Journal Of Cybertherapy And Rehabilitation, Volume 3, Issue 1, 2010 6j28f

Volume 3, Issue 1, Spring 2010

Adolescent Internet Depression Prevention: Preferences for Intervention and Predictors of Intentions and Adherence The Sense of Olfaction: Its Characteristics and Its Possible Applications in Virtual Environments Can We Combine Learning with Augmented Reality Physical Activity? Sex and Race Differences in Rating Others’ Pain, Pain-Related Negative Mood, Pain Coping, and Recommending Medical Help The Effect of Activities in Virtual Worlds as a Communication Environment to Understand Each Other

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Journal of CyberTherapy & rehabiliTaTion Volume 3, Issue 1, Spring 2010

San Diego, California - Brussels, Belgium

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Journal of CyberTherapy & Rehabilitation

ediTor-in-Chief

assoCiaTe ediTors

Brenda K. Wiederhold, Ph.D., MBA, BCIA Virtual Reality Medical Institute Brussels, Belgium Virtual Reality Medical Center San Diego, California

Cristina Botella, Ph.D. Jaume I University Castelló de la Plana, Spain

Luciano Gamberini, Ph.D. University of Padova Padova, Italy

Stéphane Bouchard, Ph.D. Université du Québec en Outaouais Gatineau, Québec, Canada

Giuseppe Riva, Ph.D., M.S., M.A. Istituto Auxologico Italiano Verbania, Italy

Mariano Luis Alcañiz Raya, Ph.D. Universidad Politécnica de Valencia Valencia, Spain

Tom Furness, Ph.D. University of Washington Seattle, Washington

Paul Pauli, Ph.D. University of Würzburg Würzburg,

Rosa M. Baños, Ph.D. University of Valencia Valencia, Spain

Charles Hughes, Ph.D. University of Central Florida Orlando, Florida

Heidi Sveistrup, Ph.D. University of Ottawa Ottawa, Ontario, Canada

A.L. Brooks Aalborg University Esbjerg, Denmark

Wijnand IJsselsteijn, Ph.D. Eindhoven University of Technology Eindhoven, Netherlands

Richard M. Satava, M.D., F.A.C.S. University of Washington Seattle, Washington

Julian Dooley, Ph.D. Edith Cowan University Mount Lawley, Australia

Linda A. Jackson, Ph.D. Michigan State University East Lansing, Michigan

Mark D. Wiederhold, M.D., Ph.D., FA Virtual Reality Medical Center San Diego, California

Paul M.G. Emmelkamp, Ph.D. University of Amsterdam Amsterdam, Netherlands

Sun. I. Kim, Ph.D. Hanyang University Seoul, South Korea

Uri Feintuch, Ph.D. Hadassah-Hebrew University Medical Center Jerusalem, Israel

Dragica Kozaric-Kovacic, M.D., Ph.D. University Hospital Dubrava Zagreb, Croatia

managing ediTor

Emily Butcher Interactive Media Institute San Diego, California ediTorial board

Joshua Fogel, Ph.D. University of New York Brooklyn, New York

José Luis Mosso, M.D. Regional Hospital No. 25 of the IMSS Mexico City, Mexico

XiaoXiang Zheng, Ph.D. Zhejiang University Hangzhou, P.R. China

Journal of CyberTherapy & Rehabilitation Spring 2010 Vo l u m e 3 , I s s u e 1

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editorial B. Wiederhold

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“adolescent internet depression prevention: preferences for intervention and predictors of intentions and adherence” M. Marko, J. Fogel, E. Mykerezi & B. W. Van Voorhees

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“The sense of olfaction: its Characteristics and its possible applications in Virtual environments” O. Baus & S. Bouchard

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“Can We Combine learning with augmented reality physical activity?” K.F. Hsiao

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“sex and race differences in rating others’ pain, pain-related negative mood, pain Coping, and recommending medical help” A. Alqudah, A. Hirsh, L. Stutts, C. Scipio & M. Robinson

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“The effect of activities in Virtual Worlds as a Communication environment to understand each other” H. Park

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Cyberprojects G. Riva

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Cyberfocus D. Stevens

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Continuing education Quiz A. Gorini

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Journal of CyberTherapy & Rehabilitation S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

ediTorial Welcome, readers and researchers, to the Spring 2010 issue of the Journal of CyberTherapy & Rehabilitation (JCR). Our peer-reviewed quarterly academic journal continues to explore and the uses of advanced technologies for therapy, training, education, prevention and rehabilitation. JCR is unique in the fact that it focuses on the rapidly expanding worldwide trend of applying ground-breaking technology towards the field of healthcare, with an emphasis on the fields of psychiatry, psychology, physical medicine and rehabilitation, neurorehabilitation, oncology, obesity, eating disorders and autism. With a growing international base of readers and ers driven by a similar goal of advancing the use of technology in the healthcare sector, JCR has received positive attention from peers, international institutions and international conferences. To keep readers abreast of new developments, within this issue of JCR we present comprehensive articles submitted by preeminent scholars in the field, featuring such topics as combining physical activity with learning in an augmented reality setting, including the sense of olfaction more commonly in VR, and how communication is used in virtual worlds like Second Life. In the first article Voorhees et al. study the relationship between attitude and adherence to treatment in adolescents with sub-threshold depression in order to improve public health strategies to prevent depressive disorders. Next, Baus and Bouchard address the sense of olfaction and ways in which it can further and enrich VR any advocate the growth of the field while discussing possible applications in virtual environments. In an attempt to merge learning and physical activity in the classroom, Hsiao next looks at using augmented reality and VR applications to provide more effective teaching methods and increase retention, while providing much-needed exercise to the younger population at the same time. In the fourth article, Alquda et al. use Virtual Humans to look at how race and sex can affect how people inter-

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pret others’ pain, pain coping skills, related mood, and other factors. Lastly, Park discusses the use of Second Life as an example of how activities in virtual worlds might be used as a communication environment to better understand each other, with an emphasis in this study on gender. As well as continuing to provide our readers with the latest studies presented in an informative and engaging medium, we will be offering one Continuing Education quiz per issue as a further added service to our subscribers and others interested in ing their education. For more information, see page 95. I would like to sincerely thank the contributing authors for their inspiring work and dedication to this field of research. I also want to thank JCR’s Associate Editors – Professor Botella, Professor Bouchard, Professor Gamberini and Professor Riva for their leadership and hard work, as well as or internationally renowned Editorial Board for their contributions. I would also like to take this opportunity to welcome new Board – Linda A. Jackson of Michigan State University, Julian Dooley of Edith Cowan University, Wijnand IJsselsteijn from the Eindhoven University of Technology, Joshua Fogel from the University of New York, and XiaoXiang Zheng of Zhejiang University – whose diverse background and placement around the globe will bring added richness to our board. We encourage readers and subscribers to us with ideas and we welcome submissions. Your input continues to enrich our publication. With the start of a new year, new possibilities abound and we will continue to promote the growth of the diverse field of advanced technologies for healthcare in Europe and worldwide. We are happy to count you as a part of this movement and thank you for your continued . Brenda K. Wiederhold, Ph.D., MBA, BCIA Editor-in-Chief, Journal of CyberTherapy & Rehabilitation Virtual Reality Medical Institute

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Journal of CyberTherapy & Rehabilitation S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

adolesCenT inTerneT depression preVenTion: preferenCes for inTerVenTion and prediCTors of inTenTions and adherenCe Monika Marko1, Joshua Fogel2, Elton Mykerezi3, and Benjamin W. Van Voorhees1, 4, 5

