Virtual reality CBT for aggressive children
Alsem, van Dijk, Verhulp, Dekkers & De Castro (2023) published Treating children's aggressive behavior problems using cognitive behavior therapy with virtual reality: A multicenter randomized controlled trial” in Child Development.
This multicenter randomized controlled trial investigated whether interactive virtual reality enhanced effectiveness of Cognitive Behavioral Therapy (CBT) to reduce children's aggressive behavior problems. Boys with aggressive behavior problems (N = 115; Mage = 10.58, SD = 1.48; 95.7% born in Netherlands) were randomized into three groups: CBT with virtual reality, CBT with roleplays, or care-as-usual. Bayesian analyses showed that CBT with virtual reality more likely reduced aggressive behavior compared to care-as-usual for six of seven outcomes (ds 0.19–0.95), and compared to CBT with roleplays for four outcomes (ds 0.14–0.68). Moreover, compared to roleplays, virtual reality more likely enhanced children's emotional engagement, practice immersion, and treatment appreciation. Thus, virtual reality may be a promising tool to enhance CBT effectiveness for children with aggressive behavior problems.
Aggressive behavior problems are the most common form of malfunctioning in school-aged children. These problems predict adverse outcomes for children later in life and have a continuing negative impact on children's environment. Many intervention programs therefore target aggressive behavior problems as they arise in childhood. Cognitive behavior therapy (CBT) can reduce aggressive behavior in children, but intervention effects tend to be modest and heterogeneous. Effects can be stronger when interventions focus more on exposure to anger and on solving real-life social problems. Hence, intervention methods that promote ecologically valid practice may enhance effectiveness. Interactive virtual reality may be a promising tool to attain this goal. In interactive virtual reality, children can walk around freely, talk to virtual peers, and play games, offering a realistic and engaging environment to practice new skills during therapy.
Virtual reality may have three important benefits for CBT with children. First, practicing in virtual reality can enhance children's emotional engagement and immersion, which is important because CBT practice has been found to be most effective when cognitions and skills are practiced in emotionally engaging situations. Children should thus ideally practice whilst experiencing feelings of anger. Virtual reality can simulate anger-provoking situations that children encounter in daily life and has been shown to successfully elicit children's anger. It may be more immersive and engaging than roleplay exercises currently used in CBT, as children do not have to rely on their memory or imagination. Supporting this idea, research found that a virtual reality assessment of aggressive behavior better predicted children's real-life aggressive behavior than an imagery-based assessment using hypothetical stories.
Second, virtual reality can enhance children's treatment appreciation and their perception of the treatment's efficacy. Children with aggressive behavior problems are often not motivated, or even resistant, to treatment. It is important to enhance these children's treatment appreciation, which has been related to increases in treatment effectiveness. As many children grow up surrounded by digital devices, using technology in interventions may have particular appeal and utility to them. Indeed, using technology (e.g., adding an internet component) in a treatment for children with aggression problems effectively increased children's treatment participation and perceived efficacy.
Third, virtual reality allows for individually tailored exercises in CBT. Most current CBTs for children with aggressive behavior problems are provided in groups. Virtual reality provides an opportunity to combine individual therapy with ecologically valid practice with virtual peers. Focusing the exercises on the situations, cognitions, and behaviors of an individual child can not only enhance children's treatment appreciation and adherence, but also the effectiveness of the intervention.
We conducted a randomized controlled trial with three conditions, comparing YourSkills virtual reality to YourSkills roleplay and care-as-usual. The first aim of our study was to examine treatment effects on children's aggressive behavior problems. As pre-registered in the clinical trial register, our first primary outcome measure was children's aggression. Specifically, we hypothesized that aggression decreases were larger for (1a) the two YourSkills groups versus the care-as-usual group, (1b) the YourSkills virtual reality versus the YourSkills roleplay group, and (1c) the YourSkills virtual reality versus the care-as-usual group. The second aim of our study was to investigate the potential experienced benefits of virtual reality above roleplays as treatment method for children with aggressive behavior problems. We hypothesized that children participating in YourSkills virtual reality would score higher than children participating in YourSkills roleplays on (2a) emotional engagement, (2b) practice immersion, (2c) treatment appreciation, and (2d) perceived efficacy. Our primary outcome was treatment appreciation (called treatment motivation in the pre-registration). Given that children's aggression and treatment appreciation were pre-registered as main outcomes, their analysis should be considered as confirmatory. The other measures were later added to explore a broader range of potential advantages of virtual reality. Although these outcomes were based on previous literature and were planned in advance, they should be considered more exploratory as they were not pre-registered.
YourSkills is a manualized CBT, based on evidence-based treatments for children with aggressive behavior problems, including Coping Power and Self-Control. We developed a new treatment manual, rather than adding virtual reality to an existing treatment. This way, we could integrate interactive virtual reality into all facets of the treatment and compare it to the identical treatment using roleplay practice. The aim of YourSkills is to reduce children's aggressive behavior problems by enhancing emotion regulation and social information processing skills. Children practice anger recognition, anger regulation, and social problem solving in social interactions. YourSkills consists of one 45-min introduction session with parents and ten 45-min sessions with the child. All treatment sessions have the same structure, making the session course predictable for children. Although YourSkills is primarily focused on the child, it also promotes parent involvement by providing them with an introduction session and including them at the end of each session (for more information, see Alsem et al., 2021).
