Sage Journals: Discover world-class research

Abstract

Background

There is growing interest in the use of virtual reality environments (VREs) in psychological treatment and assessment. Most research has focused on the application of VREs in adult psychological disorders with fewer studies focusing on its applicability with children and adolescents. A systematic scoping review was undertaken of research assessing how VREs have been used in the treatment and assessment of childhood mental health disorders to provide an overview of the current state of the literature and identify future research directions.

Method

Systematic searches of online databases were conducted in PsycInfo, PubMed, Embase, Scopus, and Web of Science.

Results

Eleven studies met eligibility criteria and were included in this review, with the majority focusing on VRE interventions for anxiety-related disorders. There is also emerging support for VRE deep breathing training for anxiety, VRE assisted treatment of internet gaming disorder and anorexia nervosa, and VRE assessment of body image evaluation in anorexia nervosa. Most studies were pilot and feasibility studies with only three randomised-controlled trials (RCT).

Conclusions

The current literature shows some promise for the use of VRE assessments and interventions of childhood mental health problems, particularly for anxiety-related disorders such as social anxiety and specific phobias. However, high-quality RCTs are now needed to establish effectiveness of VREs in this population, and how it compares to existing evidence-based approaches, given its promise to improve both engagement and outcomes.

Keywords

Virtual reality mental health children adolescent

Introduction

Mental health problems in childhood and adolescence are prevalent, with up to half of young people not accessing treatment, and for the majority of those that do, not maintaining contact for the duration required for standard treatment (Sawyer et al., 2019). As such, it is important to continue to develop effective, therapeutically engaging, accessible assessment and treatment and virtual reality environments (VRE) have the potential to contribute to all of these areas. Advances in VRE technology have led to increased interest in its use across a range of conditions, including mental health.

VRE refers to a computer-generated simulation of a three-dimensional environment that is experienced through sensory stimuli. Facilitated via the use of tracking technologies, physical user movements are replicated within the simulated environment to provide user perspective within the virtual space, thus providing a sense of presence and embodiment. VRE is most commonly experienced through head-mounted displays (HMDs) and cave automatic virtual environment (CAVE) systems. HMD based VREs differ to that of CAVE systems, in that HMDs often provide increased interpupillary distance (IPD) customisation and higher capable screen refresh rates. This is due to CAVE VREs being projected onto the walls of a room and consumed using 3D glasses, whereas HMD VREs are visualised using small screens and lenses within the device itself.

This VRE technology present an opportunity to expose children to simulated scenarios in a controlled clinical setting, where clinicians can assess behaviour and guide desired behavioural responses. Another potential benefit of VREs is the accessibility clinicians could have to various simulated environments that would mitigate difficulties with conducting in vivo observations and therapy. Responding to this potential, there is emerging evidence for the efficacy of using VREs in the treatment of psychological disorders. Recent reviews demonstrate most research in this field has focused on the assessment and treatment of adult anxiety-related disorders, (Cieślik et al., 2020; Freeman et al., 2017). Ceislik et al. concluded that VRE tools were generally used as an add-on to therapy rather than a replacement stand-alone intervention. Reviews reported similar effectiveness to treatment as usual and to conventional interventions (e.g., Cieslik et al., 2020) or active controls (e.g., for PTSD, Kothgassner et al., 2019). Other reviews report research into VREs in populations with neurodevelopmental disorders, such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), eating disorders, psychotic disorders, depressive disorders, and substance use disorders (Carl et al., 2019; Cieślik et al., 2020; Clus et al., 2018; Freeman et al., 2017; Maples-Keller et al., 2017; Valmaggia et al., 2016). These report an emerging evidence base supporting the efficacy of VREs in assessment and treatment.

While research on VREs in adult mental health disorders is advancing, there is less research evaluating whether VREs can be similarly applied to child and adolescent populations. Sharar et al. (2007) suggest children experience VREs more vividly and perceive it as more real compared to adults. This suggests that VREs could elicit responses from children that are similar to their usual response to a situation, and prove useful for assessing symptomatic behaviour and practising adaptive behaviour. The limited literature on VREs in psychological assessment and intervention with children has focused on neurodevelopmental disorders and procedural anxiety. Emerging evidence suggests that the use of VREs as a distraction tool can be effective in preventing and reducing procedural distress (Eijlers et al., 2019). In childhood ADHD most research has sought to validate the use of virtual environments for the assessment of attention (Parsons et al., 2019; Romero-Ayuso et al., 2021). Recent reviews examined VRE interventions in children with ASD, concluding that VREs can be effective in improving cognitive and emotional processing, social communication and attention (Bailey et al., 2021; Mesa-Gresa et al., 2018).

Beyond procedural anxiety and neurodevelopmental disorders, limited research has been conducted with children and adolescents. Bouchard (2011) summarised early work in the area of anxiety disorders noting encouraging findings for simple phobias. A systematic review of both VREs and applied games (digital games that aim to educate and/or change patterns of experience or behaviour) interventions for childhood mental health disorders, only included three VRE studies (Halldorsson et al., 2021). While these studies indicated that there may be potential for the use of VREs as a tool in the treatment of anxiety-related disorders, no further conclusions could be reached (Halldorsson et al., 2021). Similarly, in a review of VR exposure therapy for anxiety disorders in children, Kothgassner and Felnhofer (2021) found only four published trials, concluding that findings suggest VR exposure therapy may be an effective treatment, but more research was needed.