Adolescents in primary care with sub-threshold depression (not reaching criteria for disorder) symptoms may be candidates for early intervention to prevent the onset of major depressive disorder. However, we know little about their attitudes toward such interventions or what may predict motivation or adherence for preventive interventions. We also describe preferences for different types of interventions and conduct exploratory analyses to identify predictors of motivation to prevent depression and subsequent adherence to an Internet-based intervention. Adolescents with sub-threshold depressed mood favored novel behavioral treatment approaches, such as Internet-based models for depression prevention. Adolescent beliefs about the intervention and perceived social norms predicted intention to participate in depression prevention. The most important significant predictors of adherence were beliefs about the intervention. Careful attention to the specific beliefs and attitudes of s toward intervention should be incorporated into intervention design as well as evolving public health strategies to prevent depressive disorders. Keywords: Depressive Disorder, Adolescents, Attitudes, Intervention, Internet

inTroduCTion Twenty-eight percent of adolescents in the United States report their current mood as depressed, while only 2-5% meet the symptom threshold for major depressive disorder at any given time (Kessler & Walters, 1998; Rushton, Forcier, & Schectman, 2002). The great majority have sub-threshold depression symptoms, which do not currently meet criteria for major depression but often will progress to major depressive disorder (Andrews, 1994). By the age of 24, one-quarter of adolescents in the U.S. will develop a depressive disorder, with a substantial adverse impact on the individual and society and with costs in excess of 100 billion dollars per year (Cicchetti & Toth, 1998; Kessler & Walters, 1998; Weissman et al., 1999). However, even sub-threshold depressive symptoms at the levels of minor depression (two symptoms

for greater than one week) are associated with considerable cost and impairment of social and academic functions (Asarnow et al., 2005). Early or preventive interventions targeting individuals with sub-threshold symptoms (20% of primary care attendees) (B. W. Van Voorhees et al., 2005, 2006) have been recommended to reduce the burden of depressive disorders (Garber, 2006; B. W. Van Voorhees et al., 2009). Unfortunately, some individuals with mild depressive symptom levels, who are the primary targets of indicated prevention strategies, demonstrate negative attitudes and beliefs toward depression, which make them reluctant to consider an intervention (Druss, Hoff, & Rosenheck, 2000; Fortney, Rost, & Zhang, 1998; Jaycox et al., 2006; Leaf, Bruce, Tischler, & Holzer, 1987; Lin & Parikh, 1999; Sihvola et al., 2006).

Corresponding Author: Benjamin Van Voorhees MD, MPH, Section of General Internal Medicine, Department of Medicine, The University of Chicago 5841 South Maryland Blvd, Chicago, Illinois, 60637 USA, Tel: 773.702-3835, Fax: 773.834-2238, Email: [email protected] Department of Medicine, The University of Chicago, Chicago, Illinois, USA Department of Economics, Brooklyn College of the City University of New York, Brooklyn, New York, USA Department of Applied Economics, University of Minnesota, Twin Cities, St. Paul, MN, USA 4 Department of Psychiatry, The University of Chicago, Chicago, Illinois, USA 5 Department of Pediatrics, The University of Chicago, Chicago, Illinois, US 1 2 3

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Pediatricians and family physicians are taking on an expanded role in screening for depressed mood, and also in identifying and treating adolescents with depressive disorders (Christensen, 2009; Grant, 2009; Kaltenthaler, 2008; Waller, 2009). The Internet offers a potentially more acceptable form of intervention in primary care settings for early intervention or prevention of mental disorders (Garber et al., 2009; B. Van Voorhees et al., in press). Motivated adolescents visit self-improvement Web sites to manage alcohol use, smoking, obesity, sexual risk and HIV/AIDS related issues, and show positive behavior change as a result(Kirk et al., 2003; Lou, Zhao, Gao, & Shah, 2006; C. A. Patten et al., 2006; Ybarra, 2006). For adults, Internet interventions may be helpful in increasing levels of exercise, adopting a more favorable diet, stopping smoking, and reducing depressed mood (Van den Berg, Schoones, & Vliet Vlieland, 2007; Walters, Wright, & Shegog, 2006; Wantland, Portillo, Holzemer, Slaughter, & McGhee, 2004). However, only 20% of the general population appears interested in Internet-based lifestyle changes, and as few as 10% actively visit such Web sites (Evers, 2005; Verheijden, Jans, Hildebrandt, & Hopman-Rock, 2007). The use of mental health related Web sites by adolescents is similarly low (G. Clarke et al., 2002; S. B. Patten, 2003; Santor, Poulin, LeBlanc, & Kusumakar, 2007) Determining preferences for intervention, and which attitudes and beliefs are associated with motivation to use a depressionprevention Web site, could facilitate the development of more acceptable public health interventions to prevent depression in community settings. The Competent Adulthood Transition with Cognitive-behavioral, Humanistic, Interpersonal Training (CATCH-IT), (B. W. Van Voorhees et al., 2007) primary care based preventive intervention was developed to target adolescents with sub-threshold depressive symptoms and provide an available broadly and low-cost, acceptable, intervention/prevention model of depressive disorders (Garber et al., 2009). This intervention/prevention model sought to overcome barriers to deployment of preventive interventions for depression by offering the intervention within the framework of primary care with an initial engagement interview by the primary care physician (Landback, 2009; B. W. Van Voorhees et al., 2007). A randomized clinical trial was conducted, comparing two forms of physician engagement (both groups having access to the Internet site), a motivational interview (MI) versus brief advice (BA) to determine whether the “patient centered” MI approach (adolescents develop their own rationale for participation) was superior to the one which relies

Adolescent Internet Depression Prevention

on physician authority of recommendation (BA) (B. W. Van Voorhees, 2009). In this trial, both groups actively engaged in exploring the Internet site and demonstrated favorable changes in vulnerability and protective factors for depressive disorder. However, the MI group demonstrated higher levels of adherence to the Internet intervention and fewer depressive episodes (B. W. Van Voorhees, Fogel, J., Pomper, B. E., & Domanico, R., 2009; B. W. Van Voorhees et al., 2008). A variety of predictors has been identified for adherence to Internet-based interventions. We know that females, school-based settings, living in a rural area and lower pretest anxiety scores predict greater adherence to Internet based depression interventions in youth (Neil, Batterham, Christensen, Bennett, & Griffiths, 2009). We also know that, for older adults, psycho-education is the least preferred option for preventing depression compared to exercise or vitamin supplementation (Grant, 2009). A few studies have reported varied levels of acceptability and satisfaction with computer-based cognitive behavioral psychotherapy (Kaltenthaler, 2008), but little is known regarding the influence of specific attitudinal factors on adherence (Waller, 2009). In contrast, we do know what adolescents in primary care think about depression prevention interventions and how such attitudes might influence motivation and adherence. The use of theoretical models of behavioral change has been proposed as a method to develop a more systematic understanding of motivation and adherence to Internet-based mental health interventions (Christensen, 2009). Organizing items according to the theory of planned behavior framework has been previously demonstrated to predict adolescent and emerging perceived need for treatment and intention in order to accept a physician’s diagnosis of major depression (B. W. Van Voorhees et al., 2005, 2006). The Theory of Planned Behavior provides a theoretical framework for understanding motivation, intention and adherence. According to this theory intention is the closest precedent of behavior, which is directly influenced by attitudes and beliefs toward a behavior (e.g., attitudes toward intervention), subjective norms (e.g., concerns with regard to family, peer or employer opinions) and perceived behavioral control (e.g., self-efficacy), as a probability that one can perform the specific behavior (e.g. adhering to the intervention) (Ajzen, 2002). In these analyses, beliefs and attitudes toward the intervention and behavior, rather than social norms, were the most important predictors of intention (B. W. Van Voorhees et al., 2005, 2006). Primary care

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Voorhees et al. physicians, health policy planners, and prevention researchers would benefit from a sound understanding of preferences for intervention and the attitudinal predictors of greater motivation for prevention and adherence to a primary care/Internet-based intervention. The purpose of this study is to provide an attitudinal description and to identify predictors of ive and active adherence within a sample of adolescents with sub-threshold depressed mood enrolled in a randomized clinical trial of a primary care/Internet-based depression intervention (B. W. Van Voorhees et al., 2009; B. W. Van Voorhees, Fogel, J., Pomper, B. E., & Domanico, R., 2009). We focus on adolescents with sub-threshold depressed mood in primary care because are the likely targets of preventive interventions for major depression (Garber, 2006; Garber et al., 2009; Landback, 2009). We provide an attitudinal description of this sample in the study and explore how specific attitudes, measured at baseline, within the framework of the theory of planned behavior may influence motivation and adherence. Based on the framework of the theory of planned behavior, we hypothesize that (1) attitudes/beliefs about intervention effectiveness would be the most important predictors of motivation for preventive intervention and participation in such an intervention in primary care. We also hypothesize that (2) adolescent primary care patients with sub-threshold depressive symptoms would exhibit ambivalence toward established traditional interventions (medications, group and individual counseling) similar to earlier studies of adolescents and adults with major depressive disorder (Cooper-Patrick et al., 1997; Jaycox et al., 2006). meThods sTudy design This study is based on a survey of adolescents enrolled to participate in a randomized controlled trial in primary care of an Internet-based depression intervention and prevention program (CATCH-IT). We conducted a phase-2 clinical trial of a primary care/Internet-based depression prevention intervention for adolescents at 13 U.S. primary care sites (B. W. Van Voorhees et al., 2009; B. W. Van Voorhees et al., 2008). Eligible adolescents were assigned randomly to either a primary care physician (P) motivational interview plus the use of a Internet Web site or to P brief advice and use of a Internet Web site. Those eligible and willing to enroll completed a baseline questionnaire relating to attitudes and beliefs, as well as motivation for prevention before they received their randomization assignment. The responses to these questions, together with

