Clay et al., 2021

Overview of the Article

• Focus: Feasibility and preliminary efficacy of using Virtual Reality–based Behavioral Skills Training (VR-BST) to teach preservice clinicians to implement Functional Communication Training (FCT)
• Authors & Affiliations: Casey J. Clay, Brittany A. Schmitz, Bimal Balakrishnan, James P. Hopfenblatt, Ashley Evans, SungWoo Kahng; Universities of Missouri & Rutgers
• Publication: Journal of Applied Behavior Analysis, 2021, Vol. 54, pp. 547-565
• Core research questions
  • Can VR-delivered BST (instructions ➔ modeling ➔ rehearsal ➔ feedback) bring novice students to mastery when teaching FCT for escape- and attention-maintained problem behavior?
  • What are the associated time, cost, and social-validity outcomes?

Key Concepts & Definitions

• Behavioral Skills Training (BST)
  • Components: written/verbal instructions, modeling, rehearsal, feedback
  • Commonly used to teach functional behavior assessment/intervention skills to staff, teachers, and parents
• Functional Communication Training (FCT)
  • Differential-reinforcement procedure teaching a socially acceptable communicative response (FCR) that accesses the reinforcer previously maintaining problem behavior
  • Evidence-based for reducing severe challenging behavior in Autism Spectrum Disorder (ASD)
• Virtual Reality (VR)
  • Immersive computer-generated environment experienced through head-mounted displays (HTC Vive® in this study)
  • Presence: psychological state in which virtual objects/actors are experienced as real; requires accurate self-location & possibilities for action
• AutSim©
  • Custom VR simulation of an autism clinic treatment room, including a motion-captured child avatar capable of scripted problem behavior and FCRs

Rationale for VR-BST

• Traditional in-vivo BST exposes trainees & clients to risks
  • Aggression, self-injurious behavior (SIB) ➔ staff injuries (Hostetler 2019, Whitman 1976)
  • Infectious-disease transmission (e.g., SARS, tuberculosis; Schablon 2009)
  • Logistical costs of human confederates (training, scheduling, social distancing)
• VR advantages
  • Eliminates direct contact; repeatable, safe rehearsal; automated or remote delivery; potentially inexpensive with modern consumer hardware

Development of AutSim© VR Simulation

• Design goal: high experiential congruence with a real autism clinic room
• Technical elements enhancing presence
  • High-detail architectural modeling (Autodesk 3DS Max)
  • Motion-captured child avatar
  • 6-degree-of-freedom navigation & hand interaction via HTC Vive controllers
  • One-way mirror, clock, FCR card, table/chairs accurately scaled to real room (10 m × 7 m)
• Software stack: Unity 3D engine + C# scripting; flexible to migrate to standalone headsets (e.g., Oculus Quest)

Method

Participants & Setting

• $N = 13$ female undergraduate Health-Science majors (no prior ABA/FCT training)
• Freshmen = 2, Sophomores = 6, Juniors = 2, Seniors = 3
• Sessions in a cleared conference room; consent obtained; optional compensation $\le 30\text{ USD}$

Experimental Design

• Non-concurrent multiple-baseline across participants
• Component analysis of BST
  1. Instructions (baseline)
  2. Modeling
  3. Rehearsal + feedback
• Mastery criterion: $\ge 90\%$ correct implementation across $3$ consecutive sessions

Session Types

1. Attention FCT (60 scripted actions/session)
   • EO: therapist withdraws attention
   • FCR prompt on FT $30\text{ s}$; deliver $30\text{ s}$ of high-quality attention for FCR
   • Ignore screaming, hitting, property destruction, threatening approach
2. Escape FCT (30 scripted actions/session)
   • EO: present academic/functional task
   • 3-step guided compliance hierarchy (instruction ➔ instruction + model ➔ physical guidance)
   • FCR prompt on FT $30\text{ s}$; deliver $30\text{ s}$ break; maintain demands for problem behavior

Response Measurement

• Data collectors observed physical trainee behavior + live overhead VR feed
• Each child action = a scored opportunity; coded correct vs error using operational definitions (see Tables 1 & 2)
• Percentage correct = \frac{#\;\text{Correct}}{#\;\text{Correct}+#\;\text{Errors}}\times100

Interobserver Agreement (IOA)

• Scored in $10\text{-s}$ intervals
• Attention sessions: IOA mean $=85\%$ (range $76\text{–}97\%$; $46\%$ of sessions)
• Escape sessions: IOA mean $=94\%$ (range $77\text{–}100\%$; $95\%$ of sessions)

Social-Validity Assessment

• 11-item Likert $1\text{–}7$ survey (adapted from Higgins 2017) via Qualtrics; anonymous responses from $12/13$ participants