As such, this review sought to broaden the scope to include both assessment and treatment of all DSM/ICD mental health disorders in children and adolescents. The review aimed to establish how VREs have been implemented in the assessment and treatment of child and adolescent mental health conditions (excluding procedural anxiety and neurodevelopmental disorders). This included understanding how VREs have been used to assess and treat mental health conditions, and so information was collated on participant demographics, assessment/treatment procedures, treatment outcome measures used, and key findings, as well as the VRE technology used. It was expected the findings would inform child and adolescent mental health clinicians and researchers about how VREs have been used, and provide future directions for work in this area.

Method

This scoping review was conducted in accordance with PRISMA-ScR (Tricco et al., 2018) and the protocol was registered (https://osf.io/gafh8). ICD mental health disorders were added to inclusion criteria after protocol registration to include internet gaming disorder which is in the “conditions for further research” section of the DSM-5 (American Psychiatric Association, 2013) but listed as a disorder in ICD-11 (World Health Organisation, 2019).

Eligibility criteria

Eligibility criteria were refined during the review to be consistent with the study aim. Studies were eligible for inclusion if:

1. They were published in peer-reviewed journals in English.

2. They reported primary data (not reviews).

3. Participants were 18 years or younger, or if average age of participants in the study was less than 18 years.

4. The VRE was deemed an immersive, interactive 3D technology (HMDs/CAVE system).

5. VRE was used to contribute to the diagnostic assessment or the measure of symptom severity, or treatment of a diagnosed DSM/ICD mental health disorder or elevated symptoms of a mental health disorder. After preregistration the decision to exclude participants with neurodevelopmental disorders or procedural anxiety was made as recent systematic reviews are available, except when the target of intervention or assessment in children/adolescents with neurodevelopmental disorders was mental health.

6. They reported any of the following:

a) The outcome of VRE interventions using a diagnostic measure or measure of symptoms of a DSM/ICD mental health disorder (this is a refinement of the preregistration criteria to include studies with mental health disorder symptom measures, as elevated symptoms indicate likely presence of the disorder)

b) The effectiveness or validity of VRE for diagnostic assessment or measurement of symptom severity of a DSM/ICD mental health disorder, by comparing it to a validated diagnostic or symptom severity measure of a DSM/ICD mental health disorder or a control group (this criterion was added after preregistration to ensure studies using VRE in assessment were included)

Search strategy

Five databases, PsycInfo, PubMed, Embase, Scopus, and Web of Science, were searched from the beginning of records to 7th June 2021 (updated 5th July 2023). The search strategies were refined by a research librarian. Keyword searches in these databases consisted of a combination of target population terms and VRE terms. Population search terms included child* OR kids OR adolescen* OR teen* OR young OR youth OR juvenile OR minor OR pediatric OR paediatric. VR search terms included virtual reality OR virtual realit* OR virtual environment* OR VR. See supplementary materials for search strategies. Search results were exported into EndNote X9. A manual search of reference lists of all included papers was also conducted.

Study selection

Figure 1 summarises the study selection process. After duplicates were removed, 8,448 studies were screened based on title and abstract with 50 articles screened by an independent second reviewer. There was 90% agreement, with disagreements resolved through discussion. After 8,331 studies were excluded, the remaining 117 studies were screened through full-text reading. Ten percent of studies were screened by the second reviewer with 100% inter-rater agreement. Manual searches of the reference lists of all included studies identified no further studies. Thirteen studies met eligibility criteria and were included in this review.

Figure 1.

PRISMA-ScR flowchart of study selection process.

Data extraction and synthesis

Extracted data included study design, aim, procedure, outcome measures, and key findings, as well as VRE technology used, and participant demographics. A narrative synthesis was conducted.

Results

Study characteristics

The characteristics and demographics of the 13 studies included in this review are presented in Table 1. Two of the selected studies investigated the use of VRE as an assessment tool, while 11 examined the use of VREs in the treatment of childhood/adolescent mental health disorders. Studies were conducted in 10 countries, mostly in Europe. Participants ranged from 7 to 25 years old, eight studies included boys and girls, two only included boys, and two only girls (one study did not report gender). Most common were feasibility studies (n = 5) with three randomised control trials. The VRE hardware used across studies varied, with four studies using the Occulus Rift HMD (Azimisefat et al., 2022; Farrell et al., 2021; Fisher et al., 2020; Shin et al., 2018), and two studies that used the “Blue Room” CAVE system (Maskey et al., 2014, 2019). The sample sizes of studies ranged from 6 to 64. Ten studies focused on anxiety-related disorders, with six of those focusing on specific phobias. The three other studies targeting internet gaming disorder (Shin et al., 2018) and anorexia nervosa (Fisher et al., 2020; Porras-Garcia et al., 2020).

Table 1.

Study characteristics and demographics.

