Feasibility of a Virtual Reality Program in Managing Test Anxiety: A Pilot Study

Abstract

Test anxiety has been a growing problem in school-aged children, especially for students in East-Asian countries where the pressure for academic achievement is high. These students are more vulnerable to academic stress, which could further lead to anxiety disorders. For this reason, this study examined the feasibility of virtual reality (VR) test anxiety program in managing anxiety in students. A total of 22 typically developing children with varying levels of test anxiety and no history of psychiatric illnesses participated in the study (mean age = 11.6 and standard deviation [SD] = 1.84). A self-reported questionnaire measuring test anxiety, state-trait anxiety, and depression was administered. Heart rate (HR) variability and subjective anxiety were also measured to examine the changes during each of the anxiety-inducing (Exam 1 and Exam 2) and meditation (Med 1 and Med 2) sessions in the program. There was a significant difference in self-perceived anxiety during the program (p < 0.001), as well as a significant main effect of time on the standard deviation of R-R interval (p = 0.002). In addition, a significant relationship between changes in HR and perceived anxiety during Exam 1 (p = 0.003), Med 1 (p < 0.001), and Med 2 (p = 0.011) was found. In conclusion, this work demonstrates the feasibility of the virtual environment to induce different levels of anxiety and explores the potential use of VR program as a viable method to manage the negative emotion in students. This work shows the potential of technology-enhanced tools in addressing psychological problems in school-aged children. Further study is needed to validate the use of the program in clinical practice.

Introduction

Test anxiety is characterized by individuals experiencing persistent fear of the evaluative situation.^1,2 The two manifestations—worry and emotionality—affect the individuals in complex ways.³ Worry is distinguished by maladaptive cognitive processes such as ruminations about the negative performance, whereas emotionality is specified by physiological arousal to the anxiety-inducing environment. Recent reports show that 15 to 22 percent of students suffer from test anxiety⁴ and there is an increasing concern for younger children.⁵ However, the lack of treatment is a concern, considering that most research on test anxiety is limited to university students.⁶ Although cognitive behavioral therapy and school-based intervention have been effective,⁵ the difficulty of exposing the patient to an anxiety-inducing environment is a major drawback.

Recently, virtual reality (VR) has been incorporated into treating anxiety disorders,⁷ such as post-traumatic stress disorder,^8,9 specific phobias,¹⁰ and social anxiety disorder.^11,12 Compared to imaginal exposure therapy, the immersive 3D visuals and sound effects increase a sense of presence in the virtual environment (VE).¹³ This environment can evoke similar reactions and emotions as from real-life experiences, allowing them to exert more attention during therapy, which in return benefits the overall process of making a therapeutic change.^13,14 By building on this, our research team has developed a novel VR test anxiety management program targeted at children and adolescents.

Meditation is an effective therapeutic tool to reduce physical and psychological stress not only in healthy individuals^15–17 but also in patients with anxiety disorders.¹⁸ Moreover, mindfulness programs have been incorporated into schools^16,19 and studies show an increased resilience to stress, improved cognitive performance,¹⁹ and a reduction in test anxiety.^20,21 There is also a growing interest in incorporating technology into meditation training as VR-based learning has shown to improve the emotional state²² and the mental health of individuals.²³ VR mindfulness learning is as effective as the traditional method in reducing negative mood, but more effective in increasing treatment adherence.¹⁸ Based on the evidence, we hypothesize that VR meditation is a useful tool for reducing test anxiety among school-aged children.

Given that the past VR test anxiety program was created over a decade ago, there is a need to investigate the changes in the feasibility of VR as a potential treatment option for test anxiety.²⁴ The purpose of this investigation is to examine whether the immersive VE can induce different levels of test anxiety and to understand the potential use of VR meditation in managing negative emotions in students.

