The Use of Virtual Reality for Managing Psychological Distress in Adolescents: Systematic Review

Abstract

Acute and chronic psychological distress are prevalent during adolescence and can have negative impacts on adolescents in all life domains. The aim of this systematic review was to appraise the use of virtual reality (VR) interventions to manage symptoms of psychological distress symptoms among adolescents. MEDLINE, PubMed, PsycINFO, and Scopus databases were searched up to June 2020. Available citations were de-duplicated and screened by two authors using title and abstract information. A total of 301 articles were retained for full-text evaluation next to eligibility criteria. Empirical studies of all designs and comparator groups were included if these appraised the impact of an immersive VR intervention on any standardized measure indicative of psychological distress in an adolescent sample. Data were extracted into a standardized coding sheet. Results were tabulated and discussed with a narrative synthesis due to the heterogeneity between studies. A total of seven studies met inclusion criteria. There were four randomized controlled trials and three uncontrolled pilot studies on new VR interventions. Distress-related issues included: state-anxiety, venepuncture, risk taking, public speaking anxiety, social anxiety disorder, sexual victimization, and chemotherapy administration. All studies reported significant changes on outcome measures after VR treatment. Six studies reported small-to-large reductions in symptoms. The average attrition rate was 3.6 percent during the active VR treatment phase. Treatment acceptability was high in the studies that assessed user engagement factors. The VR technology can provide a safe, rapidly efficacious, and acceptable treatment modality for managing psychological distress in several key adolescent populations.

Introduction

Acommon mental health challenge for adolescents is psychological distress.^1–4 This can be construed as a transient state of emotional suffering that broadly includes any combination of negative mental symptomology (e.g., depression, anxiety, and perceived stress).^5,6 Psychological distress can arise from negative life events such as physical health problems,⁷ relationship difficulties,^8,9 and environmental issues.^10,11 Neurocognitive development in adolescents, where the emotional brain matures before the regulatory capacity of the prefrontal cortex matures, is seen as an additional contributor to the experience of distress.¹² This distress is often associated with somatic complaints such as pain, fatigue, heart palpitations, breathing difficulties, nausea, and other unpleasant bodily symptoms.¹³ Psychological distress can significantly impair daily functioning and life quality, both chronically and acutely.⁶ For instance, adolescent psychological distress from school bullying has been linked to restrictive eating,¹⁴ sleeping difficulties,¹⁵ school absenteeism,¹⁶ self-injury, and suicidality.¹⁷ Acute distress may arise as a response to unexpected or distressing environmental events such as vaccination and other painful medical procedures. Therefore, it is essential to help adolescents suffering from psychological distress with evidence-based mental health interventions.¹⁸

Virtual reality (VR) provides one treatment modality for mental health issues.^19,20 It involves the use of immersive computer technology (e.g., stereoscopic headsets, motion sensors, and haptic feedback devices) to imbed users into interactive digital worlds.²¹ This can induce “presence,” a cognitive state of being deeply connected and engaged in the VR world.²¹ Empirical evidence indicates that immersive VR interventions can therapeutically distract people from painful and distressing real world experiences,^22,23 induce relaxation with calming virtual environments,²⁴ and provide mental health skill training with virtual avatars.²⁵ Participants can learn to overcome anxiety-related disorders with VR exposure therapy (VRET), presenting digital representations of real-life distressing stimuli. For instance, moderate-to-large effect sizes in symptom relief have been reported for VRET compared with waitlist and placebo control conditions.^26–28 This level of treatment effectiveness is comparable to traditional cognitive behavioral therapy and in vivo exposure.^26,29 Overall, VR appears to be a promising health care tool for managing psychological distress. However, some limitations have been identified.

The VR has potential ethical, health, and safety risks.³⁰ These can include physical injuries from poor posture, repetitive strain, user collisions with real-world objects, and particularly in health settings, discomfort with headsets, infection control, and risk of inducing epileptic seizures and migraine headaches.^19,30–33 The VR may cause “simulator sickness,” a physiological condition consisting of nausea, disorientation, and oculomotor difficulties.^34,35 There are also concerns about negative mood changes.³⁰ For instance, VRET stimuli may be too anxiety provoking and lead to participant dropout.²⁹ However, Benbow and Anderson³⁶ found that VRET attrition is not significantly different to in vivo exposure. Further, deterioration is less likely in VRET patients compared with waitlists.³⁷ When looking at safety outcomes, a recent review on VR interventions for distressed burn victims found little-to-no negative side effects.²³ Nevertheless, VR use may be problematic for some people depending on individual characteristics, specific technology, and virtual task requirements.^30,34 Therefore, user engagement factors are important to consider when determining populations that are suitable for VR interventions.

