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Abstract

Children with developmental disabilities (DD) experience higher rates of mental health (MH) concerns than their non-disabled peers, yet school-based mental health professionals often lack the training needed to support this population effectively. One contributing factor is limited clinical preparation during graduate education. This pilot study examined the use of mixed-reality simulation as a training tool for school psychology and school counseling graduate students to increase their clinical interactions with children presenting with co-occurring MH and DD. Participants reported increased confidence and preparedness in addressing mental health needs among children with DD. Implications will be discussed.

Keywords

mixed-reality simulation school psychologists school counselors developmental disabilities mental health

Introduction

Children with developmental disabilities (DD) exhibit co-occurring mental health conditions at higher rates than children without DD. Some estimates suggest that 25% to 49% of children with DD have a co-occurring psychiatric disorder (Buckley et al., 2020; Dekker & Koot, 2003; Lambros et al., 2015; McIntyre, 2011). Yet many children with co-occurring mental health disorders and developmental disabilities (MH/DD) do not receive treatment for their mental health concerns (Graaf & Snowden, 2020). Swick and Powers (2018) examined the availability of school-based mental health services for students with co-occurring MH/DD, and they found that although some schools offered these services, they are often insufficient for students with MH/DD. Training school-based mental health professionals may increase access to services for this population and help them tailor supports to students with DD (Finkelhor et al., 2021). This study explored the pilot implementation of a graduate-level mixed-reality simulation (MRS) training experience focused on students with MH/DD for school psychology and school counseling students.

Mixed-Reality Simulation Training

Mixed-reality simulation (MRS) combines virtual and physical elements to create a realistic and interactive environment for learning, training, or research. The MRS lab in the current study utilized the TeachLivE^® teaching environment (CREST/TeachLivE, 2024), which resembles an elementary, middle, or high school classroom or a one-on-one interaction with an avatar of a student. Research on the use of MRS within education training programs suggests that lab-based learning may increase feelings of self-efficacy and preparedness among education graduate students, facilitating classroom lessons in actual school classrooms (Gonzalez, 2011; Kelley et al., 2025). Ten minutes of practice in a TeachlivE simulator is equivalent to 45-60 min of real-world practice (Dieker et al., 2014).

Current Study

Using MRS technology, we developed a set of scenarios for school psychology and school counseling students to practice their clinical skills with students with MH/DD. We aimed to answer the following research questions:

(1) Does participation in the MRS lab lead to increased confidence and self-reported preparedness among school psychology and school counseling graduate students to support students with MH/DD?

(2) What is the acceptability of the MRS technology among school psychology and school counseling graduate students?

(3) What were the trends in active listening skills across MRS scenarios?

Method

Participants

Participants were recruited from a third-year school psychology cohort and a second-year school counseling cohort, each with approximately 15 students. Using quota sampling, we emailed the recruitment flyer to all students in the cohorts and recruited until we received signed consents from five students from each program. Within their respective programs, each cohort had recently completed its required sequence of Active Listening skills courses. This study was approved by the Institutional Review Board of the researchers’ university. Ten graduate students (five in school psychology and five in school counseling) participated in the study. Participants had no prior experience in a simulation lab.

Intervention

As part of the TeachLivE™ lab experience, each participant interacted with four avatars: Bailey, Martin, Sean, and Ed. Bailey and Martin were both high school students with developmental disabilities and an individualized education program (IEP). Both avatars had an IQ of 70 and read below grade level; they also struggled with some school subjects. Sean and Ed did not have disabilities and were both in the 10th grade with average IQs.

Each participant interacted with each avatar twice. They received faculty feedback in between each interaction. Before each interaction, participants were informed that the avatars had recently presented with changes in their mood and behavior. Participants were instructed to build rapport, identify and build on the avatars’ strengths, and gather more information about potential causes of changes in their mood and behavior. Each participant received a brief description of each avatar before the MRS scenario began. The participants’ virtual interactions with the avatars were recorded, and the recordings were scored and analyzed by the research team. Participants completed one pre- and one post-survey.

Measures

Self-Reported Preparedness and Confidence Questionnaire

The Self-Reported Preparedness and Confidence Questionnaire was developed for this study to assess confidence and preparedness among school counseling and school psychology students. This questionnaire consists of 11 items in which participants ranked their preparedness to recognize and discuss a student’s concern about psychological distress, as well as their confidence in helping and referring students for mental health support.

