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Head-Mounted Display-Based Virtual Reality Social Story as a Tool to
Teach Social Skills to Children Diagnosed with Autism Spectrum Disorder
Ali Adjorlu*
Aalborg University
Aishah Hussain†
Aalborg University
Camilla Mødekjær‡
Aalborg University
Nicoline Warming Austad§
Aalborg University
ABSTRACT
In this paper, we present a study conducted to investigate the fea-
sibility of using a Head- Mounted Display (HMD) based Virtual
Reality (VR) application as a tool to teach social skills to children
diagnosed with Autism Spectrum Disorder (ASD). In collaboration
with teachers at a school for children and adolescents diagnosed with
mental disorders, an HMD VR based social story application was de-
veloped with the purpose of teaching children diagnosed with ASD
about sharing, turn taking, and theory of mind. Via a Mixed Method
Sequential Explanatory Design, the application was evaluated by
two teachers who conducted social story sessions on a total of five
students diagnosed with ASD. Results indicate that HMD based VR
intervention has the potential of teaching appropriate social behavior.
Index Terms:
Human-centered computing—Visualization—Visu-
alization techniques—Treemaps; Human-centered computing—
Visualization—Visualization design and evaluation methods
1 INTRODUCTION
The most recent edition of the Diagnostic and Statistical Manual
of Mental Disorder (DSM-5) describes social communication and
social interaction as two of the primary deficits of individuals diag-
nosed with ASD [4]. More specifically, people diagnosed with ASD
display deficits in social and emotional reciprocity and had difficul-
ties adjusting their behaviours to match different social scenarios. As
a result, children diagnosed with ASD are often victims of social re-
jection and targets of bullying, which have a negative impact on their
emotional and mental well-being [32]. Social anxiety, depression,
and poor academic achievement are some of the consequences of the
impaired social communication in the ASD population [6]. These
deficits are also associated with lower daily living skills, resulting in
a vast number of adults diagnosed with ASD to rely on support from
their parents or social services. In the USA, the social cost during the
lifespan of an individual diagnosed with ASD is 3.2 million dollars,
consisting mainly of adult care services and lost productivity [12].
Furthermore, the prevalence of ASD has substantially increased dur-
ing the last two decades [8], showcasing the importance and agency
of Social Skills Training (SST) interventions to help children diag-
nosed with ASD towards an independent and comfortable adulthood.
The National Professional Development Center on Autism Spectrum
Disorder describes SST as techniques developed to teach groups
or individuals diagnosed with SSD ways to appropriately interact
with other individuals. These methods involve instructions on basic
social behaviours through role-playing, practising and feedback [31].
Wang and Spillane conducted a review of the literature on SST in-
terventions, categorizing it into five groups including social stories,
peer-mediated interventions, video modelling, cognitive behavioural
*e-mail: adj@create.aau.dk
†e-mail: ahussa14@student.aau.dk
‡e-mail: cmadek14@student.aau.dk
§e-mail: nlarse14@student.aau.dk
training and other [30]. Out of these five categories, Wang and
Spillane concluded that only video modelling have demonstrated
high-effectiveness. The remaining strategies illustrated promising
results, but with moderate effectiveness. Video modelling refers to
a technique that involves watching a video that shows a targeted
social behaviour, while video self-modelling is a variation of video
modelling in which the individual watch a video of himself or herself
performing a specifically targeted behaviour. According to Charplot-
Christy and Daneshvar, the reason children with ASD attend to video
models than real people is the level of anxiety and distress they feel
interacting with people in real life [7]. Furthermore, according to
Sherer et al. [27] children with autism are often very easily distracted
and cannot attend to humans or their environment. If the learning is
mediated via an exciting medium, the children are far more likely to
dedicate their full attention. Recent research illustrates the potentials
of computer simulation as an effective medium for teaching a wide
range of skills to individuals diagnosed with ASD [29]. Computer
simulation based interventions enable rehearsal of skills in control
environments, allowing the individual to work on his or her own
pace. This is especially effective for the ASD population given their
discomfort with unpredictable situations and interacting with other
people. Furthermore, according to several sources [22], [13] mul-
timodal learning interventions can generally create better learning
condition by limiting the cognitive load and cognitive overload com-
pared to single modality learning interfaces. Furthermore, teachings
that involve more spatial and visual cues are better preserved in
young people diagnosed with ASD compared to verbally mediated
knowledge [9].