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11 the ive and active adherence to the Web site, are the subject of our analysis. The ive and active adherence of the intervention was approximated by time spent on the Web site and number of characters typed in, respectively. Both measures were obtained by using simple algorithms in the Web site. The randomized controlled trial methods have been fully described in prior publications (B. W. Van Voorhees et al., 2009; B. W. Van Voorhees et al., 2008). The University of Chicago Institutional Review Board, as well as those with responsibility for each site ,approved this study. sTudy sample and eligibiliTy Participants were adolescents (N=83) between the age of 14-21, recruited from 13 primary care sites throughout the Southern and Midwest U.S., and reported at least one core symptom of depression at both the initial screening and the at the full eligibility assessment istered one to two weeks after the initial screening. Potential participants were identified by completing a two-item screening questionnaire based on the Patient Heath Questionnaire Adolescent (PHQ-A-2) core depression symptom items in the routine process of care (all adolescents visiting the clinic) (Johnson, Harris, Spitzer, & Williams, 2002). Adolescents reporting any core depressive symptom lasting longer than a few days in the two weeks prior to the screening were considered “positive.” Those with “positive” screens and who consented to be ed by study staff were called by phone for eligibility assessment. Inclusion criteria included aged between 14-21, presence of one core symptom of depression, but below the level of major depression (four or fewer symptoms, “sub-threshold depressed mood”). Exclusion criteria included meeting criteria (or getting treatment) for minor or major depression, expressing frequent suicidal thought or intent, bipolar disorder, conduct disorder, substance abuse, generalized anxiety disorder, or any type of eating disorder. Consent from adolescents and parents (if adolescents were under 18 years old) was collected by study staff at the clinic. A full description and the criteria of the recruiting method have been previously reported (Johnson et al., 2002). demographiCs Information on age, gender, race/ethnicity, and education level was recorded. Furthermore, family’s history of depression or any depressive disorder pertaining to the individual was assessed by asking, “Have you ever been treated for depression (via medication or counseling)?” and “Have any of your family (mother, father, sister(s), brother(s)) ever been treated for depression that

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lasted at least four weeks?” For the participant’s dimensional measures of depressed mood we report Center for Epidemiologic Studies Depression Scale 10 items (CESD10), scored as double to create the 60-point scale. preferenCes for inTerVenTion Preferences for treatment (get over it naturally, medication, one-on-one or group counseling) were developed from the Quality Improvement in Depression study, which showed that among primary care adult patients viewing treatments as unacceptable, there is an association with a lower likelihood of seeking treatment (Rost, Nutting, Smith, & Werner, 2000). Responses were recorded in a Likert-type scale ranging from “1=definitely acceptable” to “4=definitely not acceptable,” where participants rated statements such as “I will wait and get over it naturally,” “Use antidepressant drugs,” “Seek one-on-one counseling from a mental health specialist,” and “Seek group counseling… led by a mental health specialist.” We added several options that were not included in the original scale, represented by statements such as “Talking with primary care physician (P) about what you can do to prevent depression,” “Talking with P and agreeing to set up a regular schedule,” “Talking with P about your feelings and situation,” “Talking with P and agreeing to complete an e-program,” “Talking to a counselor through the phone about your feelings,” “Complete a questionnaire with your P,” “Complete a questionnaire Online,” “Start an exercise program with thirty minutes of aerobic activity, individually,” “Start an exercise program with thirty minutes of aerobic activity with a group,” “Participate in a religious youth group,” “Take a health class to learn about feelings and coping skills,” and “Group meeting with 6-10 peers from your school.” All items were scaled in accordance to the original scale, as mentioned above. depression preVenTion iTems based upon Theory of planned behaVior We adapted the items from a previous questionnaire, which was modified based on the preventive health model (Myers et al., 1996; B. W. Van Voorhees et al., 2006). The original instrument, developed for prostate cancer, was adapted to primary care based depression prevention. The reliability (Cronbach alpha =0.89) and validity of the instrument was evaluated during a pilot study of the CATCH-IT intervention in 2004. Validity is ed by several items demonstrating a trend toward predicting intervention performance (predictive validity) and post-study qualitative interviews suggested that the concerns/themes identified were consistent with items on the scale (face validity). The participants

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indicated a level of agreement based on a Likert-type scale ranging from “1=strongly disagree” to “5=strongly agree.” Beliefs about the intervention were defined by such statements as “depression intervention makes sense to me,” “protecting yourself from depression through intervention,” “participating in intervention is important,” “if depression is found early it can be prevented,” “depression intervention could prevent further depression,” “depression intervention will help me to get healthy,” and “would be better off without the intervention.” Attitudes toward the behavioral intervention were measured by the statements “going through depression intervention is too much trouble,” “the benefits of the prevention outweigh any difficulty,” and “going through a depression intervention is too embarrassing.” Subjective social norms were measured by such statements as “ of my family me going through intervention,” “I want to please family,” “I want to do what the doctors want me to do about depression,” “I think physicians want me to do a depression intervention,” “my close friends my going through a depression intervention,” and “I want to please my close friends.” Perceived behavioral control was measured by self-efficacy and had items of “going through this depression intervention would be easy” and “arranging the schedule for the intervention will be easy.” We had previously istered this questionnaire in a pilot study and found it acceptable and easily understood. moTiVaTion ToWard preVenTiVe inTerVenTion These items were adapted from Miller and Rollnick’s three-item assessment of motivation (Miller & Rollnick, 1991). The measures of motivation toward treatment or intervention were constructed from the responses to the following statements measured with a Likert-type scale ranging from “1=not important” to “10=very important”: “rate your ability to learn coping skills to reduce your risk of clinical depression,” “rate your readiness to reduce your risk of clinical depression by learning coping skills,” and “rate the importance of preventing an episode of clinical depression over the next year.” ouTCome Variables BEhavioral iNtENtioN Behavioral intention was measured by the stage of changing ways to deal with problems in order to prevent depression. It was measured by the response to the question, “Please indicate which statement best fits your current position with regard to changing the way you think about and solve everyday problems to reduce your risk of developing clinical depression.” Participants indicated their responses

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Voorhees et al. using a Likert-type scale, consisting of “1=I have not given any thought to changing...”, “2=I am giving some thought to changing...”, “3=I am preparing to change...”, “4=I have decided to change...but do not have a plan...” and “5=I have decided to change...and I have a plan...” where higher scores indicate a more active adherence towards changing the behavior. ivE adhErENcE We measured ive adherence on the Web site by calculating the total amount of time participants spent online throughout the intervention. This variable was constructed by a simple algorithm, which subtracted the first page load timestamp from the last page load timestamp in a given session. The length of time for each session was capped at seven minutes, since that is the approximate maximum amount of time required to review the materials on each page. In cases when sessions lasted more then seven minutes, we assumed the participant was not reviewing material and the page was still loading. The length of all sessions was then added together to generate the total amount of time spent online. We chose to calculate time spent on the Web site because this is a broad measure of willingness to at least review material related to depression prevention and its ease of measurement (B. W. Van Voorhees et al., 2009). Visitation of the Internet Web site was done entirely at the adolescents’ discretion and occurred completely separate from the physician encounter. activE adhErENcE Active adherence was measured by a proxy measure of the total number of characters typed throughout the intervention. The variable was constructed by counting the total number of characters typed by each participant as a part of completing exercises and writing notes at the end of each module, and then adding the characters together across all modules to generate the total number of characters typed. This outcome variable was used to measure the active behavior of the participants. It was selected because of its ease of measurement and its relationship to choosing to actively participate in a behavior change process (B. W. Van Voorhees et al., 2009). This is similar to “homework” in cognitive behavioral psychotherapy. statistical aNalysEs Descriptive statistics were calculated for the demographic variables, preferences for treatment variables, and depression prevention items based upon the theory of planned behavior. Separate linear regression analyses were performed for the three outcome variables of intention, ive adher-

