sequence point-of-view videos depicting the
construction of the paper folding projects were created in both
Machine Translated by Google
VM and VR formats. To maximize participant attention on task-
relevant stimuli, the VR clips were designed to have 180 degrees
of visual stimuli with the remaining 180 degrees presented as blank
space.
All videos were layered with audio narrations, which were
recorded simultaneously. This narration took the form of self talk
about each step, coinciding with the visual depiction of each step.
task analyzes
Task analyzes were undertaken for each project and used to
prepare the scoring sheets for each task. (Details available on request.)
Assignment of projects to conditions
A different paper folding project was presented in each condition
for each participant. Projects were randomly assigned to conditions performance in both conditions.
using a coin toss.
Intervention
In the VM condition, participants were presented with a video
depicting the construction of one paper folding project.
Immediately after viewing this video, participants were instructed
to construct the corresponding project. The participants were given of learning (ROL) was evident in VM compared to VR. No prompts
5 or 10 min respectively to complete easy and intermediate
projects. When the timer signaled the participant was stopped.
The VR condition followed the same procedure except that the
Oculus RiftTM Consumer Version 1 (CV1) HMD was used to view
the relevant construction video. No reinforcement or prompting
was provided. A prompt (ie a picture of the completed project)
was provided to participants only if they did not show any progress
for 10 consecutive trials for a particular project.
Participants were given a 5-min break between trials.
Treatment fidelity and inter-observer agreement (IOA)
Treatment fidelity was assessed via direct observation during 30%
of trials using fidelity checklists for each task. One hundred percent
fidelity was observed with both participants.
Figure 1. Jackson's percentage of correctly completed steps for projects 3 and 4.
DEVELOPMENTAL NEUROREHABILITATION 3
To assess the reliability of observations, two observers inde
pendently observed 30% of all sessions. Percent agreement was
calculated by dividing the number of agreements by the sum of
agreements plus disagreements and multiplying the product by
100. IOA for both participants was 100%.
Results and discussion
Jackson correctly completed 100% of steps in both Project 1 (VM)
and Project 2 (VR) within two trials, creating a ceiling effect. He
was then presented with the intermediate projects.
In the VM condition, he correctly completed 21% of steps in Project
4 in the first trial (see Figure 1). He achieved 100% correct by the
3rd VM trial and achieved mastery by Trial 5.
Similarly, in the VR condition, he correctly completed 26% of steps
in the first trial, 100% by Trial 3, and mastery by Trial 5.
Visual analysis reveals a steep and equivalent increase in
Luke's performance during the intervention is presented in
Figure 2, displaying the percentage of correctly completed steps
for the easy projects (Projects 1 and 2). In the VR condition, Luke
did not achieve mastery, only ever correctly completing 50% of
steps having correctly completed 37.5% of steps on the first trial
and plateauing from Trial 7. In the VM condition, Luke achieved
100% correct by the 5th, and but tery by the 6th trial. A higher rate
were required, and no maintenance data was obtained.
Results from exit interviews indicated that both partici pants
enjoyed participating and were satisfied with their over all
experience. Jackson initially reported the VR presentation more
interesting/exciting than VM. Overall, Jackson appreciated the
potential of VR for teaching more complex skills.
However, in this proof-of-concept study where the video content
was simple with minimal background stimuli, he opined that the
format of the videos became irrelevant. Luke indicated that he had
no preference and that he enjoyed both formats equally. He
reported that he initially felt disoriented due to the VR HMD and
that it took him longer to adjust to this VE. To further strengthen
social validity, a follow up study should use questionnaires based
on the Treatment
Machine Translated by Google
4 E. FITZGERALD ET AL.
Figure 2. Luke's percentage of correctly completed steps for projects 1 and 2.
36
Acceptability Rating Form-Revised or the Intervention
37
Rating Profile in addition to exit interviews.
Our data confirmed previous findings regarding the effec
9, 10, 38
spirit of VM in teaching adults with ASD. VM proved
an effective method for instruction, with both participants
clearly acquiring paper folding skills quickly. In contrast VR
proved effective with only one participant. For Luke VM was
more effective in teaching paper folding than was VR. In the
VR condition, his skill acquisition quickly plateaued, with no
further improvement for the remaining trials. On this index,
Luke's ROL was greater with VM, this differen tial
performance suggests VM is more effective than VR.
There are a number of possible explanations for the
observed difference in Luke's ROL under VM and VR.
Firstly, this study used the Oculus RiftTM HMD to create an
immersive VE. Immersive VEs contain multiple interacting
layers of audio-visual and textual information, surrounding
39
the user with realistic 3D images of the virtual world. While
the multi-modal information and advanced graphics can
provide impressive immersion, it may overwhelm observers,
39
detrimentally affecting performance. Hence, it is possible that
learning could be hampered rather than facilitated by these
sophisticated visuals. Secondly, Luke reported that he
regularly uses laptop devices similar to the one used in the
current VM condition, as well as having previous exposure
to VM interventions through participation in a prior university
study. Therefore, Luke's relative familiarity with laptop
devices and with viewing videos on this medium means that
greater familiarity with one medium than the other cannot be
discounted as an explanation for the observed differential
learning effects. Thirdly, the task in this study was relatively
simple, with minimal background stimuli and devoid of social
interaction and the opportunity to explore the virtual setting.
As Jackson observed, the task simplicity in this proof-of-
concept study may have reduced the impact of the 3D
immersive qualities of VR. This is consistent with the work of
Hubbard, Sipolins, and Zhou who found that the benefits of
VR are likely task-dependent whereby the simplicity of an
40
intervention task may reduce the benefits of VR. Therefore, future
follow up studies should examine the effectiveness of VR
when incorporating more complex tasks and skills that require
interaction with an avatar or the exploration of the
VE (eg social skills). Through this, researchers might better
exploit the defining features of VR, thereby optimizing the
potential benefits for users.
These findings support previous research demonstrating
the efficacy of VM as an intervention strategy for adults on
the spectrum. However, systematic replications, perhaps tar
getting social skills, are needed to determine whether VR
merits the additional production expense, time, and effort
compared to effective procedures like VM.
Declaration of Interest
All authors report no conflict of interest.
ORCID
Emily Fitzgerald http://orcid.org/0000-0002-4353-5852
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