Using interactive virtual reality to treat aggressive behavior problems in youth

A large proportion of children and youth in the mental health care shows
externalizing problem behavior, such as aggression (Nederlands Jeugdinsituut,
2015). The prevention and treatment of these problem behaviors is necessary,
since this a serious risk factor for the development of adverse outcomes later
in live (Sukhodolsky, Kassinove, & Gorman, 2004). Moreover, these children are
at enhanced risk for behavior problems later in life, internalizing problem
behavior, substance abuse, and school failure (Sukhodolsky, Kassinove, &
Gorman, 2004; Weisz & Kazdin, 2001). Furthermore, it is demonstrated that young
children with behavior problems will later in life face more problems, receive
mental care more often and costs for society are higher (Scott, Knapp,
Henderson & Maughan, 2001).

Over the past years, knowledge regarding the effectiveness of interventions for
aggressive behavior problems has increased (Weisz & Kazdin, 2017). Moreover,
several (group)intervention are found to effectively decrease aggression, even
on the long term (Nederlands Jeugdinsituut, 2015).
However, the effects of current evidence-based cognitive behavioral treatments
(CBT) on children*s aggressive behavior problems are modest at best and do not
work for all children (McCart, Priester, Davies, & Azen, 2006).

Therefore, it is necessary to examine whether the effectiveness of intervention
for children with aggressive behavior problems can be enhanced. Moreover, CBT
interventions are expected to be most effective when children*s aggressive
cognitions are challenged in emotionally involving social situations, because
these are the situations that trigger their aggression in real life (Suveg,
Southam-Gerow, Goodman, & Kendall, 2007). Virtual reality allows for such
exposure within a controlled treatment context. In addition, virtual reality
has been found to enhance treatment motivation, which may foster intervention
adherence as well as effectiveness. However, it is yet unknown if virtual
reality can enhance treatment effects for children with aggressive behavior
problems.

The goal of the present research is to test the effectiveness of an interactive
virtual reality intervention for children with agression problems. Moreover, it
is expected that (1) the VR-intervention will decrease aggressive behavior
problems, (2) in addition will possibly be more effective in treating
aggressive behavior problems than current treatments (in which cognitions and
skills are being practiced in role plays), and (3) that children will have more
treatment motivation.

A randomized controlled trial will be conducted to examine the effectiveness of
the interactive virtural reality treatment. Children will be randomized into
three groups:
1. The virtual reality intervention. This is an individual cognitive behavior
therapy (CBT) intervention consisting of 10 sessions. Children practice the
skills in the VR environment.
2. An active control group. This is an individual cognitive behavior therapy
(CBT) intervention consisting of 10 sessions. Children practice the skills
within role plays with the therapist.
3. An passive control group (care-as-usual). These boys will receive
care-as-usual.

The current intervention is based on principles of cognitive behavior therapy
to enhance emotionregulation and social information processing of boys with
aggressive behavior problems. The intervention start with an intake with
parents and 10 45-minute sessions with the child will follow. The current
intervention will be delivered individually, since earlier research showed
larger reductions in cihildren's aggression for individual delivered therapy
compared to group delivered therapy. During the intervention children will
learn to recognize their anger and train skills to cope with anger. Examples of
those skills are taking a time-out, do relaxation exercises and use coping
statements.
Participants receiving the virtual reality intervention will practice the
skills during the therapy in a virtural reality environment. Participants in
the active control group will practice in role plays with the therapist.
Participants in the passive controle group will receive care as usual.

The burden placed on the participants is small. The virtual reality condition
and active control condition will exist of an intake with parents and 10
intervention sessions with the child (all 45 minutes). This is comparable to
current treatments for children (Nederlands Jeugdsinstituut, 2015). Children
and their parents will fill in questionnaires at three occasions; this will
take 15-30 minutes. In total, all participants and their parents invest a
maximum of 1 hour, 30 minutes by filling in questionnaires and children in the
intervention conditions invest an additional 7.5 hours in treatment.

Furthermore, the risk of harm to the participants as a result of participating
in the study is smal, as also described in our earlier virtual reality study
(NL61205.041.17). Since the therapeutic contents of the active and passive
control condition are similar to current treatments, no risks are expected.

Since virtual reality allows for practicing skills in realistic, emotionally
involving situations, it is expected that VR-scenario's will elicit
frustrations or mild aggression that is similar to frustrations and mild
aggression in daily life. Previous research has demonstrated that real-time
mild provocations and social dilemma's can elicit mild aggressive behavior
within ethical boundaries (Matthys et al., 1995; Matthys et al., 1995; Van
Nieuwenhuijzen et al., 2005; Kempes, de Vries, Matthys, van Engeland, & van
Hooff, 2008 ).

In addition, virtual reality-environments could elicit cyber sickness. Cyber
sickness consists of symptoms of nausea, drowsiness, impaired visual perception
and concentration deficits and is caused by a discrepancy between sensory
perception and the vestibular system (LaViola Jr., 2000). It is important to
note that approximately 30% of participants exhibit some symptoms of cyber
sickness (Chen et al., 2011 ). However, research shows that participants build
a tolerance against cyber sickness and that the quality and adjustment of the
virtual reality hardware and software can reduce symptoms of cyber sickness
(Kennedy, Stanney & Dunlap, 2002; Rebenitsch & Owen, 2016; Kennedy & Fowlkes,
2000). In this study, the discrepancy between sensory perception and the
vestibular system is expected to be minimal because participants are able to
freely move in the virtual reality-environments and the quality of the hardware
and software is high. Therapists will monitor symptoms of cyber sickness and
will temporarily pause the session if they perceive symptoms. The session will
be proceeded only when participants are feeling well and are willing to
continue.