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13 ence, and active adherence. As ive adherence and active adherence were both skewed data, they were logarithmically transformed to allow for a normal distribution. There were four models for each analysis. Model 1 was a univariate analysis. Model 2 adjusted for age, race/ethnicity (white/non-white), and gender. Model 3 adjusted for the items from the same category/block. Model 4 simultaneously adjusted for all items that were significant or approached significance for each outcome (p-value<0.10) in model 3 in order to understand the strongest correlates from the category/block in a multivariate framework. Motivation items were added as predictors to the ive adherence and active adherence outcome analyses. They were not included for the intention outcome analysis, as the theory of planned behavior does not typically include motivation as a predictor for the intention outcome. STATA 10 was used to conduct the analyses ("Stata Statistical Software: Release 10," 2009). resulTs demographiCs The total number of participants screened reporting at least one core depressive symptom in the two weeks prior to the screening comprised 21% (N=293) of the entire sample, with participants aged from 14-21 years. One hundred and sixty-two participants were ed to participate in the full assessment, (N=131 were not able to be ed). Of the 162 participants, 71.6% (N=116) agreed to a full assessment and 13 were ruled ineligible (i.e., due to major depression, conduct disorder, or suicide intent). The remaining 103 participants were found eligible and 80.6% (N=83) enrolled. Fifty-seven percent were females (N=47). Race/ethnicity varied and included, 61% (N=49) whites and 24% African American (N=19), followed by 6% Asians (N=5), 5% Hispanics (N=4), and 4% of other racial composition (N=3). Average age was 17.5 years old (SD=2.04). Twentyseven percent of the adolescents (N=20) sampled were currently attending college, with one individual who had already completed college, while over half of the teens had finished at least 10 years of education (N=43) and 14% (N=10) had completed 12 years of education. The mean household income of the sample measured by zip code information obtained from the U.S. Census 2000 was $40,249 (SD=$14,500). More than half of the screened adolescents in the sample had a family history of depression (N=43), while 31% (N=21) of the adolescents had received prior counseling, and 18% (N=13) had been previously treated with medication. The demographic profile of this sample has been reported in greater detail in the primary clinical trial publication (B. W. Van Voorhees et al., 2009).

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preferenCes for inTerVenTion As shown in Table 1, most adolescents preferred primary care based interventions, such as talking to their primary care doctor about what to do to prevent depression

Adolescent Internet Depression Prevention

(86.95%, N=60 chose definitely acceptable and probably acceptable). Other popular preferences endorsed by more than 75% included talking with P and agreeing to set up a regular schedule of pleasurable activities, starting an in-

Table 1 Preferences for Treatment

Note. ** Adjusted for similar items in the block

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Voorhees et al. dividual aerobic exercise program for thirty minutes a day, talking with P about feelings and situation, completing Internet questionnaires, seeking one-on-one counseling from a mental health specialist, starting a group aerobic exercise program for thirty minutes a day, and completing questionnaires with a P. The least preferred preferences for treatment that were endorsed by less than 40% included talking to a counselor by phone about their feelings, and a

15 group meeting with 6-10 peers from your school. Almost three-fifths endorsed “waiting and getting over it naturally” (i.e., no treatment) as acceptable. depression preVenTion iTems based upon Theory of planned behaVior As shown in Table 2, most adolescents endorsed favorable beliefs toward a primary care Internet-based depression

Table 2 Depression Prevention Based on Theory of Planned Behavior

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Table 2 cont.

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Voorhees et al.

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Table 2 cont.

prevention intervention program, indicating that it makes sense to them (68%, N=53 chose strongly agree and agree) and believing it will help them be healthy (70%, N=53 chose strongly agree and agree). Additional beliefs favored by more than 64% (N=50) included beliefs that depression, if detected early, can be prevented, prevention intervention could prevent further depression (65% N=51), and strongly disagree/disagree with being better off without a depression prevention intervention (68% N=54). For the attitude items, 60% (N=46) favored that the benefits of a depression prevention program outweigh any difficulty. Similarly, adolescents (62.83% N=49) generally disagreed with the concept that the intervention was “too much trouble” but only a minority reported favorable social norms toward the intervention. In of self-efficacy, while most felt it would be easy to arrange their schedule to participate (59% N=45) only less than half the adolescents in the sample felt that completing such an intervention would be “easy” (42% N=32). prediCTors of inTenTions As shown in Table 3, with regard to beliefs, the belief of “participating in an intervention like this is important” significantly predicted intentions for changing ways to deal with problems in order to prevent depression for Models 1 and 3 and approached significance in Model 2. Also, the belief of “a depression prevention intervention could prevent further depression” was significant in Model 1 and approached significance in Model 2. None of the attitudes significantly predicted intentions. Social norms had significance in Model 3 for the family item of “I want to please my family,” the physician item of “I want to do what the physicians want me to do about depression prevention” in Model 1 and Model 3, and approached significance for friends for the item of “My close friends my going

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through a depression prevention program” in Models 1 and 3. No self-efficacy items were significant. The demographics item of male gender significantly predicted lower intention in Model 1 and 3, but depressed mood (CES-D score) did not predict intentions. In Model 4, only the social norms item of family was significantly associated with intentions. prediCTors of iVe adherenCe As shown in Table 4 with regards to beliefs, the belief of “participating in an intervention like this is important” and “a depression prevention intervention could prevent further depression” all significantly predicted total time spent online as a measure of ive adherence to prevent depression for Models 1 and Model 2. Also, there was a significant negative association with “being better off without a depression prevention intervention” and total time spent online in Models 1, 2, and 3. The attitude item of “the benefits of a depression prevention intervention outweigh any difficulty” significantly predicted total time spent online in Models 1 and 2. None of the perceived social norms significantly predicted total time spent online. The perceived behavioral control item of “arranging my schedule for depression prevention intervention will be easy” significantly predicted total time spent online in Model 3. Motivation item of “rate your ability to learn coping skills to reduce your risk of clinical depression” significantly predicted total time spent online for both Models 1 and 2 and the motivation item of “readiness” approached significance in Model 1 and was significant in Model 2. The motivation item of “preventing an episode” approached significance in Model 2. Depressed mood did not predict total time spent online in any of the models with which it was included. In Model 4, only the belief about “being better off without a depression prevention intervention” was significant with a negative association with total time spent online.

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prediCTors of aCTiVe adherenCe As shown in Table 5 with regards to beliefs, the beliefs of “protecting myself from depression through a depression prevention intervention,” “participating in an intervention like this is important,” and “when depression is found early it can be prevented” all significantly predicted the total

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numbers of characters typed, as a measure of active adherence in preventing depression in Models 1 and 2. The belief of “depression prevention intervention could prevent further depression” for Models 1 and 2, and also “depression prevention intervention will help me to be healthy” for Model 1, all approached significance. With regard to atti-

Table 3 Predictors of Intention

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Table 3 cont.

tudes, the item of “the benefits of a depression prevention intervention outweigh any difficulty” significantly predicted number of characters typed in Models 1, 2, and 3. The social norm item of “I want to do what the physicians want me to do about depression prevention” significantly predicted the dependent variable only in Models 1 and 2

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and approached significance in Model 3. Also, there was a negative association of “immediate family ” for significantly predicting number of characters typed in Model 3. None of the perceived behavioral control items were significant predictors. Male gender approached significance for a negative association with number of characters

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Table 3 cont.