Several studies have examined the effectiveness and feasibility of
interactive virtual environments as SST intervention for individuals
diagnosed with ASD. Didehbani et al. [10] measured the effect
of interaction within a virtual environment using keyboard and
mouse to train social skills on thirty children diagnosed with ASD
between the age 7-16. The participants completed some true-to-
life social scenarios, each designed to emphasize targeted social
learning objectives in a variety of contexts such as dealing with
bullies, confronting conflicts or bonding with a friend. Three main
skills were measured pre-post the experiment: emotion recognition,
social attribution, attention, and executive function. The participants
showed improvement in all the measured skills.
Mitchel et al. [19] examined the effects of an interactive desktop-
based virtual cafe to teach social understanding to 6 adolescents
diagnosed with ASD. The participants started at the till with a tray
containing food and drinks, while they were asked to navigate the
cafe and find a place to sit on. Pre-post measurements indicate
that participants showed a significant improvement in their social
decision making after the virtual environment training sessions. The
rapid development of affordable head-mounted displays (HMD)
enables development of immersive SST interventions where we can
place the learner inside a simulated environment in which he will not
be disturbed by external stimuli. As one of the common overlapping
syndromes with ASD is attention deficit hyperactivity disorder
(ADHD) [18], it’s essential to reduce the number of external factors
that can disturb the students during the SST intervention. Due
to the novelty of affordable HMD equipment, there have been
limited studies on interventions to teach social skills to individuals
diagnosed with ASD [23]. Research conducted by newbutt et
al. [21] show that the ASD populations acceptance have a high sense
of presence and enjoyment during HMD based VR experiences.
In this paper, we present an experiment aimed to evaluate a
virtual reality social skills training intervention at Valhøj school in
Copenhagen. Part of the training of the students diagnosed with
ASD at Valhøj school consists of social training via social stories
where the student and the teacher look at comic strip illustrating
different social contexts while discussing the right behaviour in
these contexts.
2 METHODS
2.1 The VR Intervention
We set out to design an HMD based VR social skills training inter-
vention to be used by the teachers at Valhøj school to teach social
skills to their students. The VR social skill training application was
developed through an user-centred design approach [1], aimed at
identifying the teachers’ current context when performing social
training sessions. Three teachers participated in an unstructured
interview with the purpose of discussing their current concerns with
their students social skills training sessions. All three teachers work
with children diagnosed with autism on a daily basis. During the
meetings, the teachers described the students’ lack of appropriate
play skills, explaining the childrens’ difficulties with basic con-
cepts such as sharing, negotiation, conflict resolution, turn-taking,
reciprocity, and manners. These deficits described by the teachers
showcased the childrens’ inability to understand and identify the
thoughts, feelings, and intentions of others, an ability which is called
the theory of mind. A study conducted by Cohen et al. [5] suggested
that children diagnosed with ASD have deficits in theory of mind
compared to their normal peers as well as peers diagnosed with
Downs Syndrom. Teachers at Valhøj school use social stories about
sharing as a tool to explain to the children diagnosed with ASD that
other people can have different thoughts, goals, and feelings than
themselves. According to Ali & Fredrickson [2], social stories can
be used to explain what another person might be thinking and why
they behave in certain ways in different social situations. However,
during the interview, the teachers revealed that it could sometimes be
hard for some of the students to understand the feelings and mental
state of the child in the social stories, who has been through an
uncomfortable play situation. Based on the concerns and current
context of the teachers, it was decided to design a VR based social
story intervention about playing, sharing and turn taking in a class-
room context. To create more empathy and understanding for the
characters involved the VR intervention, the child is to experience
the VR social stories from a first-person perspective. One of the
main requests of the teachers was a social story that takes place in an
environment similar to the students’ current classroom. By bridging
the gap between the context of the VR social story to a real-world
context in which the desired social skills are to be performed, we
would create the possibility for a near transfer of learning. Accord-
ing to Arnold et al. [3], when a child diagnosed with ASD learns new
behavioural skills in a specific context, the newly gained knowledge
often falls short when the individual is presented with a deviation
of the social scenario in a different context. An extensive body of
research suggests that children diagnosed with ASD have limitations
with regards to generalization, which describes the behaviour change
in training setting naturally transfers to other settings and context [3].