The aim of this systematic review was to appraise the empirical status of VR interventions for managing psychological distress among adolescents. Prior VR mental health research has predominately focused on adults,^29,37,38 or mixed age samples of youth and adults.^23,39,40 Adolescents are developmentally distinct from young children and adults in their neurocognitive, psychosocial, and physical development.⁴¹ They face unique life challenges related to puberty, schooling, self-identity, intimate relationships, and financial dependencies.⁴¹ Clinically, adolescence is a critical period for the onset of mental health disorders.^42,43 It is, therefore, important to evaluate how VR has been used to manage their distress on key factors of effectiveness, acceptability, and adherence. Further, an up-to-date account of the evidence base in this domain is warranted, as VR is a rapidly evolving field with new technological advances being made in hardware and software capabilities.^21,44,45 By synthesizing extant research findings, it will be possible to identify effective and engaging VR interventions for adolescent psychological distress. This information can help guide future efforts when researching and implementing VR in health settings.

Method

This systematic review was conducted by using the PICO (patient/population, intervention, comparison, and outcomes) framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.⁴⁶ The protocol of this systematic review was prospectively registered in the PROSPERO international database (CRD42020198984).

Search strategy

The following electronic databases of scientific research were extensively searched: PubMED, MEDLINE, PsycINFO, and Scopus. Keywords used to search each database were: ((virtual reality or VR) and (child* or adolescent* or pediatric* or youth or teen* or high school or juvenile) and (depress* or anxiety or stress or distress or phobia or fear or pain or anger or frustration or well-being or mental health)). The reference lists of included papers were also manually searched.

Eligibility criteria

To be included in the review, articles needed to meet the following criteria. Based on the World Health Organization⁴⁷ definition of adolescence, an age range of 10 to 19 years was specified for participants. If the data set contained participants who were older or younger than the age range of interest, their data were only used if subgroup analysis was available or if adolescents made up greater than 50 percent of participants. The VR intervention under investigation needed to be delivered through a head-mounted display (HMD) hardware system. This is the most widespread and affordable form of immersive VR technology.^21,44,45,48 Empirical studies of all research designs (e.g., randomized controlled trials [RCT], nonrandomized studies, quantitative descriptive studies) and all comparators (e.g., waitlist control, active intervention, no treatment concurrent control) were included. This criterion was set to ensure that the review was comprehensive. The studies were required to report on empirical outcomes obtained from any standardized measure indicative of psychological distress (e.g., depression, anxiety, traumatic stress, anger, frustration, or other negative mood states). This criterion was set to ensure the psychometric validity and reliability of the reported VR intervention outcomes and to ensure a broad range of potential distress-related conditions were included. Articles were restricted to those written in the English language and published in peer-reviewed journals from January 2005 up to June 2020. This time frame was set to ensure that modern VR technology was evaluated.²¹

Article selection

After de-duplicating search results, two researchers (J.K. and B.R.) scanned the remaining article titles and abstracts. Promising articles were retained for full-text appraisal. Study inclusion was then determined by both researchers using the eligibility criteria. Divergent views on inclusion were resolved through discussion and mutual agreement.

Data extraction

Data from included studies were extracted by one reviewer (J.K.) into a standardized coding sheet and then checked by a second reviewer (B.R.). Data items extracted for synthesis included the following: 1.

Reference source: first author surname, year of publication, and title.

Participants: distress issue, clinical status, sample size, age, sex, and country.

Methodology: study design, comparator trial arms, measurement points, and study quality rating.

VR intervention: name, software, hardware, treatment purpose, treatment length, and therapist guidance.

Treatment efficacy: distress measures, outcomes, and effect sizes.

User engagement: attrition rate, treatment satisfaction, and intention-to-treat analysis.

Attrition in this review was defined and measured as the relative number of participants who completed the pretest measurements but did not complete the post-test measurements for the active VR treatment phase.

Quality assessment

This systematic review included non-RCT studies. Therefore, the Mixed Methods Appraisal Tool was used to assess the quality of all included studies.⁴⁹ This critical appraisal tool can assess methodological quality across five study categories: RCT, nonrandomized studies, quantitative descriptive studies, qualitative studies, and mixed-methods studies.

Data analysis

A narrative synthesis approach was used to describe the findings of this systematic review. This is due to the small number of included papers and their heterogeneity on key data items (e.g., methodology, measures, comparators, and outcomes).

Results

Study selection

The literature search yielded 2,150 papers. A total of 1,457 records remained after duplicate removal. Of these records, seven met the eligibility criteria (Fig. 1).

FIG. 1.

Flowchart of systematic review search results.

