Virtual Reality Victories for Special Populations

Dec 22/Jan 23 Closing The Gap Solutions - Collaborating With Augmentative and Alternative Communication (AAC) Users Gains A New Perspective To Best Support Clients By Lydia Dawley

Virtual Reality Victories for Special Populations instruction, literacy & inclusion Summary: Practice makes possible. Floreo is an FDA-approved, evidence-based virtual reality platform that helps neuro- diverse individuals build social and daily living skills in safe, real-world scenarios. The author will share early impressions and observations of VR with special needs learners, introduce the Floreo platform, and address common concerns about headset use. Stories from a speech-language pathologist, a special education teacher, and a parent will illustrate Floreo’s impact across different users.

Figure 1: This image was generated using AI. It represents a child engaging in a VR lesson, while an adult monitors his progress via a tablet, providing guidance and encouragement to ensure success.

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PRACTICE MAKES PROGRESS The first time I witnessed virtual reality’s potential to reach and teach students with special needs, my heart melted. It was 2017, and Floreo, the virtual reality (VR) startup company I had joined, was launching its first pilot study. Our mission was to de- velop learning opportunities in VR to help autistic individuals. Toward that end, our small team had been building lessons for about a year, but we were seeking some confirmation that what we had created in VR would be safe, engaging, and useful. For this pilot study, Floreo partnered with a self-contained, special education school in New Jersey, called Celebrate the Children, and recruited 12 students between the ages of 9 and 16, most of whom were either non-speaking or minimally ver- bal. We developed a 5-week study to discover if the students would tolerate wearing the headset and to explore the effects of the lessons. At the mid-study point, we were allowed to review some of the compelling video footage collected. Small gestures and responses implied big steps in engagement and cognition. One student reached out to try to touch the animated giraffe in a scene. Another student stopped her self-stimulatory behavior as soon as the googles went on. The students were engaged and happy to participate. Having worked with students of similar profiles, I felt deep appreciation for a tool that is both accessible to and empowering for these students. That same year, Floreo developed a partnership with Chil- dren's Hospital of Philadelphia (CHOP) at their Center for Autism Research to create a different type of meaningful content. We applied for and were awarded an NIH grant to study whether practicing in virtual reality could be beneficial for autistic indi- viduals who might someday have an unexpected encounter with a police officer. This study was conducted with more verbal- ly fluent individuals. Once again, the feedback from participants was quite positive. With these individuals, we collected specific feedback about their experiences: • “It was really cool and I learned how to talk to cops. I felt more confident at the end.” (15-year-old male) • “It took a little bit to finally feel comfortable, but once I was in, I felt like I was there on the street. I felt like I was inter- acting with someone… I felt like I was talking to a police officer...” (27-year-old male) • “It was a positive experience. I enjoyed it once again and found it very interesting and kind of cool.” (20-year-old

male) • “Pretty good and feel prepared to talk to a police officer.” (12-year-old female) • “I was a little scared of police officers at first, but then got used to it and felt good.” (15-year-old male) One of the more compelling aspects of virtual reality is that it is a medium that can be equally impactful for vastly different profiles of individuals. Since 2017, Floreo has expanded its tar- get audience to the neurodiverse, or anyone in need of practice with social interactions and other practical skills. The ever-grow- ing content library continues to engage children and adults who wear the headset, as well as the support teams who implement the lessons. (Publications resulting from these two research efforts are the last two bullet points in the studies listed at the end of this article. Floreo's research page cites additional publications.) HOW DOES FLOREO WORK? Floreo is a virtual reality (VR) platform especially designed to support neurodiverse individuals in developing and refining a broad range of social interaction, emotional regulation, and life skills. In these immersive VR experiences, the individual wearing the VR goggles (the "Learner") is immediately transported to a relevant environment, such as a movie theater or a school cafe- teria, and interacts with objects and characters. Simultaneously, another individual, such as a clinician, teacher, paraprofessional, or caregiver (referred to as the "Coach") views what the Learner is viewing in VR on a computer or a tablet. The Coach can guide the Learner to navigate the events safely and successfully. En- gagement and repetition build strong connections between learning and real-life implementation. Floreo is an easy tool to implement because it provides in- structions for the Coach that update in real time. While simple to operate, Floreo is not simplistic. It can become a sophisticated and powerful tool in the hands of a skilled professional.

RITA SOLÓRZAN0, MA, CCC-SLP is Director of Applied Digital Therapy at Floreo, Inc. Working as a Speech Language Pathologist since 1993, Rita has designed and delivered speech, language, literacy and social communication therapies primarily for students and clients between the ages of 2 and 22. She began working at Floreo in 2016, initially overseeing the development of VR curriculum designed to improve social and communi- cation skills. Currently, she supports those using VR lessons to improve the skills of their students and clients.

