Exploring the Combination of Serious Games, Social Interactions, and Virtual Reality in Adolescents with ASD: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The paper presents a scoping review investigating the potential of combining Serious Games and Virtual Reality to improve social skills in adolescents with Autism Spectrum Disorder.

In my view, the paper addresses an important and timely topic by reviewing the potential of SGs combined with VR to improve social skills in adolescents with ASD. The focus on adolescents with ASD is interesting since it is well known that this developmental stage presents unique challenges and opportunities for social skills training. However, several aspects limit its overall impact. In particular, in my view, the methodology lacks critical details and justifications which raises questions about the robustness of the review. In addiction, the findings' description often lacks coherence and depth, especially in linking the results to the research objectives and gaps addressed by the study. In addition, the paper could benefit from a stronger narrative flow, particularly in the introduction, where the rationale for the study and its novelty are not well-articulated. Finally, the discussion and conclusions do not fully integrate the findings into existing literature and adequately highlight the innovative contributions of this scoping review.

Specifically, from my standpoint, the overall quality of the paper should be improved by addressing the following issues:

1. The abstract should be revised to offer a clearer overview of the paper by adhering to the typical structure of a research article abstract, which includes the following topics: background/context, objective, methods, main findings, and conclusions/implications.

 

2. The authors should improve the logical flow of the Introduction as there are often jumps back and forth on the topics discussed, making it difficult to follow the thread. For example, the tech-oriented method is introduced in the second paragraph and partially argued and justified also in the fifth paragraph. In addition, in the Introduction, the authors should deeply and clearly detail: (i) the study rationale, emphasizing why they specifically focus on VR-based SG targeting social skill learning/training by adolescents with ASD, (ii) how this study contributes to scholarly knowledge beyond existing literature (reviews, systematic reviews, etc.), i.e., the research gap they intended to fill. (iii) The research questions addressed by the study. Moreover, The authors should ensure that all statements are properly referenced to maintain scientific rigor, provide context, and ensure transparency. For instance, the following statements lack appropriate references: (i) “Autism spectrum disorder (ASD) is a neurodevelopmental condition that negatively impacts how individuals communicate, interact socially, and behave.”; (ii) “Recognizing these unique challenges, researchers and clinicians are increasingly exploring tech-driven methods to help adolescents with ASD build essential social skills”; (iii) “One promising approach involves using Serious Games (SGs) and Virtual Reality (VR).”. Finally, at the end of the introduction, the authors should provide an overview of the subsequent sections to improve the readability of the paper.

 

3. I suggest authors create a dedicated section (titled “Background” or “Related Work” or similar) summarizing prior research on the topic addressed by the presented study to clearly demonstrate the need for and importance of conducting the study presented in the paper, as it addresses a research gap that has never been filled and thus can effectively contribute to the research. In addition to the studies included in the paper's bibliography (e.g., Mesa-Gresa, Grossard, Zhang, Valencia, Caruso, Bozgeyikli), I suggest the following (non-exhaustive) list of additional studies in the field to be included in this section:

·       M. Bellani, L. Fornasari, L. Chittaro, and P. Brambilla, ‘‘Virtual reality in autism: state of the art,’’ Epidemiology and psychiatric sciences, vol. 20, no. 3, pp. 235– 238, 2011.

·       S. Parsons and S. Cobb, ‘‘State-of-the-art of virtual reality technologies for children on the autism spectrum,’’ European Journal of Special Needs Education, vol. 26, no. 3, pp. 355–366, 2011.

·       Peretti, S., Pino, M. C., Caruso, F., & Di Mascio, T. (2024). Evaluating the Potential of Immersive Virtual Reality-Based Serious Games Interventions for Autism: A Pocket Guide Evaluation Framework. Education Sciences, 14(4), 377.

·       N. Glaser and M. Schmidt, ‘‘Systematic literature review of virtual reality intervention design patterns for individuals with autism spectrum disorders,’’ Int. J. Hum.-Comput. Int., pp. 1–36, 2021.

·       Miller, H. L., & Bugnariu, N. L. (2016). Level of immersion in virtual environments impacts the ability to assess and teach social skills in autism spectrum disorder. Cyberpsychology, Behavior, and Social Networking, 19(4), 246-256.

·       A. Nordahl-Hansen, A. Dechsling, S. Sütterlin, L. Børtveit, D. Zhang, R. A. Øien, and P. B. Marschik, ‘‘An overview of virtual reality interventions for two neurodevelopmental disorders: intellectual disabilities and autism,’’ in International Conference on HumanComputer Interaction, pp. 257–267, Springer, 2020.

·       B. Karami, R. Koushki, F. Arabgol, M. Rahmani, and A.-H. Vahabie, ‘‘Effectiveness of virtual/augmented reality–based therapeutic interventions on individuals with autism spectrum disorder: A comprehensive meta-analysis,’’ Frontiers in Psychiatry, vol. 12, p. 665326, 2021.