Stokes & Bear [28] propose a strategy to promote generalization
skills in individuals diagnosed with ASD called ”Program Common
Stimuli”. The Program Common Stimuli is a strategy that attempts
to include common stimuli across both the training and generaliza-
tion setting where the social skills will be needed. Therefore, the
VR social story will take place in a virtual classroom environment
which is designed to look similar to the Valhøj school students’ real
classroom (figure 1). During the focus group interview, the teachers
Figure 1: On the left: the virtual classroom. On the right: the real
classroom
also requested the ability to communicate with their students while
they are experiencing the VR social story. Enabling a communica-
tion channel between the teacher and student during the VR social
skills training intervention can enable the teacher to encourage re-
placement of maladaptive behavior and promote prosocial behavior.
According to Gray & Garand [14] social stories should include:
• A specific target behavior of concern
• Help identify an appropriate behavior
• Be written from the childs perspective
•
Include pictures or drawing to help child relate to the desire
behavior.
•
Include a ratio of one directive sentence for every two to five
sentences that are describe, perspective or both.
The specific targeted behaviour of concern in this study will be
sharing. The teacher will help the child identify the appropriate
behaviour by talking to the child during and after the VR intervention
via directive, describe or perspective sentences. The VR social story
application will be viewed from a first-person perspective and will
include 3D visuals designed to look pleasing to a child. The VR
Figure 2: The virtual teacher in the virtual classroom
intervention was designed and developed using Autodesk Maya
and Unity. HTC Vive was chosen due to its room scale tracking
as well as its intuitive hand controllers. A computer consisting of
an Intel i7 7700k processor, GTX 1080 GPU, and 16GB of DDR4
ram was built for the study. Voices of authors were recorded, and
their pitch changed to sound more like a child. An avatar of the
teacher was placed in the virtual classroom (figure 2). The teacher
could communicate with the child via a microphone. Danish is the
main language of the application. The application consisted of 3
scenarios:
•
The child is standing in the virtual classroom. A virtual child is
sitting in front of a computer playing a game. The child is than
told to walk towards the computer and try to grab the computer
using the VIVE controller. This will trigger an animation,
moving the computer from the virtual child towards the real
child. The virtual child will look up and say, Stop it while
looking sad
•
The child is now sitting in front of the computer and have a
chance to play a game himself (figure 3). The games purpose
is to press the button with the same colour that is appearing
on the computer screen. The interaction is performed using
the VIVE controllers. Once the teacher feels that the child is
sufficiently engaged in the game, he can activate a scenario
where a virtual child will take away the real childs computer.
•
Like the first scene, the avatar is playing the game on the
computer while the user is standing next to him. The teacher
will then tell the user to appropriately ask the avatar if he can
play on the computer. Once the question has been formulated,
the teacher can activate two different avatar feedback. The
first feedback will have the avatar looking up and saying ”no,
I am playing right now. You can have it once I am done”.
The second feedback will activate the avatar looking up and
saying ”yes of course. Here you go” (figure 3) while turning
the computer towards the real child.
Figure 3: On the left: the students view while playing the game himself.
On the right: the the vir tual student accepting to share the computer
with the real student.