Methods

Participants

Twenty-two participants between the ages of 9 and 16 were recruited through advertisements online. They were screened by a clinical psychologist for psychiatric disorder designated by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).²⁵ None of them had a history of psychiatric illness, according to the Mini-International Neuropsychiatric Interview for Children and Adolescents (MINI-KID 6.0).²⁶ One was excluded from the analysis due to issues with physiological recordings.

Measures

Clinical scales

A shortened Wechsler Intelligence Scale for Children-3rd edition was conducted to assess the intellectual quotient (IQ).²⁷ The Korean Test Anxiety Inventory (K-TAI) was used to measure the severity of test anxiety. The children and adolescent versions consisted of 25 items (Cronbach's α = 0.90) and 35 items (Cronbach's α = 0.94), respectively, rated on a 4-point Likert scale (1 = almost never and 4 = always).²⁸ T-scores were calculated to compare across the versions, where the higher score indicates more test anxiety. The Children's Depression Inventory (CDI) consisted of 27 items, including three statements in the order of increasing severity (Cronbach's α = 0.88).²⁹ The range is between 0 and 54, and a higher score represents more depression.³⁰ The Korean state-trait anxiety inventory (STAI-C) comprised two 20-item subscales that measured trait (TAI-C) and state anxiety (SAI-C).^31,32 Individuals respond on a 3-point Likert scale (1 = almost never and 3 = very often). The range of the total score is between 40 and 120 (Cronbach's α = 0.94).

Physiological measures

Heart rate variability (HRV) was measured using BIOPAC MP 160 system and AcqKnowledge 5.0.1 software (BIOPAC Systems, Inc., Goleta, CA). The obtained measures are as follows: normal-to-normal (NN) intervals, average of NN (AVNN), standard deviation of NN (SDNN), pNN50, and root mean square of the successive differences (RMSSD). Supplementary Data S1 includes a detailed explanation.

VR anxiety measures

The visual analogue scale (VAS) was used to measure the participant's subjective feelings of anxiety immediately after each session in the VE. Participants chose from a scale of zero (0) to a hundred (100), each labeled as “not at all” to “very much.”

Procedure

This study was approved by the Institutional Review Board of Yonsei University, Gangnam Severance Hospital. Written informed consent was obtained from all participants and parents. First, clinical interviews and IQ assessments were conducted. Then, participants filled out self-report questionnaires and were moved to the testing room to place the BIOPAC electrodes. Before initiating the study, 30 seconds of baseline measurements were acquired to stabilize the physiological signals. Once the head-mounted display was worn, in-app instructions were given for 30 seconds. During this time, participants familiarized themselves with the VR controller and the VE. All the participants experienced each session in chronological order (Supplementary Table S1). The overall procedure took ∼90 minutes.

Virtual environment

System design

The VR system was developed on a mobile-based platform. The content was designed on Unity 5.6.5 f1 software (Unity Technologies, San Francisco, CA). The program was downloaded on a Samsung Galaxy 8+ smartphone for use with a Samsung Gear VR (Samsung Electronics, Seoul, Korea). The program connects to a server that encodes the demographic information and the user type data collected during testing.

Program design

The overall VR program was divided into two sessions: Session A and Session B. Each session includes subsessions: Exam and Meditation (Med) (Fig. 1 outlines program flow and the approximate duration). In the Exam sessions, the users were exposed to an anxiety-inducing scenario that includes receiving a text from a worried friend the night before and overhearing anxious classmates. In the Med sessions, the users were guided through meditation in the same environment as the Exam session. Supplementary Data S2 outlines the program script.

FIG. 1.

Program flow, screenshots, and duration of the program. (a) The night before the exam (Exam 1); (b) at-home meditation scene (Med 1); (c) the day of the exam (Exam 2); (d) at-school meditation scene (Med 2). Color images are available online.

Results

Demographic information

Twenty-two students between the ages of 9 and 16 participated in the study. The average age was 11.6 years (standard deviation [SD] = 1.84). Nineteen males (mean age = 11.5) and three females (mean age = 12.0) were included. A majority of students reported low levels of test anxiety, although three students showed relatively higher levels. The demographic characteristics are specified in Table 1.