·       G. Lorenzo, A. Lledó, G. Arráez-Vera, and A. Lorenzo-Lledó, ‘‘The application of immersive virtual reality for students with asd: A review between 1990–2017,’’ Educ. Inf. Technol., vol. 24, no. 1, pp. 127–151, 2019.

·       R. Bradley and N. Newbutt, ‘‘Autism and virtual reality head-mounted displays: a state of the art systematic review,’’ Journal of Enabling Technologies, 2018.

·       A. Dechsling, S. Orm, T. Kalandadze, S. Sütterlin, R. A. Øien, F. Shic, and A. Nordahl-Hansen, ‘‘Virtual and augmented reality in social skills interventions for individuals with autism spectrum disorder: A scoping review,’’ Journal of autism and developmental disorders, pp. 1–16, 2021.

·       E. Thai and D. Nathan-Roberts, ‘‘Social skill focuses of virtual reality systems for individuals diagnosed with autism spectrum disorder; a systematic review,’’ in Proceedings of the Human Factors and Ergonomics Society Annual Meeting, vol. 62, pp. 1469–1473, SAGE Publications Sage CA: Los Angeles, CA, 2018.

·       Azadboni, T. T., Nasiri, S., Khenarinezhad, S., & Sadoughi, F. (2024). Effectiveness of serious games in social skills training to Autistic individuals: A systematic review. Neuroscience & Biobehavioral Reviews, 105634. Doi= 10.1016/j.neubiorev.2024.105634

·       Carneiro, T., Carvalho, A., Frota, S., & Filipe, M. G. (2024, February). Serious Games for Developing Social Skills in Children and Adolescents with Autism Spectrum Disorder: A Systematic Review. In Healthcare (Vol. 12, No. 5, p. 508). MDPI. Doi= 10.3390/healthcare12050508

·       de Carvalho, A. P., Braz, C. S., dos Santos, S. M., Ferreira, R. A., & Prates, R. O. (2024). Serious games for children with autism spectrum disorder: A systematic literature review. International Journal of Human–Computer Interaction, 40(14), 3655-3682.

·       Hassan, A., Pinkwart, N., & Shafi, M. (2021). Serious games to improve social and emotional intelligence in children with autism. Entertainment computing, 38, 100417.

·       Tsikinas, S., & Xinogalos, S. (2019). Studying the effects of computer serious games on people with intellectual disabilities or autism spectrum disorder: A systematic literature review. Journal of Computer Assisted Learning, 35(1), 61-73. Doi= 10.1111/jcal.12311

 

4. In the METHOD section:

o   The authors state that their study is a scoping review, yet they used the PRISMA protocol, which is designed for conducting systematic reviews and meta-analyses. However, there is a specific PRISMA extension for scoping reviews (PRISMA-ScR, https://www.prisma-statement.org/scoping), which the authors should have used instead or clearly motivated this decision.

o   The authors should provide a rationale for choosing the scoping review methodology over other approaches, such as systematic reviews, narrative reviews, or meta-analyses.

o   The authors should also explain why they consulted only Scopus as a digital resource and did not include other databases like PubMed, IEEE Xplore, ACM Digital Library, Web of Science, Google Scholar, or ScienceDirect.

o   In the title, abstract, and introduction, the authors focus on the adolescent age range, yet in their inclusion criteria, they specify the inclusion of studies targeting individuals aged 5-18 years. This discrepancy should be clarified.

o   The inclusion and exclusion criteria should be presented more clearly and precisely, preferably in a bullet-point format or a table. Additionally, all criteria should be thoroughly explained and justified, even if the reasoning appears obvious or straightforward, as these criteria define why certain studies were selected and others excluded. For instance:

1.    Why were only articles published from 2013 onward included? The authors state in the "Literature Overview" section that "Documents published between 2013 and 2024 were considered to ensure the inclusion of the most recent and relevant studies," but this reasoning seems weak. This justification should instead be detailed in the METHODS section under inclusion criteria. For example, was the focus on more recent VR technologies? Was this aligned with similar reviews in the field?

2.    Why were only studies in English included? Was it because most scientific studies are in English ([including a reference])? Or because the reviewers only had expertise in English?

·      The search string used to identify articles should be better explained. For instance, why were the specific terms chosen? Why do "social interactions" and not "social skill*" or “social cognition” or similar terms refer to the same concept?

·      In Figure 1, under the "identification" step, it is mentioned that 12 articles were removed for "other reasons." In the following step, there are still 20 articles included, which implies no articles were actually discarded. What exactly are these "other reasons"? This should be clarified.

·      Some information included in the PRISMA checklist attached to the paper is not actually provided in the paper. For example:

1.    "Specify the date when each source was last searched or consulted."

2.    "Present the full search strategies for all databases, registers, and websites, including any filters and limits used."