2.2 Evaluation
Two teachers from Valhøj School, both experienced with running
social story sessions agreed to participate in an evaluation of the
intervention. The teachers evaluated the VR social story application
by running social story sessions on five students diagnosed with
ASD. The students’ age ranged from 9 to 11, and all of them were
male which is roughly consistent with the gender ratio of 5:1 (male:
female) in children diagnosed with ASD [11]. Consent forms were
sent to and signed by the children’s parents prior to the study. Before
the study, the teachers tried the VR social skills training by running
a social story session on each other to get comfortable with the ap-
plication. Due to the small sample size, a Mixed Method Sequential
Explanatory Design method was used for the experiment [16]. This
method involves the collection and analysis of quantitative data first,
followed by qualitative data in two sequential phases within one
study. The basis for mixing both quantitative and qualitative data is
grounded in that neither the quantitative nor the qualitative methods
on their own are sufficient to capture the effects of the intervention.
Quantitative data was collected via questionnaires filled out by the
teachers, one after each VR social story session and another after
finishing all the sessions. The first questionnaire was designed to
assess the extent of which the teacher felt that each student under-
stood and could relate to the social story. The survey items formed
five-point Likert-scale and involved the following variables. The
second questionnaire consisted of five-point Likert-scale items in-
volving seven questions on the application’s effect as social skills
learning intervention. The qualitative part of the study consisted of
a semi-structured interview with the two teachers to validate and
triangulate the data collected from the questionnaires.
3 RE SULTS
The goal of this study was to investigate whether VR can be applied
as a tool for the teachers, to conduct social story sessions on children
diagnosed with ASD. Through a mixed-methods sequential explana-
tory design, quantitative and qualitative data were collected from the
teachers in the following order:
• Questionnaire filled out after each social story session.
• Questionnaire filled out after all the social story sessions
• Follow up unstructured interview
3.1 Result of the likert-scale questionnaire after each
VR Social skills training session
Results of the 5-point Likert-scale questionnaires after each VR
social skills training session are reported in (table 1).
Table 1: Results of the 5-point Likert scale questionnaire filled after
each VR social story session. The test was conducted on five students.
1 is the lowest rate while 5 is the highest rate.
Question
Student one
Student two
Student three
Student four
Student five
The program was good at targeting the behavior of concern 3 4 4 4 4
The student could relate to the social story 3 4 4 5 4
The student correctly explain the right social behavior 3 3 5 5 5
The first teachers conducted social story session on student one
and two while the second teacher conducted social story session on
students three, four, and five. There were some technical issues with
the sound of the microphone that was implemented to be used to
communicate with the students in the virtual environment. Therefore,
after the first session with student one, the microphone was not used.
The students could hear the teachers voice through the headset,
although not as clear as we would like. The teacher rated the three
questions on student one, while the rating for the program was good
at targeting the behaviour of concern and the students could relate
to the social story received a four on the story session with student
number two. Student twos explanation after the VR social story
session was rated lower on a three. The second teacher rated all
his students explanation of what is the right behaviour as high as
possible. Student number four was rated five on his ability to relate
to the social story. The second teacher rated the rest of the questions
with fours.
3.2 Questionnaire after finishing all the VR social skills
training sessions
The results of the questionnaire filled out by the teachers after they
have conducted all the VR social story sessions can be seen in (table
2).
The second questionnaire was filled out after both teachers had
finished all their VR social story sessions. The first teacher, who
experienced the glitch with the microphone rated the programs ef-
fectiveness in communicating the social story three. The rest of the
questions were rated four by the first teacher. The second teacher
Table 2: Questionnaire after the teachers finished all the social story
sessions. The questions are on a 5 point Likert-scale
Question
Teacher one
Teacher two
Effective in communicating the social story 3 4
Scenarios help the child relate to the characters in the social story 4 5
Can be useful for more students in our school 4 5
Can be used to help identify an appropriate behavior 4 4
Is useful for rehearsing appropriate social behavior 4 5
rated five out of five on questions on VR usefulness for rehearsing
appropriate social behaviour, VR social story usefulness for more
of his students and Three scenarios help the student relate to the
characters in the social story. The rest of the questions were rated
four by the second teacher.