Acceptability of MRS

Participants were asked five post-survey satisfaction questions about their experience in the MRS lab and comfort with interacting with the avatars.

Active Listening Skills Behavior Observation Form (ALSBOF)

The ALSBOF was developed to align with the skills taught in the Active Listening course sequence required by each graduate program. The form assessed five sets of active listening skills (see Table 1) and deductions, including inappropriate responses to the avatars’ comments (e.g., advice giving, judging/praising, inappropriate self-disclosure, closed questions, and interruption of the avatar).

Table 1.

Examples from the ALSBOF.

Active listening skill	Skill description
Invitational skills
Opening the session	Initial intervention that orients avatar and helper to beginning of session
Reflection skills
Paraphrasing	Restate same information using different words to more concisely reflect what avatar said
Questions
Open question	Open-ended questions encourage avatar to control direction of conversation rather than give one word responses, aid in client safety and expression
Challenging & other skills
Giving feedback	Listening to understand without judgment. Reflecting avatar’s comments back to them while sometimes reflecting their feeling or meaning.
Closing skills
Session summary	Participant provides a synopsis of the content, feelings, and meaning of what avatar shared in session

Hits & Misses Behavior Observation Rating Form

Hits & Misses are terms used within MRS to reflect on the participants’ skills at eliciting desired engagement from the avatars. A Hits & Misses Behavior Observation Rating Form was developed by the research team for each of the four avatars (see Table 2). The Hits & Misses form was organized using an if-then structure to outline where interactions were successful (Hits) and where they were not (Misses) in engaging the avatar. A 2-hr training session took place with the interactor, who controls the avatars, and members of the research team to ensure the interactor enacted the behaviors with fidelity.

Table 2.

Examples from the Hits & Misses Behavior Observation Form for Bailey.

Participant Hits it. . .	Avatar should. . .
Here, describe specific examples of a participant being successful. For example, uses. . .	Here, describe specific examples of how the avatar should react if the participant hits the mark. For example,
Inquiring about the avatar’s wellbeing	Nod, have semi-open body language
>Explains the reason for interaction	Nod head or confirm verbally (“yes,” “mmmhm,” “I see,” etc)
Engages in 6 Active Listening skills	Responds in 3–4-word phrases
○ Invitational Skills	Delay in response to all questions
○ Reflection Skills	Answer questions asked by the participant after they shift from open-ended to closed questions
○ Questions
○ Challenging and Others Skills	Intermittently gives eye contact
○ Closing
Ask about student’s interests, preferences, and preferred activities

Results

Research Question 1: Self-Reported Preparedness and Confidence

We compared pre- and post-survey responses on the self-reported preparedness and confidence survey. In seven of the 11 self-report items, participants showed a positive trend in their confidence and preparedness levels from pre- to post-interaction, and a slight negative change in three items, while one item showed no change. For example, question 1 asked participants to rate their preparedness in recognizing when a student’s behavior is a sign of psychological distress; their preparedness ratings increased from pre-survey (M = 3.1, SD = 0.6) to post-survey (M = 3.5, SD = 0.7), with 20% reporting a “High” rating pre- compared to 60% post-survey. Question 5 asked how participants would rate their preparedness in recommending mental health support services to a student exhibiting signs of psychological distress; their preparedness increased from pre-survey (M = 3.0, SD = 0.7) to post-survey (M = 3.5, SD = 0.5), with 20% reporting a “High” rating at pre- and 50% post-survey. Question 11 asked if participants felt confident in their ability to help a suicidal student seek help; their confidence slightly increased from pre-survey (M = 2.6, SD = 0.5) to post-survey (M = 2.7, SD = 0.7), with 0% “Strongly Agreeing” at pre- and 10% “Strongly Agreeing” post-survey.

Research Question 2: Satisfaction/Acceptability of MRS Lab

The participants were asked five Satisfaction questions about their overall experience with the MRS lab. Many participants (n = 6) noted that the simulation experience enhanced their active listening skills (M = 1.6, SD = 0.5). Most participants (n = 9) also reported feeling more comfortable interacting with the avatar students after their first session (M = 1.9, SD = 0.4).