Participant characteristics

Four of the VR studies were from the United States and one each from Iran, Norway, and Netherlands (Table 1). Nearly all participants were aged between 10 and 19 years. However, the Gold and Mahrer⁵⁰ study had a small number of participants aged 20–21years (16/143, 11 percent of sample) that were defined as adolescents by the authors as they were attending a Children's Hospital. Across all studies, sample sizes ranged from 8 to 143 participants (median of 41). Participants were mainly female with an average sample proportion of 65.6 percent (range 12.5 to 100 percent). Each study focused on a unique distress-related issue. Four studies tested VR therapy on clinical samples, consisting of adolescents with various clinical diagnoses of mental disorders^51,52 and medical conditions,^50,53 whereas the remaining three studies tested VR with nonclinical samples.^54–56 Clinical diagnoses included attention-deficit/hyperactivity disorder, autism spectrum disorder, reactive attachment disorder, oppositional defiant disorder, personality disorder, social anxiety disorder, eating disorder, and cancer (i.e., osteosarcoma, Ewing's sarcoma, brain tumors, ovarian cancer, and skeletal muscle cancer.

Table 1.

Description of Participants and Research Designs in Reviewed Studies

First author (year)	Country	Problem	N ^a	Mean age (SD) in years	Age range in years	Females in total sample, n^b (%)	RCT	Trial arms (n)	Design	Measurements
Bossenbroek (2020)⁵¹	Netherlands	State-anxiety	8	14.7 (1.83)	12.9–17.3	1 (12)	No	VR (8)	BC	ABAB phases
Gold (2018)⁵⁰	United States	Venepuncture (blood draw)	143	15.4 (3.13)	10–21	72 (50)	Yes	VR+SC (70); SC (73)	WG; BG	Pre, Post
Hadley (2019)⁵⁴	United States	Risk-taking behavior	85	12.9 (0.86)	12–15	46 (54)	Yes	VR+ER (44); RP+ER (41)	WG; BG	Pre, 3-month Post
Kahlon (2019)⁵⁵	Norway	Public speaking anxiety	27	14.2 (0.64)	13–16	21 (78)	No	VR (27)	WG	1-week Pre, 1-week Post, 1-month FU, 3-month FU
Parrish (2015)⁵²	United States	Social anxiety disorder	41	16 (1.65)	13–18	27 (65)	No	SA (20); Non-SA (21)	WG; BG	One for each condition
Rowe (2015)⁵⁶	United States	Sexual victimization	83	15.6 (0.95)	14–18	83 (100)	Yes	VR (47); WLC (36)	WG; BG	1-week Pre, 1-month Post, 2-month FU, 3-month FU
Sharifpour (2020)⁵³	Iran	Chemotherapy	30	14.9 (2.1)	14–18	30 (100)	Yes	VR+SC (15); SC (15)	WG; BG	Pre, Post, 1-week FU, 1-month FU

Refers to total number of participants in the study.

Refers to number of participants.

ABAB, baseline (A), intervention (B), withdrawal or no intervention (A), intervention (B); BC, between-cases; BG, between-groups; ER, emotion regulation; FU, followup; Post, post-test; Pre, pretest; RCT, randomized controlled trial; RP, role-play; SA, socially anxious; SC, standard care; VR, virtual reality; WG, within-groups; WLC, waitlist control.

Research designs

Table 1 shows that four studies used RCT designs. Control groups consisted of standard care (n = 2), waitlist (n = 1), and role-play intervention (n = 1). The chemotherapy study by Sharifpour et al.⁵³ has been classified as an RCT in this review. The authors confirmed in e-mail correspondence that participants were randomly assigned, with the control group receiving the same standard of care as the intervention group but without the VR component. The remaining three studies were uncontrolled pilot studies. Five studies reported between-group analyses, six studies reported within-group analyses, and one study reported between-cases analyses on their respective measures. Pretest and post-test assessments were used in five studies, with three of these studies also having followup assessments ranging from 1 week to 3 months.

Details of the VR interventions

All studies tested a unique VR intervention (Table 2). Six studies made use of interactive virtual environments that were custom-built for their intended treatment purpose. The remaining study used a passive VR film to distract participants during chemotherapy.⁵³ Treatment purposes included distraction, relaxation, exposure therapy, and psychological skill training. Across all studies, treatment ranged from 1 to 8 sessions, with a mode of 1. The time length of each session ranged from 5 minutes to 2.5 hours. A facilitator was present in all sessions to help guide the adolescent participants. All studies used a unique HMD configuration.

Table 2.