Table 1.

Demographic Characteristics and Self-Reported Clinical Scale

Variables	Mean (SD)
n	22
Age (years)	11.59 (1.84)
FSIQ	111.19 (10.45)
CDI	6.91 (6.38)
STAI	55.05 (12.26)
TAI	50.00 (10.00)

CDI, Children's Depression Inventory; FSIQ, Full Scale Intelligence Quotient; SD, standard deviation; STAI, State-Trait Anxiety Inventory; TAI, Test Anxiety Inventory.

Subjective measures

Changes in VAS anxiety

A repeated-measures analysis of variance (ANOVA) was conducted to measure the mean differences in VAS anxiety during the program. Since the assumption of sphericity was violated χ²(9) = 33.28, p < 0.001, the Greenhouse-Geisser correction revealed that the mean VAS rating differed significantly between time points [F(2.42, 50.88) = 7.94, p < 0.001] (Fig. 2). A post hoc pairwise comparison using Bonferroni correction revealed that the rating significantly increased after Exam 1 (p = 0.012), decreased after Med 1 (p = 0.001), increased after Exam 2 (p = 0.006), and decreased after Med 2 (p = 0.015).

FIG. 2.

Changes in the mean VAS anxiety score. Asterisks indicate statistical significance (*p < 0.05, **p < 0.01). VAS, visual analogue scale.

There was a strong correlation between test anxiety and depression (CDI), r(20) = 0.73, p < 0.001 as well as anxiety (STAI), r(20) = 0.86, p < 0.001 (Supplementary Table S2 for the correlation matrix). A significant positive correlation was also found between TAI and VAS anxiety in pre-Med 1 (Exam 1 VAS), r(20) = 0.53, p = 0.01, and pre-Med 2 (Exam 2 VAS), r(20) = 0.69, p < 0.001 (Fig. 3).

FIG. 3.

Relationship between TAI score and VAS anxiety. TAI, Test Anxiety Inventory. Color images are available online.

Physiological measures

Heart rate and VAS anxiety

The change in VAS anxiety was calculated by subtracting the baseline from pre-Med 1 VAS for Session A and subtracting the post-Med 1 from pre-Med 2 VAS for Session B. A more positive score indicates that the anxiety rating was higher after the exposure to the Exam sessions. A significant positive correlation was found between changes in VAS anxiety and the average heart rate (AVHR) during Exam 1, r(19) = 0.62, p = 0.003 (Fig. 4a). No significant correlation was found between the changes in VAS anxiety and HRV parameters during Exam 2.

FIG. 4.

Relationship between changes in VAS anxiety and average heart rate during (a) Exam 1; (b) Med 1; (c) Med 2. Color images are available online.

The change in VAS anxiety was calculated by subtracting the pre-Med from the post-Med scores. A more negative score indicates that the anxiety was lower after the Med session. A significant correlation was found between the change in VAS anxiety and the AVHR during Med 1, r(19) = −0.66, p = 0.001, and Med 2, r(19) = −0.54, p = 0.011 (Fig. 4b, c).

Physiological changes

A mixed-design ANOVA with a within-subjects factor of four sessions, age, STAI, and CDI scores as covariates were used to compare the changes in the HRV measures. Covariates were added to control for individual variations that could confound the results. A significant main effect of time was found for RMSSD [F(3, 20) = 3.45, p = 0.036], AVNN [F(3, 20) = 3.04, p = 0.05], and SDNN [F(3, 20) = 7.2, p = 0.002)], except for pNN50 [F(3, 20) = 1.70, p = 0.199]. Results from post hoc analysis are specified in Table 2.

Table 2.