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Video 1 shows a view of the Coach's device while a lesson is running. The video includes the author's voiceover explain- ing how a Coach would utilize the features of the platform. The lesson featured here is designed to practice differentiating and responding to different types of greetings: friendly, unfriendly, and neutral.

In addition to allowing the Coach to witness what the Learner is seeing, the Coach view provides navigation and data collec- tion buttons. If the lesson is one that uses movement, the Coach can tap a button and transport the Learner to the next location. Additionally, the Coach uses the buttons to collect data. Behind the scenes, Floreo software is keeping a record of the events, ac- cessible to the Coach via the Floreo portal. Through the portal, the Coach can review the Learner's history and measure prog- ress. The portal allows for note-taking and for creating custom lesson plans that appear at the top of the screen when signing in to the Learner's profile. Lastly, the portal houses an artificial in- telligence tool that will create a lesson plan based on a descrip- tion of lessons that are specified.

See Figure 2 and Figure 3

BENEFITS OF VR FOR SKILL ACQUISITION With lessons constructed with input from clinicians, educa- tors, and researchers, Floreo offers VR lessons covering a wide range of real-world scenarios. Floreo's mission is to provide learning experiences to both children and adults at any devel- opmental level. Generally, the current content covers social in- teractions, communication, emotional regulation, daily living skills, and executive functioning skills. The company is actively developing new lessons and features to support the neurodi- verse community. The Learner interacts with the VR environment, but the Coach sets the pace. This is particularly useful when it comes to social interaction, since, in a social interaction, there are often so many transient signals (gestures, body language, voice tone, words) happening simultaneously that they can be difficult to interpret all in real time. When the Coach can reduce the speed of the interaction, have the VR character wait for as long as necessary while the Coach explains the events, the Learner has a greater opportunity to fully comprehend what is happening. Moreover, the Learner can repeat the exact same interaction or type of in- teraction as many times as needed. The immersive nature of a VR experience often limits outside distractions, allowing the Learner to focus on the important sights and sounds inside the VR goggles. The VR event is safe and predictable. The same cannot always be said when crossing a real street. The impulse control that may be needed when in the vicinity of a swimming pool is not an issue when the VR experience only allows the Learner to enter the virtual pool after reviewing all the rules. Floreo is able to en- gineer the environment to allow for early and often success.

YouTube Video 1: CoachDeviceView - A demonstration and explanation of how the Coach's device works. https://www.youtube.com/watch?v=701N3rTXnKI

The Floreo Learner device may be an all-in-one headset, or it may run on an iPhone running the Floreo app. Video 2 shows the iPhone running the app with a view of what the Learner would see. The sound (background sound and character dialogue) comes from the iPhone, but the Learner does not see any of the behind-the-scenes controls that are visible on the Coach's de- vice.

YouTube Video 2: LearnerDeviceView - Once the phone is placed in the plastic VR goggles, the two images become merged in the Learner's view. https://www.youtube.com/watch?v=2NeVGVKD_6c

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Figure 2: Sample page from the data section of the Floreo portal. This page shows some of the data for the lesson "Join a Conversation: Park"

Figure 3: In the portal, the Coach can predetermine a lesson plan by selecting the lessons that are most relevant to that Learner. These lessons appear at the top of the screen when that Learner profile is selected

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WILL MY LEARNER EVEN WEAR THE HEADSET? Before trying it out, a common concern about Floreo is whether a Learner with tactile sensitivities (especially around the head and face) or one who is generally apprehensive will wear the VR headset. The overwhelming majority of Floreo cus- tomers report success with their Learners wearing the headset. The estimate is that about 80-85% of the Learners who attempt the headset will wear it. There have even been anecdotal reports that some children who reject other objects on their heads, such as hats or glasses, are interested in wearing the VR goggles once they realize there is something fun to see and do while wearing the headset. The best advice is to start slowly using a VR experience that the Learner will enjoy and can navigate relatively independent- ly. Floreo has a 360-degree, gaze-activated marimba/xylophone that is often a good starting point for many Learners. As the Learner looks at the keys on the marimba, a tone will play and the key will light up. It is also important to keep the first VR experience very short (a minute or two) to ensure that the Learner is feeling well and is not experiencing any eye strain. Floreo has plenty of VR lessons that can be enjoyed and completed quickly, sometimes in under a minute. These can be good starter lessons. In most of the Floreo lessons, the Learner stays in one loca- tion in the scene. Learners will still have the ability to look in all directions and feel immersed, but there is much less of a chance of feeling queasy if Learners are stationary. After a few sessions, people typically become acclimated to the experience and can tolerate movement. In lessons where there is movement, the Learner's view moves, although the Learner can remain station- ary in the real world. Floreo is very careful that the movement in scenes such as street crossing or moving through the grocery store is not jarring. Similarly, Floreo has always been very careful about the kind of light and the colors that appear in the scenes. The Floreo website has information on what to watch for, tips and tricks on introducing the headset, as well as visual supports that can be used to help Learners communicate about their gen- eral well-being before and after VR. Resources are here. EQUIPMENT AND INTERNET ACCESS To use Floreo, a Learner device, a Coach device, and a wifi sig- nal are all needed. The wifi wirelessly connects the two devices. Learner device options: • iPhone 7 or more recent running iOS 15.0 or later, and any compatible Google Cardboard VR headset that fits your iPhone. This setup can be used by children as young as 5 years of age and can be used by Learners through adulthood. OR • a Meta Quest compatible headset. This may be used by anyone 10 years of age or older.