Study	Country	Study design^a	VRE technology	Target population	Age range	Sample size	Gender
Assessment studies
Fisher et al. (2020)	France	Cross-sectional descriptive	Oculus Rift HMD	Anorexia nervosa	11–18	31	31 girls
Parrish et al. (2016)	USA	Feasibility study with clinical and non-clinical groups	VFX-3D interactive imaging systems HMD	Social anxiety disorder	13–18	41	27 girls, 14 boys
Intervention studies
Azimisefat et al. (2022)	Iran	Randomised controlled pre-post-test study	Oculus Rift Dk2 virtual reality headset	Specific phobia -acrophobia	16–18	45	45 girls
Bossenbroek et al. (2020)	Netherlands	Single-case experimental	DEEP program with HTC Vive HMD and headphones	Anxiety and disruptive classroom behaviour	12–17	8	7 boys, 1 girl
Farrell et al. (2021)	Australia	Multiple baseline controlled case series	Oculus Rift HMD	Specific phobia of dogs	8–12	8	4 boys, 4 girls
Kahlon et al. (2019)	Norway	Non-randomised feasibility and pilot study	Apple iPhone 7 with cardboard type VR HMD	Public speaking anxiety	13–16	27	21 girls, 6 boys
Maskey et al. (2014)	England	Pilot feasibility study	Blue room (CAVE system)	Specific phobia in ASD	7–13	9	9 boys
Maskey et al. (2019)	England	Single blind randomised control trial	Blue room (CAVE system)	Specific phobia in ASD	7–14	32	25 boys, 7 girls
Porras-Garcia et al. (2020)	Spain	Randomised controlled trial	VR head mounted display (HTC-VIVE), 3 body trackers and VR HMD FOVEEye tracking	Anorexia nervosa	14–18	17	Not reported
Servera et al. (2020)	Spain	Pre-experimental	Psious VR HMD	Specific phobia of the dark	8–12	6	3 boys, 3 girls
Shin et al. (2018)	South Korea	Feasibility study with clinical and non-clinical groups	Oculus Rift HMD with tracker and Leap Motion controller	Internet gaming disorder	12–25	64	64 boys and men
St-Jacques et al. (2010)	Canada	Feasibility study	nVisor SX HMD	Specific phobia of spiders	8–15	31	26 girls, 5 boys
Whiteside et al. (2020)	USA	Feasibility study	Google pixel Android smartphone with daydream Viewer HMD with motion controller.	Anxiety related to academic performance	8–18	20	14 girls, 6 boys

Note. HMD: head-mounted display; VR: virtual reality; CAVE: cave automatic virtual environment.

^aAs reported by study.

Synthesis of results

Assessment studies

Two studies investigating the use of VREs to assess symptoms of mental health disorders were identified (see Table 1). Fisher et al. (2020) assessed the effectiveness of a VR-based scale for adolescents with anorexia nervosa to rate their body image perception and desired body, by comparing it to conventional paper-based figure rating scales. The outcomes of this descriptive cross-sectional study showed that body image disorders symptoms reported on the VR-based scale were comparable to symptoms reported on the paper-based figure rating scales. Also using VRE for assessment, Parrish et al. (2016) reported the feasibility of VREs differentiating between adolescents with and without social anxiety disorder, and whether exposure to VRE social environments (a party, giving a presentation) was more anxiety producing than exposure to VRE neutral environments (art gallery). Adolescents with social anxiety disorder reported significantly higher Subjective Units of Distress (SUDS) than the control group when exposed to the VRE social environments, and both groups found the VRE social environments significantly more distressing than the VRE neutral environment.

Intervention studies

Eleven studies that evaluated VREs in the treatment of mental health conditions were identified. A summary of outcomes is presented in Table 2. Nine studies focused on treating anxiety symptoms and one on internet gaming disorder (Shin et al., 2018). Furthermore, 10 studies utilised VREs as a mode of exposure therapy (Azimisefat et al., 2022; Farrell et al., 2021; Kahlon et al., 2019; Maskey et al., 2014, 2019; Porras-Garcia et al., 2020; Servera et al., 2020; Shin et al., 2018; St-Jacques et al., 2010; Whiteside et al., 2020). The majority of the anxiety-related studies applied VREs as an exposure therapy tool (Farrell et al., 2021; Kahlon et al., 2019; Maskey et al., 2014, 2019; Servera et al., 2020; St-Jacques et al., 2010; Whiteside et al., 2020), while one study utilised VRE to engage adolescents in deep breathing practice (Bossenbroek et al., 2020). One study used VRE for exposure therapy, but not in the context of an anxiety disorder- Porras-Garcia et al., (2020) used VRE to expose adolescents with anorexia nervosa to an avatar with gradually increasing body mass index. They reported reduced eating disorder symptoms as well as lower body-related attentional bias toward weight-related body parts and higher BMI. Seven studies measured the impact of VRE exposure therapy on symptoms of anxiety, and all found reductions after one session (Farrell et al., 2021; Kahlon et al., 2019; Whiteside et al., 2020) and four or more sessions (Azimisefat et al., 2022; Maskey et al., 2014, 2019; Servera et al., 2020). St-Jacques et al. (2010) examined whether VRE exposure therapy would increase children’s motivation for therapy but found no differences in motivation between those who received VRE exposure therapy and in vivo exposure therapy. Using a VRE biofeedback game where adolescents controlled a game by deepening their breathing, which was detected by a biofeedback belt around their diaphragm, Bossenbroek et al. (2020) found that adolescent’s daily levels of anxiety were reduced. Results also showed that disruptive classroom behaviour for 62.5% of adolescents was significantly reduced. In the treatment of internet gaming disorder, Shin et al. (2018) assessed whether exposure to a VRE internet gaming café elicited cravings and the feasibility of VRE refusal skill training. They reported that the VRE elicited greater cravings in the clinical sample than in the non-clinical control group, reductions in cravings following VRE refusal skills practice, and cravings were positively associated with addiction severity (Shin et al., 2018).

Table 2.

Summary of the primary aims, procedure, outcome measures, and key findings of studies.