3.    "Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and, if applicable, details of automation tools used in the process."

5. In the LITERATURE REVIEW section:

- The overview of the reviewed studies lacks a clear analytical framework and reads as a general description of the studies or their abstracts without focusing on specific aspects that the scoping review aims to examine. For example, some sections reference the design of the technological tool, while others mention aspects of the evaluation design. The studies should be presented in a consistent manner, highlighting the key elements emphasized in the scoping review.

- The table included in this section should also be revised to serve as a support tool for the analysis and discussion of the studies reviewed in the study. For example, it could include details such as: The purpose of the presented tool (e.g., is the VR-based serious game aimed at learning/training a specific social skill or social skills more broadly?); The technology used (e.g., desktop-based VR, immersive VR such as CAVE or HMD); The number of participants involved. The diagnosis of participants (e.g., low-functioning ASD, high-functioning ASD, or comorbid diagnoses); Age range and gender of participants; Experimental design (e.g., pre-post, between-group, within-group, follow-up); Focus of the evaluation (e.g., acceptability, feasibility, effectiveness, usability); Whether parents/caregivers were involved in the study; The design methodology employed in developing the tool; and so on.

6. The Discussion and Conclusions sections should be revised to clearly highlight what is already known in the literature, what findings from the scoping review confirm existing knowledge, and what innovative insights the study has uncovered. Currently, these aspects do not emerge clearly, leaving the significance of the findings underdeveloped.

7. The limitations of the scoping review should be explicitly addressed (e.g., the authors should mention that only one digital library was investigated, that the study was limited to articles in English, and that only studies published after 2013 were included). These factors could have influenced the breadth and comprehensiveness of the review and should be discussed to provide a balanced perspective of reported findings.

Author Response

1. Specifically, from my standpoint, the overall quality of the paper should be improved by addressing the following issues:The abstract should be revised to offer a clearer overview of the paper by adhering to the typical structure of a research article abstract, which includes the following topics: background/context, objective, methods, main findings, and conclusions/implications.

 

1. we revised the abstract to offer a clearer overview of the paper by adhering to the typical structure of a research article abstract, which includes the following topics: background/context, objective, methods, main findings, and conclusions/implications.

 

2. The authors should improve the logical flow of the Introduction as there are often jumps back and forth on the topics discussed, making it difficult to follow the thread. For example, the tech-oriented method is introduced in the second paragraph and partially argued and justified also in the fifth paragraph. In addition, in the Introduction, the authors should deeply and clearly detail: (i) the study rationale, emphasizing why they specifically focus on VR-based SG targeting social skill learning/training by adolescents with ASD, (ii) how this study contributes to scholarly knowledge beyond existing literature (reviews, systematic reviews, etc.), i.e., the research gap they intended to fill. (iii) The research questions addressed by the study. Moreover, the authors should ensure that all statements are properly referenced to maintain scientific rigor, provide context, and ensure transparency. For instance, the following statements lack appropriate references: (i) “Autism spectrum disorder (ASD) is a neurodevelopmental condition that negatively impacts how individuals communicate, interact socially, and behave.”; (ii) “Recognizing these unique challenges, researchers and clinicians are increasingly exploring tech-driven methods to help adolescents with ASD build essential social skills”; (iii) “One promising approach involves using Serious Games (SGs) and Virtual Reality (VR).”. Finally, at the end of the introduction, the authors should provide an overview of the subsequent sections to improve the readability of the paper.:

2. We have added the references and the questions

 

3. I suggest authors create a dedicated section (titled “Background” or “Related Work” or similar) summarizing prior research on the topic addressed by the presented study to clearly demonstrate the need for and importance of conducting the study presented in the paper, as it addresses a research gap that has never been filled and thus can effectively contribute to the research. In addition to the studies included in the paper's bibliography (e.g., Mesa-Gresa, Grossard, Zhang, Valencia, Caruso, Bozgeyikli), I suggest the following (non-exhaustive) list of additional studies in the field to be included in this section:

• M. Bellani, L. Fornasari, L. Chittaro, and P. Brambilla, ‘‘Virtual reality in autism: state of the art,’’ Epidemiology and psychiatric sciences, vol. 20, no. 3, pp. 235– 238, 2011.
• S. Parsons and S. Cobb, ‘‘State-of-the-art of virtual reality technologies for children on the autism spectrum,’’ European Journal of Special Needs Education, vol. 26, no. 3, pp. 355–366, 2011.
• Peretti, S., Pino, M. C., Caruso, F., & Di Mascio, T. (2024). Evaluating the Potential of Immersive Virtual Reality-Based Serious Games Interventions for Autism: A Pocket Guide Evaluation Framework. Education Sciences, 14(4), 377.
• N. Glaser and M. Schmidt, ‘‘Systematic literature review of virtual reality intervention design patterns for individuals with autism spectrum disorders,’’ Int. J. Hum.-Comput. Int., pp. 1–36, 2021.
• Miller, H. L., & Bugnariu, N. L. (2016). Level of immersion in virtual environments impacts the ability to assess and teach social skills in autism spectrum disorder. Cyberpsychology, Behavior, and Social Networking, 19(4), 246-256.
• A. Nordahl-Hansen, A. Dechsling, S. Sütterlin, L. Børtveit, D. Zhang, R. A. Øien, and P. B. Marschik, ‘‘An overview of virtual reality interventions for two neurodevelopmental disorders: intellectual disabilities and autism,’’ in International Conference on HumanComputer Interaction, pp. 257–267, Springer, 2020.
• B. Karami, R. Koushki, F. Arabgol, M. Rahmani, and A.-H. Vahabie, ‘‘Effectiveness of virtual/augmented reality–based therapeutic interventions on individuals with autism spectrum disorder: A comprehensive meta-analysis,’’ Frontiers in Psychiatry, vol. 12, p. 665326, 2021.
• G. Lorenzo, A. Lledó, G. Arráez-Vera, and A. Lorenzo-Lledó, ‘‘The application of immersive virtual reality for students with asd: A review between 1990–2017,’’ Educ. Inf. Technol., vol. 24, no. 1, pp. 127–151, 2019.
• R. Bradley and N. Newbutt, ‘‘Autism and virtual reality head-mounted displays: a state of the art systematic review,’’ Journal of Enabling Technologies, 2018.
• A. Dechsling, S. Orm, T. Kalandadze, S. Sütterlin, R. A. Øien, F. Shic, and A. Nordahl-Hansen, ‘‘Virtual and augmented reality in social skills interventions for individuals with autism spectrum disorder: A scoping review,’’ Journal of autism and developmental disorders, pp. 1–16, 2021.
• E. Thai and D. Nathan-Roberts, ‘‘Social skill focuses of virtual reality systems for individuals diagnosed with autism spectrum disorder; a systematic review,’’ in Proceedings of the Human Factors and Ergonomics Society Annual Meeting, vol. 62, pp. 1469–1473, SAGE Publications Sage CA: Los Angeles, CA, 2018.
• Azadboni, T. T., Nasiri, S., Khenarinezhad, S., & Sadoughi, F. (2024). Effectiveness of serious games in social skills training to Autistic individuals: A systematic review. Neuroscience & Biobehavioral Reviews, 105634. Doi= 10.1016/j.neubiorev.2024.105634
• Carneiro, T., Carvalho, A., Frota, S., & Filipe, M. G. (2024, February). Serious Games for Developing Social Skills in Children and Adolescents with Autism Spectrum Disorder: A Systematic Review. In Healthcare(Vol. 12, No. 5, p. 508). MDPI. Doi= 10.3390/healthcare12050508
• de Carvalho, A. P., Braz, C. S., dos Santos, S. M., Ferreira, R. A., & Prates, R. O. (2024). Serious games for children with autism spectrum disorder: A systematic literature review. International Journal of Human–Computer Interaction, 40(14), 3655-3682.
• Hassan, A., Pinkwart, N., & Shafi, M. (2021). Serious games to improve social and emotional intelligence in children with autism. Entertainment computing, 38, 100417.
• Tsikinas, S., & Xinogalos, S. (2019). Studying the effects of computer serious games on people with intellectual disabilities or autism spectrum disorder: A systematic literature review. Journal of Computer Assisted Learning, 35(1), 61-73. Doi= 10.1111/jcal.12311

3. We have added a new section where we summarized prior research on the topic addressed by the presented study to clearly demonstrate the need for and importance of conducting the study presented in the paper

 

4. In the METHOD section:

o   The authors state that their study is a scoping review, yet they used the PRISMA protocol, which is designed for conducting systematic reviews and meta-analyses. However, there is a specific PRISMA extension for scoping reviews (PRISMA-ScR, https://www.prisma-statement.org/scoping), which the authors should have used instead or clearly motivated this decision.

4. Our choice was based on the alignment of PRISMA 2020 with our aim to transparently report the systematic process of identifying, screening, and including relevant studies. We recognize that PRISMA-ScR provides specific guidelines for scoping reviews and will incorporate its framework in future iterations for increased methodological clarity and adherence to best practices.

o   The authors should provide a rationale for choosing the scoping review methodology over other approaches, such as systematic reviews, narrative reviews, or meta-analyses.

- We selected a scoping review methodology because it is particularly suited for exploring broad and emerging research fields, such as the intersection of SGs, VR, and social skill development in adolescents with ASD.

o   The authors should also explain why they consulted only Scopus as a digital resource and did not include other databases like PubMed, IEEE Xplore, ACM Digital Library, Web of Science, Google Scholar, or ScienceDirect.