OR • a PICO Business compatible headset. This may be used by anyone 10 years of age or older. Coach device: Internet-connected device with a browser. The following browsers are compatible with Floreo: Safari, Chrome, Edge, and Firefox. Wifi — Please note: The Coach and Learner devices do not need to be on the same wifi signal. Floreo is tele-health ready, so that a Coach could run a session from an office computer, while connected to the Learner's device at home. Then, the Coach would interact with the Learner over a teleconference call, such as Zoom, Teams, or Google Meet. FLOREO CONTENT FROM DIFFERENT PERSPECTIVES Due to its immersive nature, Floreo's various lessons provide many hidden learning opportunities. The content can be viewed from a variety of angles, and the application of the platform may be seen differently depending on the background of the Coach reviewing it. For example, Floreo’s yoga lessons were de- veloped as an emotional regulation lesson, and a social worker or psychologist may implement them as such. An SLP may look at these lessons and capitalize on all of the listening compre- hension opportunities it offers, while an OT might use them as a motor imitation opportunity. The following are a few categories of lessons to consider: Non-speaking individuals: The lessons related to Communi- cative Eye Gaze (joint attention and precursor skills related to joint attention) are accessible to these Learners, because the Learner simply shifts gaze in response to a particular event, such as a pointing gesture or the character’s shift of eye gaze. Two of the imitation lessons (“Be a Copy Hero” and “Show 'Em What to Do”) only require an action on the Learner's part, with the Coach determining when the action was performed adequately, tapping a button for the lesson to continue. The early gestures lessons are based on a simple play narrative. In these lessons, Learners impact their environment by demonstrating commu- nicative gestures, such as pointing, waving come over, gesturing stop, etc. Non-speaking Learners can access many of the sensory experiences in the Emotional Regulation Skill Category, as well as engage with the street crossing lessons. Many of the other lessons can be adapted for use by non-speaking individuals. Us- ers of AAC may be able to use the conversation-based lessons if they tip the headset up briefly, engage their personal AAC de- vice, and then return to VR to continue the interaction. Motor skills: As mentioned above, the Yoga lessons, the mo- tor imitation lessons, and the communicative gestures lessons may be appropriate for learners who are working on motor tar- gets. Additionally, there is a "Crystal Cave" lesson in the emo- tional regulation category in which Learners are asked to open and close their hands, lift and lower their shoulders, and then raise and lower their toes.