3.3 Interview results
The interview transcripts were coded using NVivo. Magnitude cod-
ing [15] was applied by assigning positive and negative values to
comments on the intervention as a tool for the teachers and students’
learning. There was a total of 18 positive comments and eight neg-
ative comments. A third category ”future development” was also
spotted after coding the interview with five comments.
3.3.1 Positive comments on learning
Both teachers had positive comments on the interventions overall
social skills teaching capabilities. One of the teachers mentioned:
”There was a transfer effect from the first scenario to the second and
third scenario. I could see that the student approached the avatar
in a much polite way in the third scenario”. The second teacher
described how the student reacted to being denied when asked to
borrow the computer in the third scenario ”At first he got frustrated,
but then he realised that this is what happened in the first scenario
when an avatar toke his computer without asking”. The teacher
also mentioned that ”The students got an ’aha-experience’ once the
avatar took the computer from them without asking”. Some of the
positive comments were more related to the student’s motivations
when it comes to new technologies. One of the teachers mentioned
that ”None of our students with ASD would ever say no to VR. They
are not always prepared to try something new unless it rings a bell
inside them”. The teachers also mentioned that ”they are already
so hype around computer games. They can easily figure out new
games, and they are not afraid to experiment and be an active actor
in the game. If it, on the other hand, were a conventional social story,
they would be more passive.”
Comments such as ”The students were good at following instruc-
tions” and ”The students were good at focusing on the teacher” show
that the teachers felt that they were still able to communicate with
students while they were experiencing the VR social story. Fur-
thermore, one of them elaborated the importance of their role in
a VR social story intervention ”A teacher is required for such an
application. Without us, the student would not be able to understand
what is going on since it was us who connected the story together for
them and they could ask us questions”. One of the teachers had one
positive comment on the usability of the system: ”After trying the
application once, I understood how to use it. It’s not rocket science”.
3.3.2 Negative comments on learning
Most of the negative comments on the students’ ability to learn from
the VR intervention concerned with the students’ ability to filter out
unwanted information. ”One has to narrow down their perception to
have their full attention. Even a shadow on the floor can sometimes
distract them, or if there is a ”slash” on the blackboard instead of
an ”and”. Even the smallest detail can sometimes get their full
attention”. On that note, another teacher added that ”It was nice
that the virtual classroom was like their real classroom, but it can
end up being a distracting element of the application. The students
diagnosed with ASD might notice if there are minor details in the
VR classroom that are not exactly the same as their real classroom.”
Finally, one of the teachers mentioned: ”Not all of our students are
used to looking at faces” when discussing whether the avatars facial
expression had any effect on the learning outcome.
The first teacher had a negative comment on the application’s
learnability: ”It was important that we conducted a pilot study with
the system. Otherwise, it would have been hard for me to use the
system”. The teacher further commented that it was hard for him to
understand his role when using the system: ”The challenge for me
was that I could not understand how to play my role as a teacher in
the virtual environment.” He further commented that ”I will need
more time with the application to better understand how to be a
teacher in it. The students learning is negatively effective due to my
lack of personal experience with the system”.
3.3.3 Comments on future development
”Our students can have very different needs so it could be nice if we
could design specific cases in VR for each of them. For instance, one
of our students is afraid of being photographed”. Another teacher
mentioned that: ”One of our students is afraid of crowded situations,
so an application that can expose him to crowded scenarios such
as the athletic day at the school could be good for him”. Another
suggestion was ”We are currently trying to teach our students skills
that help them towards independent adulthood. Therefore, it could
be nice with a VR experience that can teach them skills such as
taking the bus on their own”. The final two comments address needs
for social communication training of their students: ”We would love
to have a scenario where they could practice keeping a low tone
when speaking to someone who seats right next to them”. And:
”..rehearsal of skills such as is it socially acceptable to hug someone
you just meet”.