Self efficacy

Demographics

typed in Model 3. The motivation item of “readiness” significantly predicted the total number of characters typed in Models 1, 2, and 3. Depressed mood did not predict number of characters typed in any of the models with which it was included. In Model 4, only the belief item of “protecting myself from depression through a depression prevention intervention” significantly predicted total numbers of characters typed. missing daTa ConCerns Participants and those eligible to participate did not differ based on PHQ-A -2 scores. Similarly, participants did not vary based on PHQ-A-2 scores from those we identified in screening but whom we either did not reach or did not consent to a phone interview. We examined reasons for non-participation in the phone assessment (N=177). Of those who did not participate in the initial phone assess-

ment, 46 answered the phone for the follow-up study. Of those who answered the phone, the most common reason for declining an interview was that they were not interested (50.0%, N=23), followed by being too young (21.7%, N=10). There was no significant difference in the level of depressed mood between those who participated in the study and those who chose not to participate. disCussion Adolescents endorsed favorable attitudes and preferences toward primary care Internet-based interventions and more ambivalent attitudes toward more traditional delivery forms such a group counseling program. While the majority of the sample participants found conventional approaches to depression prevention, such as talking to their primary care doctors about depression prevention and feelings and setting up a regular schedule

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Voorhees et al. with their family practitioners acceptable, a great number of the adolescents found novel forms of intervention acceptable, such as completing an Internet questionnaire and starting an individual exercise program. Furthermore, most of the adolescents we assessed agreed that intervention programs were important and relevant and more than half believed that an intervention program Table 4 Predictors of ive Adherence

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21 could help prevent further depression. The most important predictors were family social norms for intentions, disagreeing with the belief about “being better off without a depression prevention intervention” for ive adherence, and the belief of “protecting myself from depression through a depression prevention intervention” for active adherence.

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Table 4 cont.

preferenCes for inTerVenTion This is the first study to consider preferences for intervention of adolescents with sub-threshold symptoms. As hypothesized, (hypothesis 2) we found that adolescents with sub-threshold symptoms in primary care preferred novel approaches such as personal exercise or completing Internet questionnaires. The preference for primary care and Internet-based approaches might be congruent to the preference reported for an autonomous-ive environment from patients’ health practitioners (Sheldon, 2003; Vansteenkiste & Sheldon, 2006; Wisdom, Clarke, & Green, 2006) and methods under personal control such as exercise or vitamin supplementation (Grant, 2009). The findings that a majority of adolescents preferred no treatment (57%) (“Waiting and getting over in naturally”) and preferred individual counseling (79%) to group counseling

(43%) are new and important. The most effective preventive intervention to date have used the group counseling approach (G. N. H. Clarke, M., Lynch, F., et al., 2001; Garber et al., 2009). This is consistent with preference expressed by older adults for less psychologically-oriented approaches such as those including exercise and vitamins (Grant, 2009). In contrast, Jaycox and colleagues demonstrated that most adolescents in primary care settings diagnosed with major depressive disorder preferred active treatment (72%) with face-to-face counseling or anti-depressants, rather than watchful waiting (28%) (Jaycox et al., 2006). This difference might be explained by the findings that symptom severity substantially predicts perceived need for intervention and willingness to accept treatment (B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al., 2005, 2006) and in our study participants had low levels

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Table 4 cont.

of depression symptom severity. Our study findings in an adolescent sample may differ due to the greater concern of adolescents with regard to opinions of peers compared to adults. aTTiTudes ToWard depression preVenTion Prior studies have assessed the influence that attitudes and beliefs of adolescents with varying levels of symptoms have on their intent to seek treatment (B. W. Van Voorhees et al., 2007; B. W. Van Voorhees et al., 2006) or preferences for treatment (Jaycox et al., 2006). However, to our knowledge this is the first study that reports specific attitudes and beliefs towards depression prevention on adolescents with sub-threshold depressive symptoms (Christensen, 2009; Neil et al., 2009). Our study also departs from the previous studies in that it assesses perceived behavioral control in accordance with the theory of planned behavior framework (Ajzen, 2002). The participants appeared to endorse primary care/Internet-based prevention, which is consistent

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with prior work demonstrating that the lay public and adolescents view primary care physicians as their first source for care (Highet, Hickie, & Davenport, 2002; Joffe, Radius, & Gall, 1988) and that they desire psychosocial interventions despite the reported growing acceptance of the “biological model” for treating depression (Blumner & Marcus, 2009). prediCTors of inTenTions The significant relationship for both beliefs about the intervention and perceived social norms with the intentions outcome is a new finding consistent with prior work that shows attitudes/beliefs toward an intervention predict both intention and service use (Jaycox et al., 2006; Leaf et al., 1987; Lin & Parikh, 1999; B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al., 2005, 2006). However, the relatively greater importance of social norms for predicting intention to prevention surprised us because our prior work with predicting treatment suggested that beliefs toward the

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Table 5 Predictors of Active Adherence

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Table 5 cont.

intervention demonstrated a primacy in decision-making (B. W. Van Voorhees et al., 2005, 2006). Similarly, self-efficacy and/or attitudes toward the behavior did not predict intention or use as it has in other studies (Leaf et al., 1988; B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al., 2005, 2006). Perhaps for new or novel preventive interventions such as our Internet-based intervention and also

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when the perceived need for treatment is low since these individuals had sub-threshold depressive symptoms, an adolescent turns to family, such as parents, and friends for guidance (DeBar, 2009). The inverse relationship between males and intention is consistent with prior work demonstrating greater use by females of the Internet-based programs (Christensen, 2009; Neil et al., 2009).

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Table 5 cont.

prediCTors of iVe and aCTiVe adherenCe The findings that beliefs about the intervention, attitudes toward behavior, self-efficacy and motivation predict ive and active adherence for the prevention intervention is a new finding. Conversely, demographic factors such as age, gender, depressed mood severity or non-white ethnicity, did not influence adherence as has been noted in prior studies (Christensen, 2009; Neil et al., 2009). The findings that beliefs concerning the intervention were the most important predictors our first hypothesis that beliefs about intervention effectiveness would be the most important predictors of motivation for preventive intervention. These findings are consistent with an extensive amount of literature linking attitudes to help seeking and/or intentions (Jaycox et al., 2006; Leaf et al., 1987; Lin & Parikh, 1999; B. W. Van Voorhees et al., 2003; B. W. Van Voorhees et al., 2005, 2006). These findings are also consistent with the theoretical models of the Theory of Planned Behavior (Hagger, Chatzisarantis, Biddle, & Chatzisarantis, 2002) and Transtheoretical Model of Change (Miller & Rollnick, 1991). Similarly, we have previously established that mo-

tivational interviewing before Web site use increases both time on the Web site and also number of characters typed (B. W. Van Voorhees, Fogel, J., Pomper, B. E., & Domanico, R., 2009). Neil and his team have previously demonstrated that symptom severity influences adherence (Neil et al., 2009). We were surprised that symptom severity did not influence adherence in our study. This may reflect that the perceived need for “intervention” was deliberately constructed around a “prevention and resiliency model” rather than an illness model (B. Van Voorhees et al., in press). Perhaps the adolescents discounted their current symptoms when determining whether or not to engage in the Internet Web site activities (B. Van Voorhees et al., in press; B. W. Van Voorhees et al., 2007). limiTaTions The primary strength of this study was the recruitment of a sample of adolescents in varied primary care settings in two U.S. regions, which resulted in a diverse sample (40% ethnic minority). Limitations of this study include the small sample size and possible selection bias toward ado-

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lescents who may be more favorably disposed toward primary care, Internet-based interventions and possibly all mental health interventions than adolescents who chose not to respond to the study after the initial screening identified them as “at risk.” Similarly, we omitted individuals who did not visit the Internet site from the adherence analyses in order to convert the outcome variable to a natural log and attain a normal distribution. Also, the small sample size limited the capacity to complete multivariate analyses and consequently may have underestimated the number of potentially significant relationships in the multivariate models. Conversely, the adolescent participants that consented to a relatively “low burden” study and were found eligible to participate in the study were not originally “seeking” treatment for depression or any other mental-health related disease. As such, they might have represented a “snap shot” of primary care attendees in these practices. Given the limitations of the sample size, we must characterize these findings as exploratory in nature.

ConClusion Adolescents in primary care are open to the idea of early preventive intervention to avert developing depressive episodes. They seem to prefer novel forms of intervention such as Internet-based types and primary care-based prescriptions for exercise. Clinicians should recognize that adolescents might be persuaded to take more proactive approaches to preventing depression based on their recommendations. Clinicians should consider the potential value of novel interventions such as adherence to daily exercises or use of cognitive behavioral therapy through Internet Web sites. Researchers should consider the value of embedding interventions into the normative framework of primary care where physicians’ persuasive influence can be exercised and controlled. Policy makers should consider primary care as an acceptable environment to intervene to prevent depressive disorders in adolescents and consider how such efforts can be ed with adequate reimbursement from the healthcare and health insurance systems.