- The exclusive use of Scopus was based on its comprehensive coverage of multidisciplinary peer-reviewed literature. However, we acknowledge that consulting additional databases, such as PubMed, IEEE Xplore, or Web of Science, could have broadened the scope. This limitation may have led to the exclusion of relevant studies. Future work will aim to expand the database search to ensure a more inclusive dataset.

• In the title, abstract, and introduction, the authors focus on the adolescent age range, yet in their inclusion criteria, they specify the inclusion of studies targeting individuals aged 5-18 years. This discrepancy should be clarified.

- The focus on adolescents in the title reflects the primary target population; however, the inclusion criteria (ages 5–18) were set to capture a broader developmental spectrum, as studies often include younger participants to address early intervention. We will clarify this in the manuscript to ensure consistency and transparency.

o   The inclusion and exclusion criteria should be presented more clearly and precisely, preferably in a bullet-point format or a table. Additionally, all criteria should be thoroughly explained and justified, even if the reasoning appears obvious or straightforward, as these criteria define why certain studies were selected and others excluded. For instance:

1. Why were only articles published from 2013 onward included? The authors state in the "Literature Overview" section that "Documents published between 2013 and 2024 were considered to ensure the inclusion of the most recent and relevant studies," but this reasoning seems weak. This justification should instead be detailed in the METHODS section under inclusion criteria. For example, was the focus on more recent VR technologies? Was this aligned with similar reviews in the field?

 

1. We will revise the inclusion and exclusion criteria for clarity, presenting them in a bullet-point or tabular format.

1. The decision to include studies published from 2013 onward reflects the rapid advancements in VR technology since that time, ensuring the inclusion of studies employing modern systems. This aligns with similar reviews in the field that prioritize recent technological applications.

2. Why were only studies in English included? Was it because most scientific studies are in English ([including a reference])? Or because the reviewers only had expertise in English?

2. The restriction to English-language studies was based on the prevalence of English as the primary language of scientific publication. This approach is consistent with other reviews in the field and was also necessitated by the linguistic expertise of the authors. We will include a citation to support this rationale.

• The search string used to identify articles should be better explained. For instance, why were the specific terms chosen? Why do "social interactions" and not "social skill*" or “social cognition” or similar terms refer to the same concept?

- We will elaborate on the search strategy, providing the full search string and rationale for term selection.

• In Figure 1, under the "identification" step, it is mentioned that 12 articles were removed for "other reasons." In the following step, there are still 20 articles included, which implies no articles were actually discarded. What exactly are these "other reasons"? This should be clarified.

The 12 articles removed for “other reasons” refer to duplicates, non-peer-reviewed sources, and studies unrelated to VR or SGs.

• Some information included in the PRISMA checklist attached to the paper is not actually provided in the paper. For example:

1. "Specify the date when each source was last searched or consulted."
2. "Present the full search strategies for all databases, registers, and websites, including any filters and limits used."
3. "Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and, if applicable, details of automation tools used in the process."

- We will ensure that all PRISMA checklist elements, such as database search dates, full search strategies, and details on inclusion criteria screening, are clearly documented in the methods section for transparency.

 

5. In the LITERATURE REVIEW section:

- The overview of the reviewed studies lacks a clear analytical framework and reads as a general description of the studies or their abstracts without focusing on specific aspects that the scoping review aims to examine. For example, some sections reference the design of the technological tool, while others mention aspects of the evaluation design. The studies should be presented in a consistent manner, highlighting the key elements emphasized in the scoping review.

5. We presented the studies in a consistent manner, highlighting the key elements emphasized in the scoping review.

- The table included in this section should also be revised to serve as a support tool for the analysis and discussion of the studies reviewed in the study. For example, it could include details such as: The purpose of the presented tool (e.g., is the VR-based serious game aimed at learning/training a specific social skill or social skills more broadly?); The technology used (e.g., desktop-based VR, immersive VR such as CAVE or HMD); The number of participants involved. The diagnosis of participants (e.g., low-functioning ASD, high-functioning ASD, or comorbid diagnoses); Age range and gender of participants; Experimental design (e.g., pre-post, between-group, within-group, follow-up); Focus of the evaluation (e.g., acceptability, feasibility, effectiveness, usability); Whether parents/caregivers were involved in the study; The design methodology employed in developing the tool; and so on.

5. We modified the table adding various sections

 

6. The Discussion and Conclusions sections should be revised to clearly highlight what is already known in the literature, what findings from the scoping review confirm existing knowledge, and what innovative insights the study has uncovered. Currently, these aspects do not emerge clearly, leaving the significance of the findings underdeveloped.

6. We modified the sections to highlight what findings from the scoping review confirm existing knowledge, and what innovative insights the study has uncovered.