4 DISCUSSION AND CONCLUSION
This exploratory study assessed the feasibility of designing an
HMD based VR invention to be used as a tool to teach social skills
to children diagnosed with ASD. Three teachers who work with
social skills training of children diagnosed with ASD as part of
their daily job were involved in the design process. The teachers
confirmed that the children they work with lack the theory of
mind. They further described social stories as their main tool to
teach social skills to their students. The teachers current main
mean of communicating social stories are comic strips design to
illustrate a variety of right and wrong behaviours. According to the
teachers, keeping the children immersed in the comic strips can
be a challenge while they are often fully attentive when playing
computer games, confirming previous research indicating the ASD
populations strong motivation towards electronic media [26]. Based
on the data from the teachers, three interactive social scenarios
were designed to utilise the main advantage of HMD based VR.
Previous studies assessing the effectiveness of virtual environments
to train social skills in children diagnosed with ASD have often used
desktop solutions [10], [19]. Desktop-based virtual environments
can be explored using keyboard, mouse or joysticks while HMD
based VR enables the opportunity to look around and explore
the virtual environment using the same motoric functions as we
use to look around and explore our real-world environment (e.g.
turning our head around). Additionally, hardware such as the HTC
Vive used for this study offers the possibility to develop virtual
environments within which the user can also move around in the
virtual environment using the same motoric functions as we use to
move around in our real-world environment (e.g. walking). HMD
based VR enables the ability to provide a continuous stream of
artificial stimuli that can lead to the perception of ecological and
non-synthetic environments that can replicate a variety of social
scenarios within which social skills can be thought to children
diagnosed with ASD.
Didebahni et al. [10] refer to motion sickness as the main
argument against using HMDs as a tool for the social training of
children and adolescents diagnosed with ASD. The teachers that
participated in this pilot study did not report any of their students
having motion sickness during the VR social story sessions. Due to
the small size of the study, it cannot be confirmed that the designed
VR social skills training intervention isnt going to induce motion
sickness to its users. However, using sensory conflict theory, it can
be argued that motion sickness is reduced if the users perception
of self-motion is congruent with the user’s vestibular system,
proprioception, and visual information as its the case with the
designed HMD VR social story intervention [24]. Furthermore, only
male students participated in this pilot study. According to [20],
the risk of motion sickness in HMD based VR can be greater for
female users than male users which is consistent with finding
that women are in general more susceptible to motion sickness
than men [17]. Finally, research conducted by Newbut et al. [21]
showcase that children with ASD are willing to wear HMDs and
reported enjoyable experience with high level of presence.
Based on the feedback in this study, it can be argued that
HMD based VR has the potential for being used as a tool by
teachers to teach social skills to children diagnosed with ASD.
Teachers comments illustrated that the children understood the
social scenario and could relate to the feelings of both characters
in the story. This is consistent with the main goal of social stories
which is to encourage a better understanding of an event and
thereby to promote a proper response [25]. In the same way,
as with social stories, the VR based social story can be used to
encourage replacement of maladaptive behaviour and to promote
prosocial behaviour through conversation with the teacher during
the sessions. Both teachers commented that the students were good
at focusing on their explanations of the situation during the VR
intervention. Having a teacher avatar in the VR environment might
have helped the children not to forget that the teacher is present in
the experiment with them. However, due to technical errors, the
teachers were not able to communicate with the students through
a microphone. Luckily the headphones worn by the students
were not noise cancelling, and they could listen to the teachers voice.
The designed HMD based VR intervention shows potential
in combining the advantages of video modelling, which is described
as a motivating SST intervention for children [7], with advantages
of social stories ability to promote understanding of a social
scenario [2]. Future research should measure childrens motivation
for learning social skills in an HMD based VR intervention.
Furthermore, future comparative studies should evaluate the HMD
based VR social story intervention compare to the conventional
social story interventions.
ACK NOWLEDGM ENT S
The authors wish to thank the teachers Claes Kiilsgaard, Michael
Povlsen, and Martin Høj, as well as the students and parents from
Valhøj school for their participation, feedback and support during
this study. Additionally, we would like to thank Sune Buch-Sloth
and the Rødovre municipality for financing the VR equipment used
in this study.
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