# High-Functioning Autism and Virtual Reality Applications: A Scoping Review
## 4 Discussion  
The present study aimed to provide literature mapping of experimental studies that involve immersive VR for HF ASD assessment and intervention. Virtual reality applications are emerging in clinical settings that can be paired with existing intervention treatments and actual assessment practices, offering therapists wider control and customization of content and patients a safer and more private context in which to be exposed [69]. Also, VR offers the possibility of generating realistic environments where users can experience a sense of immersion and its psychological consequences on perception, that is, the sense of presence [20]. Technology-based interventions are emerging, and several systematic reviews have been published to evaluate their effects on specific skills, but only the contribution of [17] focused on the effectiveness of VR-based interventions in ASD. This contribution, however, included only children and adolescents and did not specify the technological device, the degree of immersion, or the specifications of the overall clinical functioning in the spectrum. The papers included in the present scoping review were mainly based on HMD technology. This might be due to the fact that this technology offers different commercial solutions, some of them easily affordable for professionals or target users. Aside from economic aspects, VR headsets are portable and flexible solutions that do not need complex setups, allowing for at-home use. Also, HMD solutions offer a wide range of immersion in the virtual environment (360 degrees) and interactions endowing the user with motion-tracking systems. The majority of these studies were explorative, and only four studies were classified as true experiments. This trend was confirmed by a recent scoping review [33] discussing the need to implement randomized-controlled trials (RCTs) to better evaluate the effectiveness of VR interventions, as well as their reproducibility. Further studies with larger samplesand a solid research design are needed to bring more evidence and reduce research biases. Because VR technology-based interventions are an innovative approach to intervention, usability, safety, feasibility, and pilot studies in the form of quasi-experimental design are represented in the included studies [44; 47; 48; 52; 62; 63; 64], thus indicating that explorative research in this field is ongoing and still required before any clinical use. The novelty of this approach is also explained by the low number of participants in most of the studies and by the scarce presence of control groups [33]. Further investigations should consider the need for more consistent studies, alongside the significant need to encourage the free and informed participation of people with autism in the research process [70]: individuals on the spectrum might be vulnerable, especially those characterized by profound language and/or cognitive impairments. According to the model of person-oriented research ethics, it is possible to envision practical strategies to address ASD needs, especially when participants under legal age are involved in data collection, by providing information to create a predictable environment using different and alternative communication methods (e.g., visual support) and setting up the physical environment to address sensory sensitivities, as well as the social context, to increase predictability and control (e.g., punctuality; the familiarity of the researcher or the room setting). Also, it should be taken into account that ASD individuals might be key informants and, consequently, contribute actively to designing the research process by bringing their perspectives. Regarding the first and second research questions, to date, VR applications with high-functioning ASD individuals are promising, and it is relevant to understand the purposes they have been used for, individually and considering age groups. Confirming the evidence from recent literature reviews, social skills are the most targeted in ASD interventions.