Details of the Virtual Reality Interventions and Their User Engagement Outcomes

First author (year)	Software	Purpose	Length	Headset	Attrition (%)	Engagement measures	Engagement outcomes
Bossenbroek (2020)⁵¹	DEEP, a VR environment of an underwater world	Relaxation	6 sessions (15 minutes each; over 4-weeks)	HTC Vive	0/8 (0)	—	—
Gold (2018)⁵⁰	Bear Blast, a VR environment with bears and a firing cannon	Distraction	1 session (5 minutes)	Samsung Gear VR with Galaxy S6 for users 10 to 12 years old. Merge VR with Google Pixel for users 13 to 21 years old.	2/72 (2.8)	NSQ	High immersion and high satisfaction reported. 92 percent reported no simulator sickness.
Hadley (2019)⁵⁴	VR environments of adolescent party, condom purchasing, sexual negotiation, and HIV/STD testing	Emotion regulation training	4 sessions (2 hours each; 1 per week)	Sony HMD	2/46 (4.3)	NSQ	High acceptability, high attendance, and no simulator sickness reported.
Kahlon (2019)⁵⁵	VR environments of lobby, empty classroom, and classroom with virtual students	Exposure therapy	1 session (2 to 2.5 hours)	Cardboard-type VR headset with Apple iPhone.	2/27 (7.4)	GPQ	No moderating effect from presence found.
Parrish (2015)⁵²	VR environments of fish gallery, party scene, public speaking scene	Exposure therapy	1 session (20 minutes)	VFX-3D tracker helmet	0/41 (0)	PQ	Acceptable presence reported.
						NSQ	Acceptable immersion reported.
Rowe (2015)⁵⁶	My Voice, My Choice, a VR environment with three sexually coercive scenes	Assertive resistance training	1 session (90 minutes)	eMagin VR headset	5/47 (10.6)	NSQ	High satisfaction and moderate engagement reported.
Sharifpour (2020)⁵³	Ocean Journey, a film of traveling along a beach and into the ocean	Distraction	8 sessions (30 minutes each; 1 per week)	Samsung Gear VR with Note 8 mobile device.	0/15 (0)	—	—

—, not applicable; GPQ, Gatineau Presence Questionnaire; HMD, head-mounted display; NSQ, nonstandardized questions; PQ, Presence Questionnaire.

User engagement with the VR interventions

The average attrition rate was 3.6 percent across all studies in the active VR treatment phase, with a range of 0 to 10.6 percent (Table 2). One study reported the use of an intention-to-treat analysis.⁵⁶ Most studies used nonstandardized questions on VR user experience factors of presence, satisfaction, acceptability, attendance, simulator sickness, and engagement. However, two studies used standardized measures on VR user presence.^52,55 These measures included the Gatineau Presence Questionnaire⁵⁷ and a modified version of the Presence Questionnaire.⁵⁸ Two studies did not report on user engagement factors.^51,53

Psychological distress measures and outcomes

Details of the psychological distress measures and their VR treatment outcomes in the reviewed studies are summarized in Table 3. Measures included the Visual Analogue Scale,⁵⁹ Facial Affective Scale,⁵⁹ Spielberger State-Trait Anxiety Inventory,⁶⁰ Affect Dysregulation Scale,⁶¹ Emotional Self-Efficacy,⁶² Public Speaking Anxiety Scale,⁶³ Subjective Units of Distress Scale,⁶⁴ Trauma Symptom Checklist,⁶⁵ Pain Anxiety Symptoms Scale,⁶⁶ Pain Catastrophizing Scale,⁶⁷ and the “Lack of Emotional Awareness” and “Difficulty Accessing Emotion Strategies” subscales from the Difficulties in Emotional Regulation Scale.⁶⁸ The VR treatment effect sizes across all studies that reported them ranged from small to large in magnitude.

Table 3.

Details on Study Psychological Distress Measures and Reported Outcomes

First author (year)	Measures	Treatment outcomes
Bossenbroek (2020)⁵¹	STAI	Small reduction in daily state anxiety from VR use (BC-SMD: −0.29).
Gold (2018)⁵⁰	FAS	Significantly less worry and bother related to pain from venepuncture in VR group compared with standard care group.
Gold (2018)⁵⁰	VAS-A	Significantly less procedural anxiety from venepuncture in VR group compared with standard care group.
Hadley (2019)⁵⁴	DEA	Significantly less (d = −0.50) emotional awareness difficulty in VR group at 3-month followup.
	DAES	Significantly less (d = −0.46) difficulty in accessing emotion regulation strategies in VR group compared with role-play group at 3-month followup.
	ESE	Significantly higher (d = 0.20) emotional self-efficacy in VR group compared with role-play group at 3-month followup.
	ADS	No significant difference in affect dysregulation in VR group compared with role-play group at 3-month followup.
Kahlon (2019)⁵⁵	PSAS	Large reduction (d = −1.53) in public speaking anxiety from pre- to post-treatment that was maintained at both 1- and 3-month followups.
Parrish (2015)⁵²	SUDS	Large increase in subjective units of distress during VR scenes of public speaking (d = 1.13) and party (d = 0.87).
Rowe (2015)⁵⁶	TSC	The VR use is significantly associated with lower psychological distress for participants with greater prior victimization.
Sharifpour (2020)⁵³	PASS	Significantly less (η_p²: 0.95) pain anxiety symptoms from chemotherapy in VR group compared with standard care group.
Sharifpour (2020)⁵³	PCS	Significantly less (η_p²: 0.82) pain catastrophizing from chemotherapy in VR group compared with standard care group.