Estimated Means (SE) of Heart Rate Variability (RMSSD, pNN50, AVNN, and SDNN) During Exam and Meditation Session (n = 21)

Variable	Session A		Session B
Variable	Exam 1	Med 1	Exam 2	Med 2
RMSSD	64.26 (6.83)	65.21 (7.09)	62.00 (6.89)	59.24 (6.05)
pNN50	38.26 (3.78)	37.83 (4.35)	36.17 (4.41)	34.15 (4.06)
AVNN	780.68 (14.27)	786.03 (13.66)	765.96 (13.88)^a	774.67 (14.70)
SDNN	71.01 (3.54)	76.10 (3.65)^b	71.69 (4.39)	77.02 (3.84)^b

Significant values are shown in bold type.

Significant difference between Session A and Session B, p < 0.05.

Significant difference between respective meditation periods and exam sessions, p < 0.05. (Exam 1-Med 1 and Exam 2-Med 2). Means adjusted for age, CDI, and STAI.

AVNN, average of NN; RMSSD, root mean square of the successive differences; SDNN, standard deviation of NN; SE, standard error.

Discussion

In this pilot study, we demonstrated the feasibility of VE in inducing different levels of anxiety and the potential use of VR meditation to manage test anxiety. A significant increase in VAS anxiety after the exposure to the Exam sessions was positively associated with the severity of test anxiety. In lines with previous research findings on the use of VE to induce an emotional response,^24,33,34 we show that students with a higher TAI tended to report feeling more anxious after the exposure. Given that a significantly lowered AVNN is indicative of mental stress^35,36 and anxiety,³⁷ it can be inferred from the decreased AVNN during Exam 2 that students' anxieties increased during the exposure. In addition, a positive association between the AVHR during Exam 1 and the change in VAS anxiety explains that a higher heart rate (HR) during the anxiety-exposure period was associated with a more considerable increase in self-perceived anxiety.

Our data further show the feasibility of VR meditation in regulating anxiety even for students with low test anxiety. A significant decrease in the subjective rating of anxiety was found after the Med sessions. Although nonsignificant, these ratings were lower than the baseline. Considering the characteristics of the sample, this is meaningful because most students had low scores at baseline. Moreover, the negative association between the change in VAS anxiety and AVHR during each of the Med sessions was significant. These are consistent with studies showing a decrease in HR with breath-focused attention training³⁸ and a 3-month meditation program for students.³⁹ Similar to research showing the protective effects of meditation,^40,41 we demonstrate the potential use of VR meditation to stabilize the autonomic nervous system. Considering that an increased parasympathetic activity (high HRV) indicates an emotionally stable state,⁴² and higher variability in SDNN reflects a healthy response to stress, a significant increase in SDNN during the Med sessions demonstrates that VR meditation can be useful in managing test anxiety.

Limitations

There are several limitations to our study. First, since this exploration was intended as a feasibility study, the small sample size (n = 22) and a wide range of ages (Min = 9 and Max = 16) may limit the generalization of our results.

Since the majority were males (n = 19), our findings may not be generalized to females. Moreover, the program may not be appropriate for younger students due to differences in the testing procedure. Second, the conditions were not counterbalanced across participants. They experienced the sessions in chronological order to maintain ecological validity. Third, a cause-effect relationship cannot be concluded since this was a cross-sectional study with no control group. A followup study should include “sham” treatment that replaces meditation or measure the effect on a clinically diagnosed group to validate the use of the VR program. Finally, the short baseline measurement of HRV may not have been sufficient to measure the physiological state at rest. Considering that students with higher anxiety responded better to the program, this study provides the basis of developing a larger randomized, controlled study to validate the use of VR program in treating test anxiety.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This research was supported by Brain Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT and Future Planning (NRF-2017M3C1B6071066).

Supplementary Material

References

Hembree

. Correlates, causes, effects, and treatment of test anxiety. Review of Educational Research, 1988; 58:47–77.

Zeidner

. (1998) Test Anxiety: The State of the Art. New York, NY: Plenum Press.

