Enhancing Emotion Regulation in Children With Autism Through Extended Reality

The majority of children with autism experience significant challenges in the domain of emotion regulation. These difficulties frequently result in conflict situations, bullying, school refusal, and increased stress for the child's social environment, particularly within the family and school context. Common therapeutic and coaching-oriented interventions are typically based on cognitive-behavioral therapy (CBT) approaches and include psycho-education, exposure techniques, and skills training. However, CBT-based interventions in children with ASD often yield only modest long-term effects. This limitation is partly attributed to the restricted generalisation of skills acquired within therapeutic settings to diverse/unpredictable real-life situations . Realistic and adaptive learning environments are therefore of critical importance for optimising learning outcomes in children with ASD-an opportunity increasingly enabled by technological advances in Virtual and Extended Reality systems.

Extended Reality (XR) is an umbrella term encompassing Virtual Reality (VR; fully immersive visual experiences), Augmented Reality (AR; real-world experiences enhanced with virtual or auditory stimuli), and the integration of biosignal parameters. High-quality simulations that allow for a substantial degree of immersion in the virtual environment are considered essential for generating therapeutically effective experiences and facilitating the internalisation of adaptive strategies.

In addition, digitally designed and gamified elements can enhance motivation-particularly in the acquisition of emotion regulation strategies, which are often associated with negative emotional experiences. Another notable advantage is that potentially hazardous real-life situations, such as crossing a street, can be practiced safely and in a stepwise, adaptive manner within XR environments.

To date, XR applications have primarily focused on training isolated skills, especially social competencies and emotion recognition. Only a limited number of studies have reported standardised outcome measures, sample sizes remain small, no formal guidelines for XR implementation currently exist, and independent replication trials of specifically developed XR paradigms are lacking. Recent technological advances, however, offer substantial potential for the development of standardised and methodologically comparable applications across independent clinical and research settings.

Few studies have systematically examined the transfer of XR-acquired skills into everyday life. One study investigated the transfer of breathing techniques into daily contexts and found that children with ASD successfully applied learned breathing patterns in anxiety-provoking situations. The use of XR systems is generally considered low-risk. In some cases, symptoms of "cybersickness" (e.g., nausea, dizziness, headaches) may occur; however, individual risk and symptom manifestation can be systematically assessed before and during application

Inclusion criteria

• Diagnosis of Autism Spectrum Disorder (ASD), without sensory impairments.
• Sufficient German language proficiency of both children and parents to enable participation in the training (German instructions and explanations) and valid completion of questionnaires.
• Inclusion of children presenting with behavioral problems.

Exclusion criteria

• Children whose families do not consent to anonymized data processing.
• Children whose families do not consent to the transmission of video-based recordings of everyday stressors for integration into the XR training.
• Children with an IQ < 85.