ADS, Affect Dysregulation Scale; BC-SMD, between-case standardized mean difference; d, Cohen's d effect size; DAES, Difficulty Accessing Emotion Strategies; DEA, Difficulty in Emotional Awareness; ESE, Emotional Self-Efficacy; FAS, Facial Affective Scale; PCS, Pain Catastrophizing Scale; PASS, Pain Anxiety Symptoms Scale; PSAS, Public Speaking Anxiety Scale; STAI, State-Trait Anxiety Inventory; SUDS, Subjective Units of Distress; TSC, Trauma Symptom Checklist; VAS-A, Visual Analogue Scale-Anxiety; η_p², partial eta-squared.

Quality assessment results

The included studies were quality assessed with the Mixed-Methods Appraisal Tool criteria. In all four RCT studies,^50,54,56,53 randomization was appropriately performed, and participants reportedly adhered to their assigned VR intervention. Except for Sharifpour et al.,⁵³ all RCT studies reported comparable baseline group analyses, and complete outcome data were defined as ≥80 percent. Only the RCT study by Gold and Mahrer⁵⁰ had blinding of outcome assessors, which was applied at pretest measurements. In the three quantitative descriptive studies,^51,55,52 the sampling strategy was relevant to the research question, measures fulfilled inclusion criteria, nonresponse bias was low, and statistical analyses were appropriate. However, nonprobability sampling was used in these studies. It is also uncertain whether the adolescents sampled in the Parrish et al.⁵² study for condition assignment were representative of those with social anxiety disorder due to the use of self-report measure scores rather than clinical diagnoses from a mental health professional.

Discussion

This review identified a low number of studies specifically directed at adolescents, with most previous studies using mixed age samples^23,39,40 and at the time of writing is the first review so to do. Psychological distress is a prevalent and debilitating issue among adolescents,^1–4 and it is important to identify and manage. Due to profound neurocognitive and psychosocial developmental differences between adolescents and these other life stages,⁴¹ as well as rapid advancements in VR technology,^21,44,45 this systematic review sought to provide a contemporary account on the impact of VR for managing psychological distress in adolescent samples. The included studies show that in various settings and contexts, VR interventions can quickly reduce negative symptoms as well as improve self-efficacy and access to emotion regulation strategies for specific adolescent populations.

Each study in this review pioneered a new VR intervention that made use of a unique HMD setup and software program. The VR hardware devices used in all included studies are affordable and commercially available for public use. Further, both active (e.g., playing an interactive game)⁵⁰ and passive (e.g., watching a film)⁵³ VR experiences were therapeutic for distressed adolescents. This implies that it may not be necessary to acquire expensive hardware, or build elaborate interactive virtual worlds, to achieve positive therapy outcomes with adolescents using VR.

The VR interventions were shown to be efficacious for distressed adolescents when delivered in a hospital,⁵⁰ research laboratory,⁵² chemotherapy clinic,⁵³ and school,^51,54,56 indicating the adaptability of VR technology to multiple settings. The large effect sizes found from the adolescent VRET feasibility studies^52,55 mirror the outcomes of adult VRET studies on social anxiety disorder and performance anxiety.²⁶ These findings suggest that the adolescents found the VR environments to be analogous to real-world settings and emotionally evocative. Given the prevalence of mental health concerns during adolescence, the fact that VR can effectively impart psychoeducation and mental health skill training to help adolescents manage distressing situations is of particular interest. Adolescents were able to learn and practice adaptive behaviors on emotion regulation⁵⁴ and assertive resistance.⁵⁶

The data on distraction during medical procedures is reassuring and results are similar in children and adults,²³ indicating that any outlay on equipment is likely to be cost-effective for health services. The VR treatment also appears to provide rapid relief from psychological distress. In four of the studies, a single session varying from 5–150 minutes was sufficient to induce positive results for distress related to exposure therapy,⁵⁵ distraction,⁵⁰ and assertive resistance to victimization.⁵⁶

When consumer response was undertaken, adolescents rated their VR experiences favorably and reported little-to-no simulator sickness. Four reviewed studies screened out adolescents who reported a history of health issues, such as seizures and audio–visual impairments, from participation.^50,52,54,55 The attrition rate appeared lower than adult studies.^29,36 This suggests that adolescents may, indeed, find VR more engaging than adults and lends support to the almost universal assumption that adolescents will naturally respond positively to digital technologies.

Our conclusions are limited by the low study and participant numbers, the heterogeneity of methods between the RCTs and uncontrolled pilot studies, most participants being from a single country setting, and variable outcome indicators. Currently, there is no single suite of empirically validated VR tools to measure the effectiveness of this treatment for adolescent psychological distress. There is also comparatively more adult VR therapy research on other distress-related conditions that also affect adolescents, such as panic disorder, fear of flying, spider phobia, eating disorders, and post-traumatic stress disorder.^26,29,37 Further, the adult data show that VR therapy effects can be sustained up to 12 months with little to no symptom deterioration.³⁷ Despite rapid advancements in VR technology posing a challenge for longitudinal intervention studies, followup periods greater than 3 months are still required to ascertain the duration of effects and whether VR could be considered a medium- to long-term management modality for adolescents, rather than just an acute intervention. Evaluating user experience factors with standardized measures (e.g., System Usability Scale) would help verify which VR devices, software environments, and therapeutic activities are preferred by adolescents, caregivers, and clinicians.