To let children practice their regulation skills whilst being emotionally engaged, therapists create challenging social situations for children in virtual reality or roleplays. In each session, therapists first explain a new skill, then model the skill using roleplay, and then use virtual reality or roleplays to let children practice the skill in anger-provoking social situations. The YourSkills materials include 26 cards with anger-provoking situations, based on a taxonomy of problematic situations for children with aggressive behavior problems. They include: being disadvantaged, authority conflicts, peer rejection, and peer provocation. Therapists select those situations that match children's individual needs.
In this study, YourSkills was delivered by 31 licensed therapists (90.3% female) working at the participating clinical centers. Therapists were trained in both versions of YourSkills in a two-day course, supervised by the first and second author and a certified CBT therapist. They learned to work with the treatment manual, how to conduct roleplay exercises, and use the virtual reality equipment.
The present multicenter randomized controlled trial examined whether interactive virtual reality enhanced the effectiveness of CBT for boys with aggressive behavior problems compared to CBT with roleplays and care-as-usual. The results indicated that CBT with virtual reality was more likely to reduce aggressive behavior than care-as-usual for six out of seven outcomes. Effects were medium-to-large for measures assessing weekly aggression (ds .59–.95) and small-to-medium for measures assessing aggression in the past month (ds .19–.33). The same pattern of results was found when we compared both CBT groups (i.e., virtual reality and roleplays) to care-as-usual, suggesting that our newly developed CBT protocol outperformed care-as-usual. When we directly compared virtual reality versus roleplays, results favored virtual reality on four of seven aggression measures, with small-to-medium effect sizes (ds .14–.68). Virtual reality clearly outperformed roleplays on other aspects: it was very likely that children were more emotionally engaged and immersed during virtual reality practice than in roleplays. Also, children most likely appreciated virtual reality more and perceived this method as more effective than roleplays.
Our findings provide the first indication that interactive virtual reality can enhance effects of CBT for children with aggressive behavior problems. Effect sizes for virtual reality versus care-as-usual were substantial (ds .19–.95) and similar or larger than in meta-analytic research comparing CBT to control groups (d = .23). In line with these effects, 48.6% of parents in the CBT virtual reality group reported clinically relevant improvements in children's aggression, and parent-rated average aggression scores decreased from subclinical levels to the normal range. Moreover, virtual reality likely enhanced children's treatment appreciation and involvement. This is highly relevant, as children with aggressive behavior problems are often not motivated for treatment, whereas enhancing treatment appreciation has been related to increases in treatment effectiveness.
Interactive virtual reality had some benefits over CBT with roleplays. Children practicing in virtual reality were more emotionally engaged and immersed, and we found some indications that virtual reality outperformed roleplays in effectiveness. These findings align with the dual-mode social information processing model for children with aggressive behavior problems. This model proposes that children process social information in either the automatic mode (i.e., fast, emotion-driven aggression) or the reflective mode (i.e., slow, deliberately selected aggression). Based on this model, interventions may be most effective when children's social information processing patterns are targeted in the mode that is also active when they engage in aggressive behavior in daily life. Virtual reality may trigger the automatic mode more so than roleplays, as children practice in realistic environments and do not have to rely on their memory or imagination, triggering the reflective mode.
Effects of CBT with virtual reality also differed between informants. Child-reported effects on aggression were generally smaller than effects reported by parents and teachers. One explanation is that children may have underreported their aggressive behavior problems at pre-assessment (e.g., due to external attributions of their own behavior). Children may then have become more aware of their problems during the treatment (i.e., response shift bias) which is in line with our finding that we found little support for decreases in child-reported aggression across all treatment groups. Alternatively, parents and teachers may have overreported effects of the treatment. They were not blind to allocation status, and may have expected the novel virtual reality treatment to be more effective. However, this alternative explanation seems less likely, as intervention effects on parent reported measures have generally been found to be similar in magnitude to actual observed effects.
In conclusion, we have found that it is likely that CBT with interactive virtual reality leads to larger decreases in children's aggressive behavior compared to care-as-usual. Compared to CBT with roleplays, results moderately favored virtual reality on four out of seven aggression measures, and clearly supported that virtual reality is likely to enhance children's emotional engagement and practice immersion, as well as treatment appreciation and perceived efficacy. Thus, interactive virtual reality seems a promising tool to enhance children's motivation during treatment and increase the effectiveness of CBT for children with aggressive behavior problems.
This is a longer than usual post because I think it’s very promising as an intervention. We know how horrific the consequences of child aggression can be in terms of school success, relationships, and future experience with the legal system. I especially like the argument that aggressive children are often treatment resistant. Anything that engages them is promising.