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Social skills: There is an extensive curriculum focused on con- versational skills in the Floreo catalog, starting with greetings (differentiating between friendly, unfriendly, and neutral greet- ings) and progressing through small talk, chit-chat, and finally freeform conversations with an AI character. Of course, a variety of social interaction targets may be found throughout most of the lessons. Listening comprehension: Coaches may find a number of listening comprehension opportunities throughout the lessons; however, the VR learning experiences that focus on animals and nature are a treasure trove for this skill. Floreo has also built a se- ries of five lessons that target following directions of increasing length and complexity. The titles of these lessons all begin with the phrase, “Listen and Find”. Emotional regulation: Emotional regulation lessons range from serene, passive experiences (sitting in an aquarium, or sit- ting in a snowfall) all the way through guided meditation experi- ences in those environments. Breathing and body awareness are both emphasized in these lessons. The “Peaceful Painting” lesson encourages Learners to consider their emotional state prior to the VR experience and again following the VR experience. Community-based skills : A critical skill for gaining indepen- dence is understanding how to navigate the community. There- fore, Floreo has developed lessons on understanding how a grocery store is organized, finding a bus stop, navigating airport security, as well as street crossing in various environments and under various conditions. Employment readiness: Floreo partnered with the Tennes- see Department of Intellectual and Developmental Disabilities (DIDD) to develop lessons on workplace readiness. These les- sons take place in common work environments, such as a mov- ie theater concession counter and a grocery store. In the movie theater, Learners are asked to manage a to-do list with one- and two-step operations, sometimes in the presence of interrup- tions or distractions. In the grocery store, Learners are asked to interact with one or two coworker characters to complete a job. Safety skills: Safety skills are another critical area needed for gaining independence. Floreo's safety-based lessons include in- teracting with police officers, crossing the street safely, dealing with bullying behavior, safety at a swimming pool, and storing groceries. Artificial Intelligence (AI) characters: For individuals who are 13 years old or older, Floreo has developed lessons involving conversations with an AI-driven character. These characters are able to have real-time conversations and respond to whatever the Learner says in the moment. The Coach is able to "prime" the AI character. For example, the Coach may ask the character to practice a job interview with the Learner or practice a difficult conversation with a roommate. The AI characters can also play word games, such as “20 questions”. Guard rails have been put in place so that Floreo’s AI characters will not deviate into inappro- priate topics of conversation. Otherwise, with these characters, the sky is the limit.

Figure 4: The full Floreo catalog with lesson descriptions may be found here.

MAKING AN IMPACT (ACCOUNTS FROM FLOREO USERS) In December 2024, Floreo co-hosted a webinar with Multiple (https://www.multiplehub.org/). This webinar featured 3 differ- ent users of the Floreo platform. These videos provide authentic, first-hand experiences with the product. A Speech Language Pathologist (SLP) from a private practice in Texas shared her experience using Floreo VR with her clients during the webinar. This SLP discussed how the tele-VR capabil- ities of Floreo allowed her to maintain an active practice during the recent pandemic and credited Floreo with making it easier for parents to continue in-person services once the restrictions were lifted. She has found Floreo practical to use with a variety of her clients. She incorporates parents into the therapy session with young children and described how Floreo is a good ave- nue for enhancing parent engagement with the therapy. She reported that by introducing VR to one of her clients, she was able to draw out this non-speaking 8-year-old in a way no tool or

YouTube Video: An SLP's experience using Floreo. https://youtu.be/cczCKwJ8AMo?si=slaxcOKFoTATHO7J

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approach ever had before. This SLP heard the first vocalizations from this little girl when she was in VR and discussed how Floreo was able to provide the 8-year-old with some self-regulation at the beginning of the therapy sessions. The SLP mentioned find- ing the emotional regulation lessons useful for helping a stutter- ing client, and the grocery store lessons being useful for an older client who needed to gain daily living skills. She noted that using Floreo brings happiness to her clients and described Floreo as a "game-changer". To see the full video, click here: An SLP's expe- rience using Floreo In this webinar, a teacher also provided her experience us- ing Floreo in her classroom in New York. This special education teacher and clinical supervisor leads a reduced-ratio classroom that serves autistic students, some of whom are expected to tran- sition to a mainstream setting. Initially apprehensive (as she did not consider herself an avid user of technology), she stated that she quickly felt very comfortable using the Floreo system. She has found Floreo quite helpful for practicing social interaction skills. In particular, it provides environments that are not avail- able in her school setting (such as a school cafeteria) that are highly relevant to students who are transitioning to a more typi- cal school setting. She is seeing generalization of skills learned in Floreo to real events and interactions. This teacher found lessons that focus on prosocial skills in the classroom (such as raising your hand and tolerating not being selected) very helpful as well. Floreo uncovered at least one gap in her student's learning that would not have been evident without Floreo. This teach- er found it very helpful to have similarly aged peers to practice conversations, rather than practicing with an adult. To view this full video, click here: A teacher's experience with Floreo

quite a bit of time and energy creating individualized materials for her daughter to support her learning. She stated that when she came across Floreo, she found the content highly applica- ble to her daughter and was thrilled to have it already created for her. This parent engages a person on her daughter's current support team to help implement the Floreo lessons with her daughter. Together, this mother and the support person review the library and find lessons that would be helpful for the daugh- ter in the community, such as crossing the street and interacting with police officers. After practicing in Floreo, they have seen her daughter's ability to generalize, not only the community-based lessons, but also, in "Cloud Chronicles", a lesson that the daugh- ter requested, designed to develop imagination and storytelling. This mother stated that her daughter began to use the system in short increments, but her tolerance for VR quickly increased. Her daughter is motivated to use the lessons and particularly enjoys the Yoga lessons in Floreo. This full video can be viewed here: A parent's experience with Floreo

YouTube Video: A parent's experience with Floreo https://youtu.be/cTGdFj6QkSQ?si=ZoZQoWNzKpmPmjCT

Additional testimonials can be found here.