 

7. The limitations of the scoping review should be explicitly addressed (e.g., the authors should mention that only one digital library was investigated, that the study was limited to articles in English, and that only studies published after 2013 were included). These factors could have influenced the breadth and comprehensiveness of the review and should be discussed to provide a balanced perspective of reported findings.

7. we have expanded the limitations section

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

By conducting a scoping review of empirical studies, the paper aimed to understand how serious games and virtual reality (VR) could be utilised to help improve the social skills of children and adolescents with autism spectrum disorder (ASD). In addition, current applications of serious games and VR, their effectiveness, their challenges and research gaps were investigated. The motivation for the research was that serious games in combination with VR may offer unique opportunities to help children and adolescents with ASD enhance their social skills. The authors claim that they provide a comprehensive review of interventions using serious games and VR to promote social interactions among adolescents with ASD.

 

A particular strength of the review was the research motivation and topic. This was particularly clear in lines 70-73 when the authors describe previous interventions (e.g., behavioural therapy) and their benefits, and how serious games and VR could also be useful in this space by offering unique immersive and interactive experiences. It is noted that using serious games and VR to simulate real-world social scenarios enables those with ASD to practice social interactions without the fear of engaging in these activities in the real-world.

 

Another strength was the identification of challenges of incorporating serious games and VR as well as limitations of the current research and future recommendations. For example, the authors note problems with the technology’s accessibility (e.g., cost, learning to use the technology), as well as a general lack of research studying whether serious games and VR are beneficial for tackling wider ranging symptoms of ASD (e.g., sensory and behavioural challenges) and the long-term benefits of serious games and VR. Moreover, limitations of the current research were noted including small sample sizes, and lack of diverse samples (studies often target high functioning ASD). Recommendations were also provided (e.g., advancing the design of VR and serious games, conducting longitudinal studies, including participants with wide ranging profiles of ASD).

 

In terms of weaknesses, the aim of the paper was unclear. Initially, the stated aim was to review how serious games and VR have been used to enhance the social skills of adolescents with ASD. However, lines 165-166 suggest that the review will investigate serious games and VR in ASD therapy more broadly. In addition, at the beginning of section IV, the researchers describe how they will identify research that has utilised serious games in healthcare and rehabilitation strategies. I would recommend that the aims outlined by the authors are reflected in the review content. Broadening the scope of the stated aims would address this.

 

Futhremore, information about the review’s target population was contradictory. Up to the method section, the authors indicate that the target population are adolescents with ASD. However, in the method section, this is changed to children and young adolescents (caregivers are also mentioned). Although in the methods section the inclusion criteria regarding age is made clear, to ensure consistency and to prevent any confusion, the researchers should refer to the same target population (e.g., children and adolescents) throughout the paper.

 

There are issues with the inclusion criteria. First, a list of keywords is provided. However, this should have been described more in-depth. For example, the keyword “autism spectrum disorders” is provided. However, this could have been elaborated upon as functional capacity (e.g., high functioning, low functioning) of ASD has significant implications for task performance. Also, the keyword “social interactions” could have been elaborated upon to describe what types of social interactions were under scrutiny. Moreover, it is stated that empirical studies were reviewed but details about each  study’s designs (e.g., observational, experimental) and inclusion criteria should be provided. Finally, only the SCOPUS database was searched to identify studies. It was unclear why additional databases were not used to broaden the search.

 

Of the seven studies that were reviewed, it was unclear how four of them relate to social skills. More specifically, the research by Simoes et al investigated bus riding routines using VR. Although the authors note that this study allowed participants to manage “in-transit activities”, which may involve, for example, the social element of buying a ticket from the bus driver, overall, it was unclear what exactly the social element of this study was. In addition, it was noted that Simoes et al compared participants with ASD to neurotypical participants. This is problematic as the groups are not matched (i.e., one group has ASD and the other does not). Therefore, it would be difficult to determine whether the results of this study are due to the intervention (i.e., the VR device) or the aforementioned individual differences. In addition to the study by Simoes et al, both studies by Johnston et al investigated exposure to distressing sounds while Tan et al investigated crossing the road. Again, it was unclear what the social element of these studies was. Therefore, to enhance the review, the authors should make it clearer what the social element was in these studies.

 

At the beginning of section V (discussion section), the researchers state that “The reviewed studies consistently highlight the importance of fostering self-determination and independence among individuals with ASD through SGs (serious games) and VR interventions”. However, there is no description of the reviewed studies measuring self-determination or independence or the benefits that possessing these characteristics may have for people with ASD. Moreover, the discussion section includes descriptions of the reviewed studies that were not included in the main results section. For example, it is described how participants’ sense of ownership and motivation were enhanced in the study by Ghanouni et al while the VR task named “Coin Hunt” and its effectiveness in fostering teamwork and collaboration is described in the study by Gabrielli et al. Other descriptions include improved communication skills leading to more harmonious family dynamics (Ghanouni et al) and practical skill acquisition reducing the need for assistance from caregivers (Simoes et al). Rather than adding additional findings from the reviewed research in the discussion section, the researchers should include this information in the main results section.