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29 Sihvola, E., Keski-Rahkonen, A., Dick, D. M., Pulkkinen, L., Rose, R. J., Marttunen, M., et al. (2006). Minor depression in adolescence: Phenomenology and clinical correlates. J Affect Disord. Stata Statistical Software: Release 10. (2009). (2009). College Station, TX: StataCorp LP. Van den Berg, M. H., Schoones, J. W., & Vliet Vlieland, T. P. (2007). Internet-based physical activity interventions: a systematic review of the literature. J Med Internet Res, 9(3), e26. Van Voorhees, B., Watson, N., Bridges, J., Fogel, J., Gallas, J., Kramer, C., et al. (in press). Development and Pilot Study of a Marketing Strategy for Primary Care/Internet Based Depression Prevention Intervention for Adolescents (CATCH-IT). Journal of Clinical Psychiatry Primary Care Companion. Van Voorhees, B. W. (2009). 12-Month outcomes of a randomized clinical trial of a primary care Internet-based depression prevention intervention (CATCH-IT). Paper presented at the Society for Prevention Research. Van Voorhees, B. W., Cooper, L. A., Rost, K. M., Nutting, P., Rubenstein, L. V., Meredith, L., et al. (2003). Primary care patients with depression are less accepting of treatment than those seen by mental health specialists. J Gen Intern Med, 18(12), 991-1000.

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need for depression treatment among young adults. Soc Psychiatry Psychiatr Epidemiol, 41(9), 746-754. Van Voorhees, B. W., Fogel, J., Reinecke, M. A., Gladstone, T., Stuart, S., Gollan, J., et al. (2009). Randomized clinical trial of an Internet-based depression prevention program for adolescents (Project CATCH-IT) in primary care: 12-week outcomes. J Dev Behav Pediatr, 30(1), 23-37. Van Voorhees, B. W., Fogel, J., Pomper, B. E., & Domanico, R. (2009). Adolescent dose and ratings of an Internet-based depression prevention program: A randomized trial of primary care physician brief advice versus a motivational interview. Journal of Cognitive and Behavioral Psychotherapies, 9(1). Van Voorhees, B. W., Vanderplough-Booth, K., Fogel, J., Gladstone, T., Bell, C., Stuart, S., et al. (2008). Integrative internet-based depression prevention for adolescents: a randomized clinical trial in primary care for vulnerability and protective factors. J Can Acad Child Adolesc Psychiatry, 17(4), 184-196. Vansteenkiste, M., & Sheldon, K. M. (2006). There's nothing more practical than a good theory: integratand interviewing motivational ing self-determination theory. Br J Clin Psychol, 45(Pt 1), 63-82. Verheijden, M. W., Jans, M. P., Hildebrandt, V. H., & Hop-

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Journal of CyberTherapy & Rehabilitation S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

The sense of olfaCTion: iTs CharaCTerisTiCs and iTs possible appliCaTions in VirTual enVironmenTs Oliver Baus1,3 and Stéphane Bouchard1,2,3

Virtual environments (VE) aim to reproduce life-like experiences, but despite indications that the olfactory sense plays a significant role in everyday life, the integration of olfactory stimuli in VEs is rare. The aim of this paper is to review the literature on olfaction and its potential applications in Virtual Reality (VR). Indications ing the integration of odorants in VR include the privileged connections between the olfactory system and the brain regions involved in the processing of virtual stimuli used in clinical applications, as well as the interaction between odors, the other senses, and various psychological processes. Presently, smells are mostly integrated in VR applications for post-traumatic stress disorder and drug addiction, but further uses of odorants in VEs could include pain distraction, various training scenarios, such as emergency response and relaxation, and investigations of multi-sensory integration. Keywords: Olfaction, Smell, Odor, Virtual Environment, Virtual Reality

“Of all the ways of getting sensory information to the brain, the olfactory system is the most ancient and perhaps the least understood” (Ratey, 2001, p. 62). The sense of smell is believed to have been a major catalyst in the evolution of the primitive brain, and it is suspected that the entire limbic system actually evolved from its original function of interpreting odorants and emitting pheromones (Ratey, 2001). Its significance for animals is readily recognized (Ache & Young, 2005). It plays a role in their search for food, navigation and orientation, reproductive behavior, and social organization (Albrecht & Wiesmann, 2006). Although many of these aspects also apply to humans (Albrecht & Wiesmann, 2006), many tend to consider olfaction of minor importance (Shepherd, 2006). The relatively minor interest in the olfactory sense is also reflected in the field of virtual reality (VR), and various factors may contribute to the underutilization of olfactory stimuli in virtual environments (VE). According to Sad-

owski (1999), these factors include the perception that incorporating olfaction stimuli would neither enhance the virtual experience, nor be useful in concrete applications. Most importantly, the primary obstacle to a generalized integration of olfactory stimuli in VEs may be the difficulty in dispensing and controlling the odorants in the environment (Sadowski, 1999). To date, relaxation techniques (Kawai & Noro, 1996), posttraumatic stress disorder (PTSD) treatment (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo, 2008), and drug addiction research (Bordnick et al., 2008; Ryan, Kreiner, Chapman, & Stark-Wroblewski, 2009) belong to the rare applications integrating olfactory cues in clinically pertinent VR scenarios. More specifically, Kawai and Noro (1996) coordinated olfactory cues with the content of stereoscopic 3-D images, for example, using the fragrance of a forest with 3-D images of a green forest, in order to experiment with the relaxation effects of such combina-

Corresponding Author: Stéphane Bouchard, Dept de Psychoéducation et de psychologie, Université du Québec en Outaouais, C.P. 1250 Succ "Hull", Gatineau, Québec, J8X 3X7, E-mail: [email protected]. University of Ottawa, Ottawa, Ontario, Canada Université du Québec en Outaouais, Gatineau, Quebec, Canada Laboratory of Cyberpsychology, Gatineau, Quebec, Canada

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tions. The results of this experiment suggest that such associations can lead to a psychological effect as measured in three psychological factors–depressive mood, anxious mood, as well as tension and excitement–that differs according to the type of fragrance (forest, marine, or lavender). In the field of PTSD treatment in VR, Gerardi and colleagues' (2008) protocol calls for exposure to visual, auditory, tactile (i.e., vibration), and olfactory stimuli (burning rubber, diesel fuel, weapons fire and spices). During treatment, the patient is exposed to multi-sensory combat zone stimuli while driving a Humvee in either urban or non-urban "Iraq-like" scenes. The intensity of these stimuli increases gradually across sessions. The results of this brief, single case VR exposure treatment included clinically and statistically significant changes in scores on the Clinician istered PTSD Scale (Blake et al., 1990) and the PTSD Symptom Scale Self-Report (Foa, Riggs, Dancu, & Rothbaum, 1993), thereby suggesting preliminary promise for this type of intervention (Gerardi et al., 2008). In the field of substance abuse and addictions, Bordnick and colleagues' (2008) VR alcohol cue reactivity assessment system incorporated visual, auditory and olfactory stimuli. These stimuli included the scents of vanilla, pizza, coffee, the preferred drink of the participant (such as whiskey, beer, brandy, tequila, gin, scotch, red wine or white wine), beer, cigarette smoke, and pine trees. During trials involving non-treatment seeking individuals with alcohol use disorders, the exposure of the subjects to multi-sensory alcohol related cues generated higher subjective alcohol cravings than when these cues were absent. Furthermore, the multi-modal VE appears to be associated with high levels of presence in VR (Bordnick et al., 2008). In an interesting variation on the previous experience, Ryan et al. (2009) found that, when exposed to multi-sensory alcohol related cues, binge drinking college students reported significantly higher cravings for, and thoughts of, alcohol than non-binge drinkers. Yet, considering that the sense of smell plays a significant role in everyday human life (Drummond, Douglas, & Olver, 2007), and that its loss or impairment has significant chances of adversely affecting an individual’s quality of living and emotional experience (Pollatos et al., 2007), it would seem that the successful integration of olfactory stimuli in VEs should be pursued more actively. Thus, the purpose of this paper is to provide VR researchers an overview of the olfactory system, and its involvement in psychological reactions, in the hope that this information may contribute to an increased use of olfactory cues in VR