Study	Primary aims	Procedure	Outcome measures	Key findings
Assessment studies
Fisher et al. (2020)	Examine effect of VRE avatar rating scale on body image perception and evaluation compared to paper-based Figure Rating scales.	Perceived and desired body figures were evaluated first with a paper-based Figure Rating scale and then with a VRE based avatar rating scale	Paper-based Figure Rating scale; VRE-based avatar rating scale;	Using VRE avatars to measure body image disorder is comparable to paper-based figure rating scales.
Parrish et al. (2016)	Assess the feasibility of VRE differentiating between clinical and non-clinical groups, as well as between social environments and neutral environments.	All participants were exposed to a neutral VRE setting followed by two different social VRE settings and a final neutral VRE setting. Exposure to each environment lasted 5 min and SUDS were measured after each exposure.	Subjective Units of Distress Scale (SUDS); Imagery Realism Questionnaire; Immersion Questionnaire	Both groups found the VRE social environments significantly more distressing that the neutral environments. Clinical group reported significantly higher distress in VRE social settings compared to the non-clinical group. Reported levels of VRE presence and immersion were acceptable.
Intervention studies
Azimisefat et al. (2022)	Examine efficacy of VRE exposure therapy and EMDR versus waitlist control on symptoms of acrophobia and anxiety sensitivity.	Six treatment sessions of 60 min, over 3 weeks with exposure to four VRE scenarios as part of CBT protocol.	Severity measure for acrophobia; anxiety sensitivity Index-R	Significant reduction in severity and sensitivity measures for both VRE and EMDR groups, and greater than reductions in controls. However, symptoms still clinically elevated.
Bossenbroek et al. (2020)	Examine effect of a VRE deep breathing game on levels of anxiety and disruptive classroom behaviour.	Six 15-min sessions at school, over 4 weeks, implemented with an ABAB withdrawal or reversal procedure.	Dutch state-trait anxiety inventory; disruptive classroom behavior scale	Significant reduction of daily levels of anxiety at individual and group level. At individual level, there was reduction in disruptive classroom behaviour in five children, but at group level reduction was nonsignificant.
Farrell et al. (2021)	Evaluate feasibility, acceptability, and effectiveness of a VRE, exposure-based one session treatment for specific phobia of dogs.	One session treatment of exposure therapy via VRE.	Anxiety disorders interview schedule: Parent version; individualised target symptoms; Behavioural approach tests; Spence Children’s anxiety scale child and parent versions; Fear survey schedule for children-Revised child Version	Significant reduction in specific phobia symptom severity at posttreatment and 1-month follow up. 75% of sample no longer met diagnostic criteria at 1-month follow up.
Kahlon et al. (2019)	Evaluate effect of single session VRE exposure therapy in reducing public speaking anxiety.	One session treatment of exposure therapy via VRE.	Public speaking anxiety scale	Significant reductions in symptoms of public speaking anxiety which were maintained at 1 and 3 month follow up.
Maskey et al. (2014)	Assess the efficacy of combining VRE exposure therapy with CBT to treat specific phobia	One 45-min CBT session, followed by four 20–30 min VRE exposure therapy sessions.	Spence Children’s anxiety scale – parent version; individually developed target behaviour scales; confident rating scales	Significant improvement in coping with specific phobia for eight of the nine children, and four children no longer met diagnostic criteria post-treatment.
Maskey et al. (2019)	Examine the feasibility and acceptability of combining VRE exposure therapy with CBT to treat specific phobia.	Participant were randomly assigned to the treatment or control group. Treatment group received one session of CBT followed by four VRE exposure therapy sessions. Control group did not receive any treatment until after a 6 month follow up.	Spence Children’s anxiety scale – parent and child version; Individually developed target behaviour scales; Fear survey schedule for children – revised; Children’s assessment of participation and enjoyment	Significant improvement in treatment group compared to control group at 2 weeks post-treatment and 6-month post treatment. One third of children showed improvements in real life exposure to phobia.
Porras-Garcia et al. (2020)	Compare efficacy of CBT with and without VRE body exposure therapy on	Five 60-min weekly body exposure VRE sessions with avatar with progressively increasing BMI	Eating disorders Inventory-3; Physical Appearance state anxiety scale; Body Appreciation scale; Figural drawing scale for body image assessment, eye gaze fixation on weight-related and non-weight related body parts	Both groups showed reduced eating disorder symptoms, the VRE group reported significantly lower body-related attentional bias toward weight-related body parts and higher BMI
Servera et al. (2020)	Evaluate the feasibility of VRE exposure therapy to treat specific phobia.	Participants received six to eight, 40-min, VRE exposure therapy sessions.	Assessment scale of fear of darkness; What my child can do at night; Current fear of darkness scale	Significant decrease in fear of darkness in five of the six children. Positive increase in ability to engage in night-time behaviours in four of the six children.
Shin et al. (2018)	Assess whether a VRE simulation of an internet gaming café elicited cue-induced craving which was significantly higher in clinical group than in non-clinical group, and the feasibility of VRE refusal skill training.	Participants exposed to four VRE tasks, with two tasks having a refusal skills practice component. Cravings were measured before simulation began and after each task.	Young’s internet addiction test; Cue induced craving visual analogue scale; Presence questionnaire; Simulator sickness questionnaire	Significantly greater cravings in clinical group than in control group. VRE induced craving positively associated with addiction severity. Significant reductions in cravings after the refusal skills practice in clinical group. Acceptable levels of presence and simulator sickness
St-Jacques et al. (2010)	Examine whether including VRE exposure to in vivo exposure therapy increased motivation toward therapy.	Participants randomly assigned to an in vivo exposure therapy group or a VRE exposure therapy group. One group received five, 60-min, sessions of in vivo exposure while the other group received four sessions of VRE exposure and one session of in vivo exposure of the same duration.	Why are you in therapy? Questionnaire for children; Spider phobia beliefs questionnaire for children; Treatment-related discomfort questionnaire; Immersion tendencies questionnaire; Child presence questionnaire; Cybersickness questionnaire	No significant difference in motivation toward therapy between VRE and in vivo group.
Whiteside et al. (2020)	Evaluate the feasibility of verbal imaginal exposure and VRE exposure therapy in the treatment of academic performance anxiety.	One sixty-minute session of verbal imaginal exposure and VRE exposure therapy.	Subjective units of distress (SUDS); Simulator sickness questionnaire-modified; semi-structured qualitative interview	Both verbal and VRE exposure elicited moderate levels of anxiety. Significant and comparable reductions in anxiety were observed after both modes of exposure. Participants found verbal exposure more accurate, and VR exposure more novel.