The paucity of studies precluded the capacity to perform a meta-analysis on VR treatment effects. Our methodology excluded conference handouts or gray literature. It is also possible that some VR intervention studies may have been missed due to nomenclature. For instance, a computer game may be playable in VR but may not have been described as a VR intervention.⁴⁴ In addition, the review focus was on HMDs, and it did not include other immersive technologies such as cave automatic virtual environments.⁴⁸

Conclusion

In summary, all studies reported benefits when using VR to manage psychological distress in adolescents and these benefits occurred across a range of treatment scenarios. One therapeutic modality serving multiple purposes is very attractive for clinical use. Adolescent participants rated their VR experience favorably, and low attrition rates were reported across all studies. However, conclusions on the effectiveness of VR in managing adolescent distress are limited by the lack of high-quality controlled studies, and the heterogeneity found in existing ones. It is unclear how effective VR interventions will be for moderate to long-term use, how they compare with other available treatment methods, and their appropriateness for adolescents across all distress-related issues and backgrounds. Therefore, more experimental studies of high methodological rigor (e.g., RCT) are required. Nevertheless, these preliminary findings suggest that VR is a valuable treatment modality for adolescent psychological distress. Moving forward, there are many opportunities for future VR studies to build on this empirical foundation.

Footnotes

Acknowledgments

This project was resourced by the Wellbeing Health & Youth Centre of Research Excellence in Adolescent Health, funded by the National Health and Medical Research Council (NHRMC).

Authors' Contributions

All authors have reviewed and approved of this article.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Jaisoorya

, Desai

, Beena

, et al. Prevalence and correlates of psychological distress in adolescent students from India. East Asian Archives of Psychiatry, 2017; 27:56–62.

, Salcuni

, Delvecchio

. Meaning in life, self-control and psychological distress among adolescents: a cross-national study. Psychiatry Research, 2019; 272:122–129.

Lin

, Yusoff

MSB

. Psychological distress, sources of stress and coping strategy in high school students. International Medical Journal, 2013; 20:672–676.

Mewton

, Kessler

, Slade

, et al. The psychometric properties of the Kessler Psychological Distress Scale (K6) in a general population sample of adolescents. Psychological Assessment, 2016; 28:1232–1242.

Drapeau

, Marchand

, Beaulieu-Prevost

. (2011) Epidemiology of psychological distress. In: L' Abate

, ed. Mental illnesses—understanding, prediction and control. Rijeka, Croatia: InTech, pp. 105–134.

Ohayashi

, Shuji

, eds. (2012) Psychological distress: symptoms, causes, and coping. Hauppauge, NY: Nova Science Publishers.

Ferro

MA.

Adolescents and young adults with physical illness: a comparative study of psychological distress. Acta Paediatrica, 2014; 103:e32–e37.

Marum

, Clench-Aas

, Nes

, et al. The relationship between negative life events, psychological distress and life satisfaction: a population-based study. Quality of Life Research, 2014; 23:601–611.

Thomas

, Chan

, Scott

, et al. Association of different forms of bullying victimisation with adolescents' psychological distress and reduced emotional wellbeing. Australian & New Zealand Journal of Psychiatry, 2016; 50:371–379.

10.

Burke

, Sanson

, Hoorn

. The psychological effects of climate change on children. Current Psychiatry Report, 2018; 20:1–8.

11.

Wang

, Meng

, Lam

, et al. Green space and serious psychological distress among adults and teens: a population-based study in California. Health Place, 2019; 56:184–190.

12.

Schulman

, Smith

, Silva

, et al. The dual systems model: review, reappraisal, and reaffirmation. Developmental Cognitive Neuroscience, 2016; 17:103–117.

13.

Williams

, Zahka

. (2017) Treating somatic symptoms in children and adolescents. New York, NY: Guilford Press.

14.

Sampasa-Kanyinga

, Willmore

. Relationship between bullying victimization psychological distress and breakfast skipping among boys and girls. Appetite, 2015; 89:41–46.

15.

Sampasa-Kanyinga

, Chaput

, Hamilton

, et al. Bullying involvement, psychological distress, and short sleep duration among adolescents. Social Psychiatry and Psychiatric Epidemiology, 2018; 53:1371–1380.

16.

, Stewin

, Mah

. Bullying in school: nature, effects and remedies. Research Papers in Education, 2001; 16:247–270.

17.