Time & Cost Tracking

• Personnel time derived from grant budgets; direct monetary costs capped by small internal grant
• Key 1-year expenditures (Table 4):
  • Programmer GA: $10\text{ h/wk} \times 40\text{ wk} = 400\text{ h}$ ➔ $10{,}015\text{ USD}$
  • Lead researcher oversight: $10\text{ h/wk} \times 52\text{ wk} = 520\text{ h}$ ➔ $19{,}500\text{ USD}$
  • Research assistants for sessions: $\approx 180\text{ h}$ ➔ $3{,}780\text{ USD}$
  • Hardware/software: gaming laptop $1{,}649\text{ USD}$ + Unity/other licenses $1{,}500\text{ USD}$
  • Participant payments: $200\text{ USD}$
  • Total direct cost: $26{,}629\text{ USD}$ (indirect costs not included)

Results

Attention-Maintained FCT (Figure 2)

• Instructions phase mean $=73\%$ (range $57\text{–}88\%$)
  • Participant “April” reached mastery during instructions alone
• Modeling phase mean $=93\%$ (range $80\text{–}100\%$); six more participants mastered
• Feedback phase mean $=99\%$ (range $99\text{–}100\%$); remaining three reached mastery
• Most frequent error: incorrect EO arrangement
• Least frequent error: provision of attention for problem behavior
• Time to mastery: mean $716\text{ min}$ post-Instructions/Modeling; mean $85.6\text{ min}$ post-Feedback

Escape-Maintained FCT (Figure 3)

• Instructions phase mean $=25\%$ (range $3\text{–}51\%$); no mastery
• Modeling phase mean $=72\%$ (range $41\text{–}91\%$); “Jennifer” mastered
• Feedback phase mean $=95\%$ (range $90\text{–}98\%$); remaining four mastered
• Most frequent error: failure to differentially reinforce compliance vs guided compliance
• Least frequent error: failure to deliver break after FCR
• Time to mastery: mean $66.8\text{ min}$ post-Instructions/Modeling; mean $78.6\text{ min}$ post-Feedback

Social-Validity Findings (Table 3 highlights)

• Highest satisfaction: modeling component (mean $6.7/7$)
• Overall technology/setup satisfaction: $5.8/7$
• Perceived utility for other clinical skills: $5.8/7$
• Lowest mean ratings (≈ $4.7\text{–}4.9/7$) tied to comfort performing while observed, especially when questions were prohibited (Instructions/Modeling phases)
• Open-ended feedback stressed enjoyment of VR, but discomfort without immediate Q&A and difficulty tracking timing/wording rules without feedback

Cost & Efficiency Insights

• Average individual training time < $100$ minutes to mastery—comparable or faster than published live BST durations
• VR removes cost of confederates, reduces trainer staffing; one-time programming cost amortizable over large cohorts

Discussion & Implications

• Efficacy: VR-BST reliably produced mastery; $7/13$ participants succeeded without feedback, suggesting virtual contingencies may provide automatic “programmed feedback” (natural consequences of correct/incorrect actions)
• Safety: Eliminates risk of trainee injury, client injury, and disease transmission during rehearsal of severe behavior intervention
• Scalability & Access:
  • Compatible with consumer headsets; future autonomous modules (gamification, automated feedback) could remove live trainers entirely
  • Potential for remote/telehealth deployment, benefiting rural or pandemic-restricted training contexts
• Educational Technology Perspective: Illustrates fusion of “technology of tools” and “technology of process” (Twyman 2014); calls for more behavior-analytic R&D in automated, competency-based VR learning

Limitations

• No assessment of generalization to live clients
• Only two behavioral functions (attention, escape) targeted
• Correct-response topographies not individually coded; limits fine-grained error analysis
• Indirect costs and potential graphics/feature upgrades not analyzed

Future Research Directions

• Direct comparison of VR-BST vs traditional BST on efficacy, safety, cost (e.g., randomized group designs)
• Test maintenance & generalization to in-vivo contexts and additional functions (e.g., tangible, automatic reinforcement)
• Expand AutSim© with variable client avatars, automated feedback, data-analytics dashboards
• Investigate training effect on trainee response variability and generalization through programmed scenario diversity

Ethical, Practical & Philosophical Considerations

• Reduces ethical concerns of exposing clients/trainees to risk prior to mastery
• Raises questions about balancing technological immersion with humanistic elements in clinician preparation
• Supports broader move toward competency-based, data-rich education in health sciences and applied behavior analysis

Quick-Reference Numerical Summary

• Participants: $13$ undergraduates
• Scripts per session: $60$ (attention) / $30$ (escape)
• IOA: $85\%$ (attention), $94\%$ (escape)
• Mastery criterion: $\ge 90\%$ correct × $3$ consecutive sessions
• Time to mastery (post-full BST): Attention $\approx 86\text{ min}$; Escape $\approx 79\text{ min}$
• Direct project cost (1 yr): $26{,}629\text{ USD}$