Note. VRE: virtual reality environment.

Discussion

The aim of this systematic scoping review was to evaluate how VREs have been implemented in the assessment and treatment of child and adolescent mental health conditions. This review included 13 studies, 11 examined use of VREs in treatment, and two examined use of VREs in assessment. Research is still mostly testing feasibility and piloting interventions with small numbers of participants. Most studies focused on examining the use of VREs as an exposure therapy tool, which findings suggest is a feasible mode of assessing and treating anxiety-related disorders and one study using VRE exposure reported to be effective with adolescents with anorexia nervosa (Porras-Garcia et al., 2020). Furthermore, this review found emerging support for VRE deep breathing training for anxiety (Bossenbroek et al., 2020), VRE assisted treatment of internet gaming disorder (Shin et al., 2018) and VRE assessment of body image evaluation in anorexia nervosa (Fisher et al., 2020). Several studies were piloting the use of VREs with next steps being RCTs. Therefore, while this review included more studies using VREs than Halldorsson et al. (2021), with findings indicating promise for the use of VREs in both assessment and treatment, and for conditions more broadly than just anxiety disorders, our recommendations regarding the need for RCTs and larger samples are similar.

Beyond the limited number of studies, there are several limitations in the current literature. This review defined VREs as a computer-generated simulation of a three-dimensional environment, which is immersive and responsive to an individual’s movements, and is experienced through HMDs and CAVE systems. However, a significant number of studies use the term VR or VRE to refer to technology that does not meet this definition. In the current review, six studies were excluded at full text screening due to the technology utilised (and described as VR/VRE) not being immersive and interactive (Dewis et al., 2001; Falconer et al., 2019; Gutiérrez Maldonado et al., 2009; Langer et al., 2016; Wong Sarver et al., 2014; Woodruff et al., 2007), with various more such studies identified in earlier stages of screening. The technology these studies refer to as VR included desktop computer displays and wall projected displays. It should also be noted that the literature also uses the term “virtual environments” to refer to virtual reality technology. It is important for future research to maintain a definition of VREs as the technology used in HMDs and some CAVE systems and separate the concept of VRE from non-immersive and interactive technology. Such differentiation would allow the field to clearly understand what is meant by VREs and facilitate synthesis of evidence. It is also important for future studies to provide clear details of the VRE hardware and software that is used, so that the VRE technology can be easily identified and comparisons to other hardware and software can be made.

Further limitations arise from the designs of the studies with only three RCTs included in this review. It is common for studies in an emerging field to be feasibility or case series studies. The primary issue with these studies is that without a randomised control group, it cannot be determined whether changes are due to the experimental intervention or due to other factors such as the natural progression of a disorder or spontaneous recovery (McNair & Lewis, 2012). As such, the most that could be said about the studies in this review is that they show promise and now should be tested using RCTs that compare VRE interventions with existing treatments. Such studies should also aim to clarify the advantages and disadvantages of VRE assisted assessments and interventions compared to traditional approaches, in particular examining motivation, engagement, and retention-aspects proposed to show an advantage for VREs, as well as efficacy.

Another limitation of the study designs were the small sample sizes, which meant they were underpowered. Although some studies had somewhat larger samples, they contained non-clinical control groups (Parrish et al., 2016; Shin et al., 2018). Furthermore, many of the studies only assessed participants at a single point in time. For intervention studies, the length of interventions varied in terms of the duration of each session and the number of total sessions. Outcomes of some intervention studies were also limited due to not conducting posttreatment follow-ups (Bossenbroek et al., 2020; Servera et al., 2020; Shin et al., 2018; Whiteside et al., 2020), which provide evidence regarding whether outcomes are maintained.

It is evident that research on the use of VRE assessments and interventions with children has mainly focused on anxiety-related disorders. While this is also reflected in the adult literature, research on VRE assessments and interventions for adults has also evaluated its application in eating disorders, psychotic disorders, depressive disorders, PTSD, and substance use disorders (Cieślik et al., 2020; Maples-Keller et al., 2017). As such, it is recommended that future research evaluate whether VRE assessments and interventions are feasible with children with a broader range of mental health problems. We only included studies where children met criteria for a mental health disorder, and so excluded studies of children with elevated levels of problem behaviours. These children may well have met criteria for a disorder and as these are children likely to be seen in child mental health services this is a limitation of our review.

Several studies did not clearly describe who implemented the VRE assessment or intervention, and the clinician training that was involved for delivering them, a key issue for implementation of these approaches. Another issue to be considered ahead of introducing these approaches to clinical practice is that the age range of participants were large, including different developmental age groups (Shin et al., 2018; St-Jacques et al., 2010; Whiteside et al., 2020). These studies applied the same VRE intervention approach to children as young as 8-years-old and as old as 15 and 18, with no indication of changing their approach due to a participant’s age. This may not reflect good clinical practice, as the approaches clinicians use with children across different developmental periods vary significantly (Weems et al., 2020). Including such large age ranges can be justified if a study aims to investigate the differences between developmental age groups, however the current studies did not indicate this as an aim of their investigations. The only study that reported different responses from participants based on age was Whiteside et al. (2020), who reported qualitative findings that younger children expressed preference for therapists that used VRE exposure therapy rather than verbal exposure techniques. These gaps in the literature raise the following questions: are outcomes and levels of acceptability and engagement different across age groups? How do VRE assessments and treatments protocols need to be modified for different age groups? Future investigations should aim to answer such questions. Further, no study has assessed whether VRE assessments or interventions can be implemented with young children below the age of 7.