CONCLUSION Floreo is an engaging, flexible, and efficient VR tool that can be used by a wide variety of professionals, caregivers, and in- dividuals. Its safe, controllable, and repeatable features contrib- ute to each lesson’s effectiveness and popularity. Floreo lessons capture a Learner’s attention, saving professionals and caregiv- ers significant time and effort. It delivers a ready-made learning environment and encourages collaboration between students, professionals, and caregivers. Most importantly, it fosters a Learner’s confidence and emotional well-being. PRODUCT DESCRIPTION Floreo is an evidence-based tool, rooted in research, and has received FDA “Breakthrough Device” designation. An ongoing randomized clinical trial is currently being conducted on Flo-

YouTube Video: A teacher's experience with Floreo. https://youtu.be/efoaNyTAOTM?si=LPu_iaA-ssfPEruE

Finally, a parent of a 25-year-old daughter with multiple dis- abilities, including ASD, joined this webinar. The family lives in Alabama, and when this mother’s daughter was young, they moved from a more rural area to a more urban area to have greater access to services. Over the years, this mother spent

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Disorder: Preliminary Results of a Feasibility and Safety Trial. Proc of the 23rd Annual CyberPsychology, CyberTherapy & Social Networking Conference, Gatineau, Canada. Ravindran V, Osgood M, Sazawal V, Solorzano R, Turnacioglu S. Virtual Reality Support for Joint Attention Using the Floreo Joint Attention Module: Usability and Feasibility Pilot Study. JMIR Pediatrics and Parenting. 2019;2(2):e14429. doi:10.2196/14429.

reo in an effort to secure full FDA approval. Floreo expects that the results of this research will support FDA approval as well as the application of the conversion of the temporary CPT-3 billing code for "VR Assisted Therapy" to the more well-established CPT (Category 1) code. The current CPT-3 code for "VR Assisted Ther- apy" is 0770T. Floreo is offered as a subscription service. The base subscrip- tion is $70 per Learner per month, with greater discounts avail- able as the number of Learners increases. For more information or to sign up for an online personalized demo, visit: https://floreovr.com/. If you have a particular ques- tion, please reach out to info@floreovr.com. SELECTED RECENT RESEARCH ON VR IN THERAPY Carballo-Marquez A, Ampatzoglou A, Rojas-Rincón J, Garcia- Casanovas A, Garolera M, Fernández-Capo M, Porras- Garcia B. Improving Emotion Regulation, Internalizing Symptoms and Cognitive Functions in Adolescents at Risk of Executive Dysfunction—A Controlled Pilot VR Study. Applied Sciences . 2025; 15(3):1223. https://doi. org/10.3390/app15031223 Mills J, Duffy O. Speech and Language Therapists' Perspectives of Virtual Reality as a Clinical Tool for Autism: Cross- Sectional Survey . JMIR Rehabil Assist Technol . 2025 Feb 27;12:e63235. doi: 10.2196/63235. PMID: 40014826; PMCID: PMC11884707. Trigueiro MJ, Lopes J, Simões-Silva V, Vieira de Melo BB, Simões de Almeida R, Marques A. Impact of VR-Based Cognitive Training on Working Memory and Inhibitory Control in IDD Young Adults. Healthcare (Basel). 2024 Aug 26;12(17):1705. doi: 10.3390/healthcare12171705. PMID: 39273729; PMCID: PMC11395001. Smith MJ, Sherwood K, Ross B, Smith JD, DaWalt L, Bishop L, Humm L, Elkins J, Steacy C. Virtual interview training for autistic transition age youth: A randomized controlled feasibility and effectiveness trial. Autism . 2021 Aug;25(6):1536-1552. doi: 10.1177/1362361321989928. Epub 2021 Feb 10. PMID: 33567883; PMCID: PMC8324503. Chard I, Van Zalk N, Picinali L. Virtual reality exposure therapy for reducing social anxiety in stuttering: A randomized controlled pilot trial. Front Digit Health. 2023 Feb 9;5:1061323. doi: 10.3389/fdgth.2023.1061323. PMID: 36845336; PMCID: PMC9947508. Parish-Morris, J., Solórzano, R., Ravindran, V., Sazawal, V., Turnacioglu, S., Zitter, A., Miller, J. & McCleery, J. (2018). Immersive Virtual Reality to Improve Police Interaction Skills in Adolescents and Adults with Autism Spectrum

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