Liebert

, Morris

. Cognitive and emotional components of test anxiety: a distinction and some initial data. Psychological Reports, 1967; 20:975–978.

von der Embse

, Jester

, Roy

, et al. Test anxiety effects, predictors, and correlates: a 30-year meta-analytic review. Journal of Affective Disorders, 2018; 227:483–493.

von der Embse

, Barterian

, Segool

. Test anxiety interventions for children and adolescents: a systematic review of treatment studies from 2000–2010. Psychology in the Schools, 2013; 50:57–71.

Ergene

. Effective interventions on test anxiety reduction: a meta-analysis. School Psychology International, 2003; 24:313–328.

Carl

, Stein

, Levihn-Coon

, et al. Virtual reality exposure therapy for anxiety and related disorders: a meta-analysis of randomized controlled trials. Journal of Anxiety Disorders, 2019; 61:27–36.

Beidel

, Frueh

, Neer

, et al. Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: a randomized controlled trial. Journal of Anxiety Disorders, 2019; 61:64–74.

Gonçalves

, Pedrozo

, Coutinho

ESF

, et al. Efficacy of virtual reality exposure therapy in the treatment of PTSD: a systematic review. PLoS One, 2012; 7:e48469.

10.

Maples-Keller

, Yasinski

, Manjin

, et al. Virtual reality-enhanced extinction of phobias and post-traumatic stress. Neurotherapeutics, 2017; 14:554–563.

11.

Kampmann

, Emmelkamp

PMG

, Hartanto

, et al. Exposure to virtual social interactions in the treatment of social anxiety disorder: a randomized controlled trial. Behaviour Research and Therapy, 2016; 77:147–156.

12.

Kim

M-K

, Kim

J-J

, Kim

, et al. Effectiveness of self-training using the mobile-based virtual reality program in patients with social anxiety disorder. Computers in Human Behavior, 2017; 73:614–619.

13.

Riva

, Botella

, Baños

, et al. (2015) Presence-inducing media for mental health applications. In: Lombard

, Biocca

, Freeman

et al., eds. Immersed in Media. New York: Springer, pp. 283–332.

14.

Kosunen

, Salminen

, Järvelä

, et al. (2016) RelaWorld: Neuroadaptive and Immersive Virtual Reality Meditation System. In: Nichols

, ed. Proceedings of the 21st International Conference on Intelligent User Interfaces. Sonoma, CA: Association for Computing Machinery, pp. 208–217.

15.

Prasad

, Varrey

, Sisti

. Medical students' stress levels and sense of well being after six weeks of yoga and meditation. Evidence-Based Complementary and Alternative Medicine: eCAM, 2016; 2016:9251849-7.

16.

Shahidi

, Akbari

, Zargar

. Effectiveness of mindfulness-based stress reduction on emotion regulation and test anxiety in female high school students. Journal of Education and Health Promotion, 2017; 6:87.

17.

Chiesa

, Serretti

. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. The Journal of Alternative and Complementary Medicine, 2009; 15:593–600.

18.

Navarro-Haro

, Modrego-Alarcón

, Hoffman

, et al. Evaluation of a mindfulness-based intervention with and without virtual reality dialectical behavior Therapy^® mindfulness skills training for the treatment of generalized anxiety disorder in primary care: a pilot study. Frontiers in Psychology, 2019; 10:55.

19.

Zenner

, Herrnleben-Kurz

, Walach

. Mindfulness-based interventions in schools-a systematic review and meta-analysis. Frontiers in Psychology, 2014; 5:603.

20.

Linden

. Practicing of meditation by school children and their levels of field dependence-independence, test anxiety, and reading achievement. Journal of Consulting and Clinical Psychology, 1973; 41:139–143.

21.

Carsley

, Heath

, Fajnerova

. Effectiveness of a classroom mindfulness coloring activity for test anxiety in children. Journal of Applied School Psychology, 2015; 31:239–255.

22.