Schneider

, O'Donnell

, Stueve

, et al. Cyberbullying, school bullying, and psychological distress: a regional census of high school students. American Journal of Public Health, 2012; 102:171–177.

18.

Das

, Salam

, Lassi

, et al. Interventions for adolescent mental health: an overview of systematic reviews. Journal of Adolescent Health, 2016; 59(4S):S49–S60.

19.

Bell

, Nicholas

, Alvarez-Jimenez

, et al. Virtual reality as a clinical tool in mental health research and practice. Dialogues in Clinical Neuroscience, 2020; 22:169–177.

20.

Freeman

, Reeve

, Robinson

, et al. Virtual reality in the assessment, understanding, and treatment of mental health disorders. Psychological Medicine, 2017; 47:2393–2400.

21.

Sherman

, Craig

. Understanding virtual reality: interface, application, and design. 2nd ed. Cambridge, US: Morgan Kaufmann Publishers, 2019.

22.

Birnie

, Noel

, Parker

, et al. Systematic review and meta-analysis of distraction and hypnosis for needle-related pain and distress in children and adolescents. Journal of Pediatric Psychology, 2014; 39:783–808.

23.

Indovina

, Barone

, Gallo

, et al. Virtual reality as a distraction intervention to relieve pain and distress during medical procedures. The Clinical Journal of Pain, 2018; 34:858–877.

24.

Anderson

, Mayer

, Fellows

, et al. Relaxation with immersive natural scenes presented using virtual reality. Aerospace Medicine and Human Performance, 2017; 88:520–526.

25.

Falconer

, Davies

, Grist

, et al. Innovations in practice: avatar-based virtual reality in CAMHS talking therapy: two exploratory case studies. Child and Adolescent Mental Health, 2019; 24:283–287.

26.

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.

27.

Goncalves

, Pedrozo

, Coutinho

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

28.

Powers

, Emmelkamp

. Virtual reality exposure therapy for anxiety disorders: a meta-analysis. Journal of Anxiety Disorders, 2008; 22:561–569.

29.

Valmaggia

, Latif

, Kempton

, et al. Virtual reality in the psychological treatment for mental health problems: an systematic review of recent evidence. Psychiatry Research, 2016; 236:189–195.

30.

Nichols

, Patel

. Health and safety implications of virtual reality: a review of empirical evidence. Applied Ergonomics, 2002; 33:251–271.

31.

Costello

(1997) Health and safety issues associated with virtual reality: a review of current literature. Loughborough, UK: Advisory Group on Computer Graphics.

32.

North

, North

. (2016) Virtual reality therapy. In Luiselli JK, Fischer AJ, eds. Computer-assisted and web-based innovations in psychology, special education, and health. San Diego, CA: Academic Press.

33.

Okudan

, Özkara

. Reflex epilepsy:triggers and management strategies. Neuropsychiatric Disease and Treatment, 2018; 14:327–337.

34.

Saredakis

, Szpak

, Birckhead

, et al. Factors associated with virtual reality sickness in head-mounted displays: a systematic review and meta-analysis. Frontiers in Human Neuroscience, 2020; 14:96–113.

35.

Weech

, Kenny

, Barnett-Cowan

. Presence and cybersickness in virtual reality are negatively related: a review. Frontiers in Psychology, 2019; 10:158–177.

36.

Benbow

, Anderson

. A meta-analytic examination of attrition in virtual reality exposure therapy for anxiety disorders. Journal of Anxiety Disorders, 2019; 61:18–26.

37.

Fernández-Álvarez

, Rozental

, Carlbring

, et al. Deterioration rates in virtual reality therapy: an individual patient data level meta-analysis. Journal of Anxiety Disorders, 2019; 61:3–17.

38.

Zeng

, Pope

, Lee

, Gao

. Virtual reality exercise for anxiety and depression: a preliminary review of current research in an emerging field. Journal of Clinical Medicine, 2018; 7:42–54.

39.

Kothgassner

, Felnhofer

Lack of research on efficacy of virtual reality exposure therapy (VRET) for anxiety disorders in children and adolescents: a systematic review. Neuropsychiatry 2020. [Epub ahead of print]; DOI: 10.1007/s40211-020-00349-7.

40.

Morris

, Louw

, Grimmer-Somers

. The effectiveness of virtual reality on reducing pain and anxiety in burn injury patients. Clinical Journal of Pain, 2009; 25:815–826.

41.

Meeus

(2018) Adolescent development: longitudinal research into the self, personal relationships, and psychopathology. New York, NY: Routledge.

42.

Collishaw

Annual research review: secular trends in child and adolescent mental health. Journal of Child Psychology and Psychiatry, 2015; 56:370–393.

43.

Merikangas

, He

, Burstein

, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the national comorbidity survey replication-adolescent supplement (NCS-A). Journal of American Academy of Child & Adolescent Psychiatry, 2010; 49:980–989.

44.

Howard

MC.