 

Finally, there are some unsupported claims in the discussion section. For example, lines 400-402, possibly in relation to the study by Gabrielli et al., (although this is unclear) suggest that, through using VR, participants (presumably those with ASD although this is again unclear) increase their comfort and intrinsic motivation to engage socially. However, no evidence is presented to support this. Furthermore, in relation to the study by Gabrielli et al. it is suggested that these researchers found that VR increased engagement and reduced frustration. However, again, there is no description of this in the main results section. In addition, the authors state that “Ghanouni et al. demonstrate that SGs and VR interventions improve quality of life by fostering social connections, self-determination, and independence. These improvements contribute to reduced stress levels within families, creating a more supportive home environment”. However, based on the initial description of this study, no measures or descriptions of social connections, stress or home environment were provided. Moreover, lines 456-459 state “Summarizing, the integration of new technologies such as SGs and VR may significantly enhance participants’ active role and constructive engagement… Their quality of life was improved accordingly. Both caregivers’ and families’ burden were relevantly reduced”. It is unclear, however, what participants’ active role and constructive engagement means and what studies evidenced this. Furthermore, it was unclear which studies measured quality of life and showed that this was improved. The same is true for the claim regarding caregivers and families’ burden being reduced.

Author Response

In terms of weaknesses, the aim of the paper was unclear. Initially, the stated aim was to review how serious games and VR have been used to enhance the social skills of adolescents with ASD. However, lines 165-166 suggest that the review will investigate serious games and VR in ASD therapy more broadly. In addition, at the beginning of section IV, the researchers describe how they will identify research that has utilised serious games in healthcare and rehabilitation strategies. I would recommend that the aims outlined by the authors are reflected in the review content. Broadening the scope of the stated aims would address this.

- This scoping review explores how combining SGs, and VR may support social skill development in children and adolescents with ASD. By systematically analysing current research, this paper aims to understand how these technologies can enhance communication, social interaction, and collaboration

 

Futhremore, information about the review’s target population was contradictory. Up to the method section, the authors indicate that the target population are adolescents with ASD. However, in the method section, this is changed to children and young adolescents (caregivers are also mentioned). Although in the methods section the inclusion criteria regarding age is made clear, to ensure consistency and to prevent any confusion, the researchers should refer to the same target population (e.g., children and adolescents) throughout the paper.

- we have modified the review’s target population throughout the paper

 

There are issues with the inclusion criteria. First, a list of keywords is provided. However, this should have been described more in-depth. For example, the keyword “autism spectrum disorders” is provided. However, this could have been elaborated upon as functional capacity (e.g., high functioning, low functioning) of ASD has significant implications for task performance. Also, the keyword “social interactions” could have been elaborated upon to describe what types of social interactions were under scrutiny. Moreover, it is stated that empirical studies were reviewed but details about each  study’s designs (e.g., observational, experimental) and inclusion criteria should be provided. Finally, only the SCOPUS database was searched to identify studies. It was unclear why additional databases were not used to broaden the search.

- We explained why we used the terms “social interactions”. The exclusive use of Scopus was based on its comprehensive coverage of multidisciplinary peer-reviewed literature. However, we acknowledge that consulting additional databases, such as PubMed, IEEE Xplore, or Web of Science, could have broadened the scope. This limitation may have led to the exclusion of relevant studies. Future work will aim to expand the database search to ensure a more inclusive dataset.

 

Of the seven studies that were reviewed, it was unclear how four of them relate to social skills. More specifically, the research by Simoes et al investigated bus riding routines using VR. Although the authors note that this study allowed participants to manage “in-transit activities”, which may involve, for example, the social element of buying a ticket from the bus driver, overall, it was unclear what exactly the social element of this study was. In addition, it was noted that Simoes et al compared participants with ASD to neurotypical participants. This is problematic as the groups are not matched (i.e., one group has ASD and the other does not). Therefore, it would be difficult to determine whether the results of this study are due to the intervention (i.e., the VR device) or the aforementioned individual differences. In addition to the study by Simoes et al, both studies by Johnston et al investigated exposure to distressing sounds while Tan et al investigated crossing the road. Again, it was unclear what the social element of these studies was. Therefore, to enhance the review, the authors should make it clearer what the social element was in these studies.

- We made the social elements clearer

 

 

At the beginning of section V (discussion section), the researchers state that “The reviewed studies consistently highlight the importance of fostering self-determination and independence among individuals with ASD through SGs (serious games) and VR interventions”. However, there is no description of the reviewed studies measuring self-determination or independence or the benefits that possessing these characteristics may have for people with ASD. Moreover, the discussion section includes descriptions of the reviewed studies that were not included in the main results section. For example, it is described how participants’ sense of ownership and motivation were enhanced in the study by Ghanouni et al while the VR task named “Coin Hunt” and its effectiveness in fostering teamwork and collaboration is described in the study by Gabrielli et al. Other descriptions include improved communication skills leading to more harmonious family dynamics (Ghanouni et al) and practical skill acquisition reducing the need for assistance from caregivers (Simoes et al). Rather than adding additional findings from the reviewed research in the discussion section, the researchers should include this information in the main results section.