Freeman

, Lessiter

, Keogh

, et al. Relaxation Island: virtual, and really relaxing. Proceedings of 7th International Workshop on Presence, 2004; 14:67–72.

23.

Navarro-Haro

, López-Del-Hoyo

, Campos

, et al. Meditation experts try Virtual Reality Mindfulness: a pilot study evaluation of the feasibility and acceptability of Virtual Reality to facilitate mindfulness practice in people attending a Mindfulness conference. PLoS One, 2017; 12:e0187777.

24.

Alsina-Jurnet

, Carvallo-Beciu

, Gutiérrez-Maldonado

. Validity of virtual reality as a method of exposure in the treatment of test anxiety. Behavior Research Methods, 2007; 39:844–851.

25.

American Psychiatric Association. (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-5^®). Washington, DC: American Psychiatric Association Publishing.

26.

Sheehan

, Sheehan

, Shytle

, et al. Reliability and validity of the mini international neuropsychiatric interview for children and adolescents (MINI-KID). The Journal of clinical psychiatry. 2010; 71:313–326.

27.

Donders

. A short form of the WISC-III for clinical use. Psychological Assessment, 1997; 9:15–20.

28.

Kim

. Development of the Korean form of the Test Anxiety Inventory. Journal of the Korean Academy Child and Adolescent Psychiatry, 1991; 2:32–42.

29.

Kovacs

, Beck

. (1977) An empirical clinical approach toward a definition of childhood depression. In: Schulterbrandt

, ed. Depression in Childhood: Diagnosis, Treatment, and Conceptual Models. New York, NY: Raven Press, pp. 1–25.

30.

Cho

S-C

, Lee

. Development of the Korean form of the Kovacs' Children's Depression Inventory. Journal of the Korean Neuropsychiatric Association, 1990; 29:943–956.

31.

Speilberger

. (1973) Manual for the state-trait anxiety inventory for children. Palo Alto, CA: Consulting Psychologists' Press.

32.

Hahn

. Korean adaptation of Spielberger's STAI (K-STAI). Korean Journal of Health Psychology, 1996; 1:1–14.

33.

Riva

, Mantovani

, Capideville

, et al. Affective interactions using virtual reality: the link between presence and emotions. CyberPsychology and Behavior, 2007; 10:45–56.

34.

Shin

Y-B

, Kim

J-J

, Kim

M-K

, et al. Development of an effective virtual environment in eliciting craving in adolescents and young adults with internet gaming disorder. PLoS One, 2018; 13:e0195677.

35.

Gorman

. Heart rate variability in depressive and anxiety disorders. American Heart Journal, 2000; 140:77–83.

36.

Pereira

, Almeida

, Cunha

JPS

, et al. Heart rate variability metrics for fine-grained stress level assessment. Computer Methods and Programs in Biomedicine, 2017; 148:71–80.

37.

Chalmers

, Quintana

, Abbott

MJA

, et al. Anxiety disorders are associated with reduced heart rate variability: a meta-analysis. Frontiers in Psychiatry, 2014; 5:80.

38.

Telles

, Nagarathna

, Nagendra

. Autonomic changes during “OM” meditation. Indian Journal of Physiology and Pharmacology, 1995; 39:418–420.

39.

Barnes

, Davis

, Murzynowski

, et al. Impact of meditation on resting and ambulatory blood pressure and heart rate in youth. Psychosomatic Medicine, 2004; 66:909.

40.

Nesvold

, Fagerland

, Davanger

, et al. Increased heart rate variability during nondirective meditation. European Journal of Preventive Cardiology, 2012; 19:773–780.

41.

Mankus

, Aldao

, Kerns

, et al. Mindfulness and heart rate variability in individuals with high and low generalized anxiety symptoms. Behaviour Research and Therapy, 2013; 51:386–391.

42.

Phongsuphap

, Pongsupap

, Chandanamattha

, et al. Changes in heart rate variability during concentration meditation. International Journal of Cardiology, 2007; 130:481–484.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.05 MB