Children may experience VREs as being more real than adults (Sharar et al., 2007). If children and adolescents do find it more difficult to separate reality from virtual reality, they may find virtual environments just as confronting or frightening as real-life situations. This suggests that further work is needed to establish whether children across developmental age groups experience the realism of VREs differently and how that would affect implementation or outcomes of VRE assessments and interventions.

Across the studies included in this review there was a range of VRE hardware and software used. There were only two studies that used the same VRE hardware and software, which was the CAVE system implemented by Maskey et al. (2014, 2019). Whether the use of different VRE technology significantly impacts the interpretability of the results is unknown, and future research should seek to identify factors of VRE hardware and software that could impact outcomes. This has also been identified as an issue in the adult literature implementing VRE assessments and interventions (Cieślik et al., 2020). Even so, this variability impacts the replicability of these studies, especially regarding the software used across studies. Some software used in the studies was independently developed and is not readily available for others to access, and even in cases where the software is publicly available, the VRE were modified by the research team. Furthermore, few papers provided detailed descriptions of what the VRE stimuli looked like and the functions that participants could perform within the VRE. Another challenge in this area is the rapid advancement of VRE technology, which may mean that the technology used in studies quickly become replaced with more advanced technology, as is the case with the VRE HMDs used in Parrish et al. (2016) and St-Jacques et al. (2010)’s studies. An answer to this issue might be for papers to provide detailed information on the hardware and software technology used, as well as detailed descriptions of the VRE stimuli presented to participants. Of note, the significant advantages of HMDs over CAVE systems, such as more accurate near field representation and the ability to use headsets with adjustment for the IPD of individual children suggest that future development of VREs are likely to be HMDs rather than CAVE systems.

Conclusion

The potential benefits of implementing VRE assessments and treatments of psychological disorders into clinical practice has raised the interest of many in the mental health field. Much of the child literature has focused on assessing the applicability of VREs in neurodevelopmental disorders and paediatric procedural anxiety. This systematic scoping review investigated how VRE assessments and interventions had been applied to other mental health disorders. The current literature shows promise for the use of VRE assessments and interventions of childhood mental health problems, particularly as an exposure therapy tool for anxiety-related disorders. There is emerging support for VRE deep breathing training for anxiety, VRE assisted treatment of internet gaming disorder and anorexia nervosa, and VRE assessment of body image evaluation in anorexia nervosa. However, most work to date is feasibility studies. High-quality research is still needed to understand whether VREs are a viable and effective mode of assessing and treating mental health disorders in children and adolescents, and how it compares to existing evidence-based approaches, given its promise to improve both engagement and outcomes.

Footnotes

Declaration of conflicting interests

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

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rachel M Roberts

Author biographies

Dana Blanco is a practicing psychologist with an interest in child and adolescent mental health.

Rachel Roberts is an academic working to improve access to mental health services for disadvantaged populations.

Anne Gannoni is a practicing clinical psychologist, with an interest in innovative approaches to working with young people.

Steve Cook is an academic with an interest in applications of virtual reality.

References

American Psychiatric Association . (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Association.

Azimisefat

de Jongh

Rajabi

Kanske

Jamshidi

(2022). Efficacy of virtual reality exposure therapy and eye movement desensitization and reprocessing therapy on symptoms of acrophobia and anxiety sensitivity in adolescent girls: A randomized controlled trial. Frontiers in Psychology, 13, 919148. https://doi.org/10.3389/fpsyg.2022.919148

Bailey

Bryant

Hemsley

(2021). Virtual reality and augmented reality for children, adolescents, and adults with communication disability and neurodevelopmental disorders: A systematic review. Review Journal of Autism and Developmental Disorders, 9, 160–183. https://doi.org/10.1007/s40489-020-00230-x

Bossenbroek

Wols

Weerdmeester

Lichtwarck-Aschoff

Granic

van Rooij

M. M. J. W.

(2020). Efficacy of a virtual reality biofeedback game (DEEP) to reduce anxiety and disruptive classroom behavior: Single-case study. JMIR Mental Health, 7(3), e16066. https://doi.org/10.2196/16066

Bouchard

(2011). Could virtual reality be effective in treating children with phobias? Expert Review of Neurotherapeutics, 11(2), 207–213. https://doi.org/10.1586/ern.10.196

Carl

Stein

A. T.

Levihn-Coon

Pogue

J. R.

Rothbaum

Emmelkamp

Asmundson

G. J. G.

Carlbring

Powers

M. B.

(2019). Virtual reality exposure therapy for anxiety and related disorders: A meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 61, 27–36. https://doi.org/10.1016/j.janxdis.2018.08.003

Cieślik

Mazurek

Rutkowski

Kiper

Turolla

Szczepańska-Gieracha

(2020). Virtual reality in psychiatric disorders: A systematic review of reviews. Complementary Therapies in Medicine, 52, 102480. https://doi.org/10.1016/j.ctim.2020.102480

Clus

Larsen

M. E.

Lemey

Berrouiguet

(2018). The use of virtual reality in patients with eating disorders: Systematic review. Journal of Medical Internet Research, 20(4), e157. https://doi.org/10.2196/jmir.7898

Dewis

L. M.

Kirkby

K. C.

Martin

Daniels

B. A.

Gilroy

L. J.

Menzies

R. G.

(2001). Computer-aided vicarious exposure versus live graded exposure for spider phobia in children. Journal of Behavior Therapy and Experimental Psychiatry, 32(1), 17–27. https://doi.org/10.1016/s0005-7916(01)00019-2

10.