Virtual reality interventions for personal development: a meta-analysis of hardware and software. Human-Computer Interaction, 2018; 34:205–239.

45.

Jerdan

, Grindle

, van Woerden

, et al. Head-mounted virtual reality and mental health: critical review of current research. JMIR Serious Games, 2018; 6:e14.

46.

Moher

, Liberati

, Tetzlaff

, et al., PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Medicine, 2009; 6:e1000097.

47.

World Health Organization. Adolescent health. Who.Int. https://www.who.int/health-topics/adolescent-health/#tab=tab_1 (accessed May 28, 2020).

48.

Slater

, Sanchez-Vives

. Enhancing our lives with immersive virtual reality. Frontiers in Robotics and AI, 2016; 3:1–47.

49.

Hong

, Pluye

, Fàbregues

, et al. Mixed Methods Appraisal Tool (MMAT), version 2018. Mixedmethodsappraisaltoolpublic.pbworks. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/127916259/MMAT_2018_criteria-manual_2018-08-01_ENG.pdf. [updated 2018-08-01] (accessed June 17, 2020).

50.

Gold

, Mahrer

. Is virtual reality ready for prime time in the medical space? A randomized control trial of pediatric virtual reality for acute procedural pain management. Journal of Pediatric Psychology, 2018; 43:266–275.

51.

Bossenbroek

, Wols

, Weerdmeester

, et al. Efficacy of a virtual reality biofeedback game (DEEP) to reduce anxiety and disruptive classroom behavior: single-case study. JMIR Mental Health, 2020; 7:e16066.

52.

Parrish

, Oxhandler

, Duron

, et al. Feasibility of virtual reality environments for adolescent social anxiety disorder. Research on Social Work Practice, 2015; 26:825–835.

53.

Sharifpour

, Manshaee

, Sajjadian

. Effects of virtual reality therapy on perceived pain intensity, anxiety, catastrophising and self-efficacy among adolescents with cancer. Counselling and Psychotherapy Research, 2020; 1–9. [Epub ahead of print]; DOI: 10.1002/capr.12311.

54.

Hadley

, Houck

, Brown

, et al. Moving beyond role-play: evaluating the use of virtual reality to teach emotion regulation for the prevention of adolescent risk behavior within a randomized pilot trial. Journal of Pediatric Psychology, 2019; 44:425–435.

55.

Kahlon

, Lindner

, Nordgreen

. Virtual reality exposure therapy for adolescents with fear of public speaking: a non-randomized feasibility and pilot study. Child and Adolescent Psychiatry and Mental Health, 2019; 13:47.

56.

Rowe

, Jouriles

, McDonald

. Reducing sexual victimization among adolescent girls: a randomized controlled pilot trial of My Voice, My Choice. Behavioral Therapy, 2015; 46:315–327.

57.

Laforest

, Bouchard

, Cretu

, et al. Inducing an anxiety response using a contaminated virtual environment: validation of a therapeutic tool for obsessive-compulsive disorder. Frontiers in ICT, 2016; 3:1–11.

58.

Witmer

, Singer

. Measuring presence in virtual environments: a presence questionnaire. Presence (Camb), 1998; 7:225–240.

59.

McGrath

, De Veber

, Hearn

. (1985) Multi-dimensional pain assessment in children. In: Fields

, Dubner

, Cervero

, eds. Advances in pain research and therapy, volume 9: Proceedings of the Fourth World Congress on Pain. New York, NY: Raven Press Books, pp. 387–393.

60.

Marteau

, Bekker

. The development of a six-item short form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). British Journal of Clinical Psychology, 1992; 31:301–306.

61.

Brown

, Houck

, Lescano

, et al. Affect regulation and HIV risk among youth in therapeutic schools. AIDS and Behavior, 2012; 16:2272–2278.

62.

Muris

Relationships between self-efficacy and symptoms of anxiety disorders and depression in a normal adolescent sample. Personality and Individual Difference, 2002; 32:337–348.

63.

Bartholomay

, Houlihan

. Public Speaking Anxiety Scale: preliminary psychometric data and scale validation. Personality and Individual Difference, 2016; 94:211–215.

64.

Wolpe

(1990) The practice of behavior therapy. 4th ed. New York, NY: Pergamon Press.

65.

Elliott

, Briere

. Sexual abuse trauma among professional women: validating the Trauma Symptom Checklist-40 (TSC-40). Child Abuse & Neglect, 1992; 16:391–398.

66.

McCracken

, Dhingra

. A short version of the Pain Anxiety Symptoms Scale (PASS-20): preliminary development and validity. Pain Research & Management, 2002; 7:45–50.

67.

Sullivan

, Bishop

, Pivik

. The pain catastrophizing scale: development and validation. Psychological Assessment, 1995; 7:524–532.

68.

Schutte

, Malouff

, Hall

, et al. Development and validation of a measure of emotional intelligence. Personality and Individual Difference, 1998; 25:167–177.