The Sense of Olfaction

clinical applications. To this end, the information is structured into six sections, the first of which briefly addresses the neuroanatomy of the olfactory system. The next two sections cover the capabilities of the olfactory sense, and the characteristics of odors. Next, the potential interactions involving the olfactory sense are covered. The fourth section presents various factors that influence olfactory processing and the fifth section presents some of the influences of odors on physiological state, perception and mental processes. Lastly, the present status of the research involving the sense of olfaction, and the use of olfactory stimuli in VEs will be discussed. This discussion will introduce some of the present, and some of the potential, applications of exposure to olfactory stimuli in VEs. neuroanaTomy of The olfaCTory sysTem Olfaction is the “sensation of odors that results from the detection of odorous substances aerosolized in the environment” (Simpson & Sweazy, 2006, p.377), and thus, it is categorized as a chemical sense, as in the sense of taste. In addressing olfaction, it is important to distinguish between the “odor” and “odorant” (e.g., Hudson, 2000; Hudson & Distel, 2002a,b). While an odorant, or olfactory stimulus, is a physicochemical entity of molecules in the environment (Hudson & Distel, 2003), an odor is the percept created by a subject’s nervous system, in reaction to the between the olfactory receptors and the molecule patterns of the odorant (Hudson & Distel, 2003). An odorant commences its transformation into an odor either from the outside (orthonasal) or from the inside (retronasal) of the subject’s body. Whereas orthonasal stimulation results from sniffing the ambient air, retronasal stimulation results when the odorants of ingested food travel up from the back of the oral cavity and through the nasopharynx into the nasal cavity (Shepherd, 2006). In either case, the odorant ends up in the olfactory mucosa, itself located in the superior and posterior part of the nasal cavity (Mackay-Sim & Royet, 2006). There, the odorant, which must be hydrophilic or lipophilic in order to dissolve in the mucus (Stockhorst & Pietrowsky, 2004), comes into with the olfactory receptors of the olfactory epithelium (Ratey, 2001). The axons of the sensory neurons fasciculate to form the fila olfactoria (MackaySim & Royet, 2006), which traverses the skull base through the cribriform plate, to then enter the olfactory bulb. The left and right olfactory bulbs are interconnected via the anterior commissure (Mackay-Sim & Royet, 2006), and axons leave the olfactory bulb via the olfactory tract, to then project onto a group of structures collectively

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referred to as the primary olfactory cortex (Mackay-Sim & Royet, 2006). These structures include the amygdala which seems to play critical roles in odor processing (Jones-Gotman & Zatorre, 1993; Zald & Pardo, 2000), conditioned fear and attention (Bremner et al., 1999), as well as aversive and negative emotional states (Hamann & Mao, 2002). There exist important differences in neuroanatomical connections between the olfactory sense and other senses. The various connections of the olfactory system are illustrated at Fig.1. While other senses go through a series of cortical relays before reaching the limbic system, the olfactory bulb projects uncrossed (Ratey, 2001), and without being mediated by the thalamus (Simpson & Sweazy, 2006), onto the amygdala. There seems, however, to exist an additional indirect and less prominent link between the primary olfactory cortex and the secondary olfactory area via the thalamus, (Djordjevic & Jones-Gotman, 2006). In addition, the connection to the orbitofrontal cortex provides olfaction with the “fastest route between perception and action” (Malaspina et al., 2006, p. 222). In summary, an odor is the result of complex interactions between the molecular pattern of an odorant, the olfactory receptors, the olfactory bulb, the primary olfactory cortex and the secondary olfactory area. Most importantly, when compared to the other senses, the sense of olfaction enjoys a more direct, and thus, faster and less filtered, uncrossed connection with the amygdala. It is this privileged relation with the limbic system, as well as that with the orbitofrontal cortex, that speak in favor of the use of olfactory cues in VR. Indeed, many of these brain regions are involved in the processing of virtual stimuli used in clinical applications, including anxiety disorders (Phillips, Drevets, Rauch, & Lane, 2003), addictions (Everitt & Robbins, 2005) and eating disorders (Beckman, Shi, Levine, & Billington, 2009). CapabiliTies of The olfaCTory sense Differentiable behavior and physiological changes expressed by newborn in reaction to odorants suggest that, unlike the visual system, the olfactory system is remarkably mature at birth (Schaal, Marlier, & Soussignan, 1998, 2000). However, other than “an aversion to decaying, putrid or bitter things” (Morean, 2007, p. 157), the only inborn olfactory preference seems to be that for the mother’s amniotic fluid (Schaal, Marlier, & Soussignan, 1998). It seems that the right hemisphere is involved in the elaboration of odors (Zatorre, Jones-Gotman, Evans, & Meyer, 1992; Zucco & Tressoldi, 1989), and that they are acquired

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as a whole entity (Zucco, 2007). Unlike vision or hearing, olfaction needs to be activated (Köster, 2002), and its olfactory bulb-produced “images” are subconscious (Shepherd, 2006). This latter point is ed by the absence of a significant relay in the thalamus (Shepherd, 2006). Furthermore, it seems impossible for a subject to conjure up an olfactory image (Moeran, 2007). Concerning this difference form the other senses, Zucco (2003) offers the explanation that, unlike olfactory representations, visual and verbal representations are conceptual, and thus, can give rise to conscious representations. Alike the other sensory modalities, the olfactory system habituates to a prevailing stimulus (Morean, 2007). This phenomenon is observable through a rapid decline in the pyriform cortex activation during constant exposure to a particular olfactory stimulus (Poellinger et al., 2001; Sobel et al., 2000). In humans, the development of different cognitive processes for socialization seems to have led to loss of function mutations in the olfactory receptor genes (Rouquier, Blancher, & Giorgi, 2000), and the human’s olfactory acuity is inferior to that of most animal species (Malaspina et al., 2006). A person’s ability to localize the source of an odorant–based on olfaction alone–is relatively poor (Kobal, Van Toller, & Hummel, 1989), and humans are anomic to certain odorants (Albrecht & Wiesmann, 2006). Nevertheless, an individual can detect up to 10,000 odorants (Albrecht & Wiesmann, 2006) with less than 10,000 receptors (Ratey, 2001). Hudson and Distel (2003) propose three ways the olfactory system is able to meet this challenge: the combination of wide spectrum receptors and neurons, the ability to learn, and the ability to adjust the sensitivity of the receptors according to the environment, the individual experience and the situation. However, despite its still impressive detection spectrum, the human is only able to discriminate between up to four separate components of an odorant (Laing & Francis, 1989). Furthermore, unless it is exposed to certain odorants early in development, the olfactory system may never develop the ability to recognize them. Conversely, one’s olfactory sense can be improved through training (Ratey, 2001). An odor incorporates a potentially great number of odorants into a single percept, for example, about 800 in the case of coffee (Deibler, Acree, & Lavin, 1998). According to Albrecht and Wiesman (2006), each individual is equipped with a different set up of receptors, and they qualify one’s olfactory world to be as individual as a fingerprint. It also appears that individual subjects encode one same odorant differently during

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The Sense of Olfaction Figure 1. Major projections of the olfactory cortex (Simpson & Sweazy, 2006).

consecutive presentations (Engen, 1983). In addition, it seems that the individuality of one’s olfactory world is further defined by contextual contributions. Indeed, Hudson and Distel (2003) suggest that individuals sharing the same sensory-chemical niche–the home, the neighbourhood, the city, etc.–will respond to an olfactory stimulus in a more similar manner than those not sharing that same olfactory niche. In of this suggestion, Stockhorst and Pietrowsky (2004) found that the perceived intensity of an olfactory stimulus depended on its concentration, as well as on the level of everyday experience with the odorant. Hence, an odor is a subjective percept produced by the combination of an olfactory stimulus and a context, it is modulated via the nervous system (Hudson & Distel, 2003), its meaning is probably acquired by individual experience (Hudson, 1999), its perceived intensity depends on interpretation and cognitive appraisal, and therefore, it can be modified through learning (Stockhorst & Pietrowsky, 2004). In summary, the olfactory sense is remarkably mature at birth. It can detect up to 10,000 odorants, but the nonexposure to some odorants in early development may lead to an inability to detect them. Olfaction must be activated, habituates to prevailing stimulus, and it is impossible for a subject to conjure up an olfactory image. An odorant may be encoded differently during consec-

utive presentations, and its resulting odor is influenced by a variety of contextual contributions and personal experiences. Of particular interest to the integration of olfactory cues in VEs is the finding that the localization of the source of an odorant, based on olfaction alone (i.e. without the of the other senses), is relatively poor. For the purpose of integrating odors in a VE, the implication of this characteristic could be three-fold. For one, it allows, within certain limits, the use of a single remote source to release the olfactory cues (instead of using multiple sources and activating one, or the other, depending on the position and/or orientation of the ). The second implication may be that, in order to trigger the 's association between the odor and the intended virtual source of that odor, the visual (and potentially auditory as well as haptic) details need to "" the intended odor. For example, the odor of a lemon should be matched with a virtual object that looks and, if applicable, feels like a lemon. Lastly, the synchronization between the 's virtual position and the timing of the releases of the olfactory cues need to controlled precisely, perhaps through a three dimensional model creating an increasing odorant intensity as one approaches the intended virtual source. CharaCTerisTiCs of odors dimensions of an odor Hedonicity, or the measure of pleasantness, familiarity and