Eijlers

Utens

E. M. W. J.

Staals

L. M.

de Nijs

P. F. A.

Berghmans

J. M.

Wijnen

R. M. H.

Hillegers

M. H. J.

Dierckx

Legerstee

J. S.

(2019). Systematic review and meta-analysis of virtual reality in pediatrics: Effects on pain and anxiety. Anesthesia & Analgesia, 129(5), 1344–1353. https://doi.org/10.1213/ane.0000000000004165

11.

Falconer

C. J.

Davies

E. B.

Grist

Stallard

(2019). Innovations in Practice: Avatar-based virtual reality in CAMHS talking therapy: Two exploratory case studies. Child and Adolescent Mental Health, 24(3), 283–287. https://doi.org/10.1111/camh.12326

12.

Farrell

L. J.

Miyamoto

Donovan

C. L.

Waters

A. M.

Krisch

K. A.

Ollendick

T. H.

(2021). Virtual reality one-session treatment of child-specific phobia of dogs: A controlled, multiple baseline case series. Behavior Therapy, 52(2), 478–491. https://doi.org/10.1016/j.beth.2020.06.003

13.

Fisher

Abdullah

Charvin

Da Fonseca

Bat-Pitault

(2020). Comparison of body image evaluation by virtual reality and paper-based figure rating scales in adolescents with anorexia nervosa: Retrospective study. Eating and Weight Disorders: EWD, 25(3), 735–743. https://doi.org/10.1007/s40519-019-00680-1

14.

Freeman

Reeve

Robinson

Ehlers

Clark

Spanlang

Slater

(2017). Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 47(14), 2393–2400. https://doi.org/10.1017/s003329171700040x

15.

Gutiérrez Maldonado

Magallón

N. E. M.

Rus-Calafell

Peñaloza Salazar

(2009). Virtual reality exposure therapy for school phobia. Anuario de Psicología.

16.

Halldorsson

Hill

Waite

Partridge

Freeman

Creswell

(2021). Annual research review: Immersive virtual reality and digital applied gaming interventions for the treatment of mental health problems in children and young people: The need for rigorous treatment development and clinical evaluation. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 62(5), 584–605. https://doi.org/10.1111/jcpp.13400

17.

Kahlon

Lindner

Nordgreen

(2019). Virtual reality exposure therapy for adolescents with fear of public speaking: A non-randomized feasibility and pilot study. Child and Adolescent Psychiatry and Mental Health, 13(1), 47. https://doi.org/10.1186/s13034-019-0307-y

18.

Kothgassner

O. D.

Felnhofer

(2021). Lack of research on efficacy of virtual reality exposure therapy (VRET) for anxiety disorders in children and adolescents: A systematic review. Neuropsychiatrie: Klinik, Diagnostik, Therapie und Rehabilitation: Organ der Gesellschaft Osterreichischer Nervenarzte und Psychiater, 35(2), 68–75. https://doi.org/10.1007/s40211-020-00349-7

19.

Kothgassner

O. D.

Goreis

Kafka

J. X.

Van Eickels

R. L.

Plener

P. L.

Felnhofer

(2019). Virtual reality exposure therapy for posttraumatic stress disorder (PTSD): A meta-analysis. European Journal of Psychotraumatology, 10(1), 1654782. https://doi.org/10.1080/20008198.2019.1654782

20.

Langer

Á. I.

Aguilar-Parra

J. M.

Ulloa

V. G.

Carmona-Torres

J. A.

Cangas

A. J.

(2016). Substance use, bullying, and body image disturbances in adolescents and young adults under the prism of a 3D simulation program: Validation of MySchool4web. Telemedicine Journal and e-Health: The Official Journal of the American Telemedicine Association, 22(1), 18–30. https://doi.org/10.1089/tmj.2014.0213

21.

Maples-Keller

J. L.

Bunnell

B. E.

Kim

S.-J.

Rothbaum

B. O.

(2017). The Use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harvard Review of Psychiatry, 25(3), 103–113. https://doi.org/10.1097/hrp.0000000000000138

22.

Maskey

Lowry

Rodgers

McConachie

Parr

J. R.

(2014). Reducing specific phobia/fear in young people with Autism Spectrum Disorders (ASDs) through a virtual reality environment intervention. PLoS One, 9(7), e100374. https://doi.org/10.1371/journal.pone.0100374

23.

Maskey

Rodgers

Grahame

Glod

Honey

Kinnear

Labus

Milne

Minos

McConachie

Parr

J. R.

(2019). A randomised controlled feasibility trial of immersive virtual reality treatment with cognitive behaviour therapy for specific phobias in young people with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders, 49(5), 1912–1927. https://doi.org/10.1007/s10803-018-3861-x

24.

McNair

Lewis

(2012). Levels of evidence in medicine. International Journal of Sports Physical Therapy, 7(5), 474–481.

25.

Mesa-Gresa

Gil-Gómez

Lozano-Quilis

J.-A.

Gil-Gómez

J.-A.

(2018). Effectiveness of virtual reality for children and adolescents with Autism Spectrum Disorder: An evidence-based systematic review. Sensors, 18(8), 2486. https://doi.org/10.3390/s18082486

26.

Parrish

D. E.

Oxhandler

H. K.

Duron

J. F.

Swank

Bordnick

(2016). Feasibility of virtual reality environments for adolescent social anxiety disorder. Research on Social Work Practice, 26(7), 825–835. https://doi.org/10.1177/1049731514568897

27.