- We delated the first part of the discussion section. We appreciate your suggestion to include descriptions from the reviewed studies in the main results section. However, we believe that retaining these elements in the discussion section serves a critical purpose. The discussion section provides an opportunity to contextualize and interpret the findings, drawing connections between the reviewed studies and the broader implications of the research. Specifically, discussing aspects such as enhanced ownership, motivation, teamwork, and communication skills allows us to explore the practical and social relevance of the interventions beyond their immediate outcomes. For instance, the improved family dynamics (Ghanouni et al) and reduced caregiver dependency (Simoes et al) highlight real-world applications and long-term benefits that extend beyond the scope of individual study results. Furthermore, including these points in the results section may disrupt the flow and coherence of the core findings, as these descriptions serve to enrich the interpretation of results rather than to present additional data. By situating them in the discussion, we ensure that readers gain a deeper understanding of the practical significance and potential impact of VR interventions, which aligns with the objectives of our study.

 

 

Finally, there are some unsupported claims in the discussion section. For example, lines 400-402, possibly in relation to the study by Gabrielli et al., (although this is unclear) suggest that, through using VR, participants (presumably those with ASD although this is again unclear) increase their comfort and intrinsic motivation to engage socially. However, no evidence is presented to support this. Furthermore, in relation to the study by Gabrielli et al. it is suggested that these researchers found that VR increased engagement and reduced frustration. However, again, there is no description of this in the main results section. In addition, the authors state that “Ghanouni et al. demonstrate that SGs and VR interventions improve quality of life by fostering social connections, self-determination, and independence. These improvements contribute to reduced stress levels within families, creating a more supportive home environment”. However, based on the initial description of this study, no measures or descriptions of social connections, stress or home environment were provided. Moreover, lines 456-459 state “Summarizing, the integration of new technologies such as SGs and VR may significantly enhance participants’ active role and constructive engagement… Their quality of life was improved accordingly. Both caregivers’ and families’ burden were relevantly reduced”. It is unclear, however, what participants’ active role and constructive engagement means and what studies evidenced this. Furthermore, it was unclear which studies measured quality of life and showed that this was improved. The same is true for the claim regarding caregivers and families’ burden being reduced.

 

- We revised the discussion to accurately reflect Gabrielli et al.'s findings. The study demonstrates how VR activities, such as "Coin Hunt," foster teamwork and collaboration. However, no direct evidence is provided regarding intrinsic motivation. I have removed this unsupported claim and clarified the focus on teamwork and communication as the key outcomes of Gabrielli et al.’s work. We specified that Gabrielli et al. reported increased engagement during VR tasks. However, since no direct measures of frustration reduction were described in the results, I have removed that claim. The revised text focuses only on the findings explicitly presented in Gabrielli et al.’s study. We revised this section to state that Ghanouni et al. emphasize the importance of participatory design for enhancing usability and engagement. While the paper discusses fostering self-determination and motivation, there is no direct assessment of stress or family dynamics. I removed unsupported claims and ensured the text aligns with the actual findings of the study. We rephrased this section to emphasize the potential of SGs and VR to enhance engagement and skill acquisition without attributing unsupported outcomes like quality of life improvement or reduced caregiver burden. Where applicable, I noted these as hypothetical benefits requiring further study.

 

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

The paper presents a review of the potential of Serious Games in conjunction with Virtual Reality for the treatment of adolescents diagnosed with Autism Spectrum Disorder.

The review comprehensively examines existing research on the topic, by presenting several case studies which clearly demonstrate the effectiveness of specific SGs and VR interventions in enhancing social skills and addressing challenges like sensory hypersensitivity and anxiety related to specific sounds. I liked especially the proposed table which helps in comparing different studies and their outcomes.

The review methodology follows established guidelines (PRISMA 2020), which is standard.

The authors acknowledge the limitations of current research, including small sample sizes, short study durations, and the need for greater diversity among participants.

Minor issues:

Line 243: “showedthat”

Line 268: the authors say “we aimed …”. Who exactly are they referring at?

The same in the table at Gabielli et al. “we had followed”

Author Response

Minor issues:

Line 243: “showedthat” :

- we have corrected the mistake

Line 268: the authors say “we aimed …”. Who exactly are they referring at? :

- it was referred at the authors (Simões et al)

The same in the table at Gabielli et al. “we had followed” :

- there was a mistake (authors had followed)

Author Response File: Author Response.docx