Research Question 3: Active Listening Skills Behavior Observation Form

Skills Observed

Across all avatars, the “Questions” skills were used most often by the school psychology students for Ed (M = 30.7, SD = 7.6), Bailey (M = 31.3, SD = 12.2), Sean (M = 30.7, SD = 17.5), and Martin (M = 27.3, SD = 10.6), followed by “Invitational” and “Reflection” skills by both school psychology and counseling students (see Table 3). The “Invitational” skills were used more often across school psychology for Ed (M = 8.4, SD = 6.9), Sean (M = 9.8, SD = 9.5), and Martin (M = 10.6, SD = 8.5), and more often for Bailey (M = 9.8, SD = 8.2) across school counseling students. The “Reflection” skills were used more often across school psychology for Ed (M = 7.8, SD = 5.0) and Sean (M = 6.3, SD = 5.5), while these skills were used more often across school counseling students for Bailey (M = 8.2, SD = 4.7) and Martin (M = 9.7, SD = 5.3).

Table 3.

Active Listening Skills Behaviors by Group.

		Bailey		Ed		Martin		Sean
Participant group	Active listing skill	M	SD	M	SD	M	SD	M	SD
School counseling	Invitational	9.8	8.2	6.2	3.7	9.0	8.0	7.6	3.6
	Reflection	8.2	4.7	7.3	4.3	9.7	5.3	5.3	4.1
	Questions	19.3	5.1	17.7	6.7	18.3	6.1	20.0	6.6
	Challenging & other skills	3.5	5.7	2.3	4.5	4.0	6.7	2.8	4.9
	Closing	0	0	0.5	0.7	0	0	0	0
	Overall	8.5	7.7	6.9	6.6	8.7	7.7	7.1	7.2
School psychology	Invitational	8.6	6.3	8.4	6.9	10.6	8.5	9.8	9.5
	Reflection	7.2	5.9	7.8	5.0	9.5	9.3	6.3	5.5
	Questions	31.3	12.2	30.7	7.6	27.3	10.6	30.7	17.5
	Challenging & Other Skills	1.5	2.4	1.5	2.4	2.5	3.3	2.3	3.9
	Closing	0.5	0.7	0	0	0	0	1.0	1.4
	Overall	9.4	11.6	9.4	10.9	10.1	11.0	9.5	12.4

Across both school psychology and counseling students, the least used skills were the “Closing” skills and deductions, or negative or inappropriate listening skills (e.g., judging/praising, advice giving). The “Closing” skills were almost identical across both school psychology and counseling students for Ed (M = 0.5, SD = 0.7), Bailey (M = 0.5, SD = 0.7), Sean (M = 1.0, SD = 1.4), and Martin (M = 0, SD = 0). Skills were used most frequently with Bailey and Martin, the two avatars with DD.

The last active listening skill was the “Challenging and Other Skills,” which consists of Giving Feedback, Confronting, and Immediacy. From these three skills, “Giving Feedback” was the skill most frequently used among all participants, but the school counseling students used them more frequently for Ed (M = 2.3, SD = 4.5), Bailey (M = 3.5, SD = 5.7), Sean (M = 2.8, SD = 4.9), and Martin (M = 4.0, SD = 6.7), especially among Bailey and Martin.

Skills Utilized with Avatars with DD

Regarding total active listening skills used with the avatars, there was a slight trend toward increased interaction or engagement among both school psychology and counseling students with the avatars with DD compared to those without. The school psychology students showed a great use of active listening skills with Bailey (M = 9.4, SD = 11.6) and Martin (M = 10.1, SD = 11.0), as did the school counseling students for Bailey (M = 8.5, SD = 7.7) and Martin (M = 8.7, SD = 7.7). The school psychology students, however, showed the most frequent use of active listening skills with all avatars compared to the school counseling students Ed (M = 9.4, SD = 10.9) and Sean (M = 9.5, SD = 12.4).

Hits & Misses Observation Rating Form

On the Hits & Misses Observation Rating Form, we looked at the overall performance objectives for each avatar. Because the Hits & Misses Observation Forms varied across avatars, the sample sizes for the performance objectives differed by avatar. Each avatar's performance objectives were analyzed. Participants demonstrated more “hits” in their interactions with Bailey (disability) and Sean (no disability). All participants had minimal missed skills.