Parsons

T. D.

Duffield

Asbee

(2019). A comparison of virtual reality classroom continuous performance tests to traditional continuous performance tests in delineating ADHD: A meta-analysis. Neuropsychology Review, 29(3), 338–356. https://doi.org/10.1007/s11065-019-09407-6

28.

Porras-Garcia

Serrano-Troncoso

Carulla-Roig

Soto-Usera

Ferrer-Garcia

Fenandez-Del Castillo Olivares

Fugueras-Puigderrajols

Santos-Carrasco

I. D.

Borszewski

Diaz-Marsa

Gutierrez-Maldonado

(2020). Targeting the fear of gaining weight and body-related concerns in Anorexia Nervosa. Preliminary findings from a Virtual Reality randomized clinical trial. Annual Review of Cybertherapy & Telemedicine (pp. 223-227). https://www.arctt.info/volume-18-summer-2020

29.

Romero-Ayuso

Toledano-González

Rodríguez-Martínez

Arroyo-Castillo

Triviño-Juárez

J. M.

González

Ariza-Vega

González

A. D. P.

Segura-Fragoso

(2021). Effectiveness of virtual reality-based interventions for children and adolescents with ADHD: A systematic review and meta-analysis. Children, 8(2), 70. https://doi.org/10.3390/children8020070

30.

Sawyer

M. G.

Reece

C. E.

Sawyer

A. C.

Hiscock

Lawrence

(2019). Adequacy of treatment for child and adolescent mental disorders in Australia: A national study. Australian and New Zealand Journal of Psychiatry, 53(4), 326–335. https://doi.org/10.1177/0004867418808895

31.

Servera

Sáez

Gelabert Mir

J. M.

(2020). Feasibility of a virtual reality program to treat children with fear of darkness with nonexpert therapists. Revista de Psicología Clínica Con Niños Y Adolescentes, 7(2), 16–21. https://doi.org/10.21134/rpcna.2020.07.2.2

32.

Sharar

S. R.

Carrougher

G. J.

Nakamura

Hoffman

H. G.

Blough

D. K.

Patterson

D. R.

(2007). Factors influencing the efficacy of virtual reality distraction analgesia during postburn physical therapy: Preliminary results from 3 ongoing studies. Archives of Physical Medicine and Rehabilitation, 88(12 Suppl 2), S43–S49. https://doi.org/10.1016/j.apmr.2007.09.004

33.

Shin

Y.-B.

Kim

J.-J.

Kim

M.-K.

Kyeong

Jung

Y. H.

Eom

Kim

(2018). Development of an effective virtual environment in eliciting craving in adolescents and young adults with internet gaming disorder. PLoS One, 13(4), e0195677. https://doi.org/10.1371/journal.pone.0195677

34.

St-Jacques

Bouchard

Bélanger

(2010). Is virtual reality effective to motivate and raise interest in phobic children toward therapy? The Journal of clinical psychiatry, 71(7), 924–931. https://doi.org/10.4088/jcp.08m04822blu

35.

Tricco

A. C.

Lillie

Zarin

O'Brien

K. K.

Colquhoun

Levac

Moher

Peters

M. D. J.

Horsley

Weeks

Hempel

Akl

E. A.

Chang

McGowan

Stewart

Hartling

Aldcroft

Wilson

M. G.

Garritty

Straus

S. E.

(2018). PRISMA extension for scoping reviews (PRISMAScR): Checklist and explanation. Annals of Internal Medicine, 169(7), 467–473. https://doi.org/10.7326/M18-0850

36.

Valmaggia

L. R.

Latif

Kempton

M. J.

Rus-Calafell

(2016). Virtual reality in the psychological treatment for mental health problems: An systematic review of recent evidence. Psychiatry Research, 236, 189–195. https://doi.org/10.1016/j.psychres.2016.01.015

37.

Weems

C. F.

Camp

R. D.

Neill

E. L.

Scott

B. G.

(2021). Developmental differences in child and adolescent reasoning about anxiety sensations. Cognitive Therapy and Research, 45(1), 166–178. https://doi.org/10.1007/s10608-020-10182-5

38.

Whiteside

S. P. H.

Brennan

Biggs

B. K.

Vickers

Hathaway

Seifert

S. J.

Kramer

K. M.

Hofschulte

D. R.

(2020). The feasibility of verbal and virtual reality exposure for youth with academic performance worry. Journal of Anxiety Disorders, 76, 102298. https://doi.org/10.1016/j.janxdis.2020.102298

39.

Wong Sarver

Beidel

D. C.

Spitalnick

J. S.

(2014). The feasibility and acceptability of virtual environments in the treatment of childhood social anxiety disorder. Journal of Clinical Child & Adolescent Psychology, 43(1), 63–73. https://doi.org/10.1080/15374416.2013.843461

40.

Woodruff

S. I.

Conway

T. L.

Edwards

C. C.

Elliott

S. P.

Crittenden

(2007). Evaluation of an Internet virtual world chat room for adolescent smoking cessation. Addictive Behaviors, 32(9), 1769–1786. https://doi.org/10.1016/j.addbeh.2006.12.008

41.

World Health Organization . (2019). International statistical classification of diseases and related health problems (11th ed.). https://icd.who.int/

Assessment and treatment of mental health conditions in children and adolescents: A systematic scoping review of how virtual reality environments have been used

Abstract

Background

Method

Results

Conclusions

Keywords

Introduction

Method

Eligibility criteria

Search strategy

Study selection

Data extraction and synthesis

Results

Study characteristics

Synthesis of results

Assessment studies

Intervention studies

Discussion

Conclusion

Footnotes

Declaration of conflicting interests

Funding

ORCID iD

Author biographies

References