Discussion

This pilot study examined the acceptability of a set of MRS training scenarios to enhance school psychology and school counseling graduate students’ confidence and competence when working with children exhibiting co-occurring MH/DD. Our findings contribute to the growing body of research suggesting that simulation-based training can be a valuable component of graduate education for school-based mental health professionals (Griffith et al., 2025).

This pilot suggests that participation in the MRS lab experience may have contributed to increased self-reported confidence and preparedness in recognizing and responding to signs of mental health concerns in students with and without DD. These findings are consistent with existing literature, which has shown that MRS experiences can improve self-efficacy and perceived readiness to apply clinical skills in real-world settings (Gonzalez, 2011; Kelley et al., 2025). Participants reported high satisfaction with the MRS lab, noting the realistic nature of the avatar interactions and the usefulness of the training for building active listening skills. Despite initial discomfort in the MRS lab, most students became more comfortable with continued practice. These responses mirror findings from prior research suggesting that MRS provides a safe environment for experiential learning, particularly when compared to more traditional methods such as role-play or practice with a real client (Spencer et al., 2019; Whitney et al., 2025). Furthermore, participants exhibited higher frequencies of active listening behaviors and elicited stronger reactions from avatars with MH/DD (Bailey and Martin) compared to those without disabilities. These findings may reflect greater participant effort or sensitivity when interacting with avatars perceived as more complex. They also point to the responsiveness of avatars as a useful feedback mechanism. For example, when participants “hit the mark,” avatars with MH/DD were more engaged, and when participants “missed the mark,” these avatars were less engaged. This pattern suggests that avatars designed with MH/DD profiles may be particularly effective in promoting participant engagement and responsiveness.

Implications

Given the persistent gap in provider readiness to support youth with co-occurring MH/DD (Vohra et al., 2014; Whittle et al., 2018), MRS offers a promising approach for bridging didactic learning with applied skill development. School psychologists and counselors are often at the frontline of supporting these students, yet traditional graduate curricula may not adequately address the dual needs of developmental and mental health challenges. Integrating MRS modules into standard coursework provides opportunities to practice core competencies and promotes greater awareness of how to support students with more complex needs.

Limitations and Directions for Future Research

This study had several limitations. The sample size was small and limited to cohorts from a single institution, which may restrict the generalizability of the findings. Additionally, participants self-selected into the study, which may have introduced response bias. The short duration of the MRS exposure may also limit the extent to which lasting skill acquisition occurred. Future studies should investigate the longitudinal impact of repeated MRS participation and explore how MRS experiences affect actual fieldwork performance.

Conclusion

This study provides data on the use of MRS in clinical training programs for school psychology and school counseling students working with children with MH/DD. The results provide preliminary support for integrating simulation-based learning into graduate curricula to help future school-based mental health professionals develop the skills required for addressing the complex needs of this underserved population. Expanding access to experiential learning opportunities, such as MRS, may improve service delivery and mental health outcomes for children with developmental disabilities.

Footnotes

ORCID iD

Emily Graybill

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Biographies

Emily Graybill, PhD, NCSP, is an Associate Professor of School Psychology at Rutgers University. Her research interests fall broadly under the translation of evidence-based interventions into practice in schools and community settings.

Sonia Sanchez-Alvarez, MPH, is an Evaluation Research Analyst at Rutgers University. Her work focuses on qualitative and quantitative data management and analysis to help guide decision-making in school districts that support students’ well-being.

Erin Mason, PhD, is an Associate Professor of Counselor Education and Doctoral Program Coordinator at Georgia State University. Her research focuses on preparing equity-centered school counselors, the role of leadership and advocacy in counselors' and counselor educators' professional identity development, and innovation in teaching and learning.

Erin Anderson is the Director of the Interactive Teaching and Learning Lab at Georgia State University and a board member of Civics of Technology, an organization helping teachers critically assess the technologies they use. Dr. Anderson uses technoskeptical design to bring pre-service teachers, especially in Special Education, into the edtech design process.

Allison Wayne, Ph.D., is a Postdoctoral Associate at the University of Virginia. Her clinical and research interests broadly focus on supporting children with disabilities across home and school settings.

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Training School Psychologists & School Counselors with Mixed-Reality Simulation: A Focus on Co-occurring Disabilities