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Baus and Bouchard intensity are the dimensions mostly used to qualify an odor, and they are not totally independent of another (Delplanque et al., 2008). Hedonicity, also referred to as valence (Schiffman, 1974), is the most salient (Engen & McBurney, 1964; Harper, Land, Griffiths, & Bate-smith, 1966) of these dimensions. Hedonicity is not quantified via a continuum of pleasantness, but via two opposing clusters of pleasantness and unpleasantness (Godinot, Sicard, & Dubois, 1995; Schiffman, 1974), and the effect of a pleasant olfactory stimulus seems to be more persistent than that of an unpleasant one (Weber & Heuberger, 2008). As proposed by the mere exposure effect (Cain & Johnson, 1978; Sulmont, Issanchou, & Köster, 2002), pleasantness and familiarity of odors seem to be positively correlated (Engen and Ross, 1973; Bensafi, et al., 2002). While Henion (1971) had suggested that, generally, an increase in intensity leads to decreased pleasantness, Moskowitz, Dravnieks, and Kiarman (1976) later suggested that, depending on the odorant used, the correlation could be positive, negative, complex or nonexistent. It has also been suggested that the path for neutral or pleasant odors is slower, and cognitively more complex, than that for unpleasant odors (Rouby & Bensafi, 2002). As the former would be associated with higher order associations, it may also be more influenced by familiarity (Royet et al., 1999; Larsson, 2002). As proposed by Delplanque and colleagues (2008), the existence of two distinct paths for pleasant and unpleasant odors is in line with models suggesting the existence of different evaluative channels for the processing of positive and negative stimuli (Cacioppo, Garner, & Bernston, 1999; Sander, Koenig, Georgieff, Terra, & Franck, 2005). Furthermore, the existence of these two distinct paths is ed by neuroimaging (Fulbright et al., 1998; Zald & Pardo, 1997) and electrophysiological (Hummel & Kobal, 1992) results of cerebral activations during odor processing. The dimensions qualifying an odor are hedonicity, familiarity and intensity and certain correlations seem to exist between these dimensions. In order to improve the VR experience, it may be useful to consider each of these three dimensions. For example, it is conceivable that the hedonicity of an odor could contribute to the determination of its intended virtual source (e.g., during immersion, the detection of a pleasant but non-specific odor, while the is positioned equidistantly from an overflowing garbage can and a bouquet of flowers, is likely to result in an association between the pleasant odor and the flowers). Furthermore, the level of familiarity is likely to lead to a more rapid, and stronger, association with the cues presented

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35 via other modalities. For example, the level of presence in a virtual kitchen may differ between s, depending on their familiarity with the type of food odorant use, which in turn, may be associated with cultural background. Finally, varying odorant intensities may be useful in cueing the about the position, and rate of position change, relative to the intended virtual source of that odor. faCTors influenCing olfaCTory proCessing gender Herz (2004) reports that women are more sensitive to olfactory stimuli than men, and although the results are not unequivocal, consistent replications suggest that women outperform men in olfactory tests (Good & Kopala, 2006; Pause, Sojka, Krauel, Fehm-Wolfsdorf, & Ferstl, 1996). These differences appear at an early age (Dorries, Schmidt, Beauchamp, & Wysocki, 1989), and apply more specifically to discrimination, recognition and identification abilities (Doty, 1997; Wysocki & Gilbert, 1989), as well as the accuracy of higher order olfactory processing, such as naming or memory tasks (Good & Kopala, 2006). The effect size of this difference increases with age (Ship and Weiffenbach, 1993), and is consistent across cultures (Barber, 1997; Doty et al., 1985). Although women detect pleasant and unpleasant odors faster than neutral ones, this is not the case for men (Pollatos et al., 2007). Neither Chen and Dalton (2005), nor Pollatos et al. (2007) found a difference in perceived pleasantness and arousal between men and women. In general, women are more sensitive to biologically relevant olfactory stimuli, such as the pheromone androsterone (Wysocki & Gilbert, 1989). This last point, when combined with women’s peak sensitivity to olfactory stimuli during the pre-ovulatory period (Good & Kopala, 2006), and the ive communication of mate quality through body odor (Sergeant, Davies, Dickins, & Griffiths, 2005), s the biological relevance of the superior sensitivity of the woman’s olfactory system. emoTional sTaTes Current emotional states also seem to influence olfactory processing (Pollatos et al., 2007). While an individual’s current emotional state does not seem to affect olfactory discrimination, it seems that across both sexes, negative emotional states are associated with an increase in judged odor intensity. For men, this increase in judged odor intensity is observed across all emotional conditions (Chen & Dalton, 2005; Pollatos et al., 2007). Viewing pleasant and unpleasant pictures, respectively, increases and decreases the pleasantness ratings of a neutral suprathreshold odor judged according to intensity and pleasantness (Pol-

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latos et al., 2007). The viewing of unpleasant pictures is followed by significantly reduced olfactory sensitivity (Pollatos et al., 2007). This result is congruent with the effect of negative emotional states on the ”primary sensory level of stimulus processing as measured by threshold tasks” (Pollatos et al., 2007, p. 587-588), as previously demonstrated with depressive patients (Serby, Larson, & Kalkstein, 1990; Pause et al., 2003). Song and Leonard (2005) suggest that, considering the projection of the olfactory system onto the limbic system (in particular, the orbitofrontal cortex and the amygdala), there could be a link between the dysfunction of a depressed patient’s limbic system and the reduced olfactory sensitivity. Interestingly, Vasterling, Braily, and Sutker (2000) found that patients with PTSD suffered from olfactory identification deficits–an observation which Doop, Mohr, Folley, Brewer, and Park (2006) report as consistent with PTSD related dysfunction of the fronto-limbic system. These findings could be considered contradictory to the use of olfactory cues in the treatment of PTSD. This apparent contradiction will be addressed in the next section. Visual sTimuli Multisensory integration is a “process by which inputs from one sensory modality influences processing of information from another modality and leads to either enhanced or dampened neural responses depending on the variety of factors, such as context and temporal or spatial concordance” (Small, 2004, p. 120). This process implies that “when two or more sensory cues occur at the same time and in approximate spatial correspondence, the firing rate of a multisensory neuron to a stimulus in one modality can be measurably altered by the presence of a second stimulus in another modality” (Österbauer et al., 2005, p. 3434). Anatomical and physiological evidence suggests that the multisensory integration of olfactory and visual stimuli involves the orbitofrontal cortex and the amygdala (Thesen et al., 2004). There seem to exist compelling color-smell associations (Österbauer et al., 2005). Indeed, color not only facilitates odorant identification, but it can also influence judgments of odor intensity and pleasantness (Zellner, Bartoli, & Eckard, 1991). The mere presence of color in an odorant-less solution increases the likelihood that subjects will report an odor (Engen, 1972), and a seemingly impossible color-smell combination (such as red colored white wine) can create perceptual olfactory illusions (DuBose, Cardello, & Maller, 1980; Morrot, Brochet, & Dubourdieu, 2001). So far, however, the literature offers little evidence whether odors can, in turn, influence visual perception (Thesen et al., 2004).

The Sense of Olfaction

In summary, women’s olfactory processing seems more sensitive than that of men, and negative emotional states are associated with an increase in judged odor. Although the gender-related difference in olfactory processing may not necessarily warrant the development of gender-specific olfactory environments, it may need to be taken into consideration during the analysis of the effect of odorants during immersion. Most importantly for the integration of olfactory cues in VEs, visual stimuli seem to influence and enhance olfactory processing. The influenCe of odors on perCepTion and menTal proCesses

A variety of studies demonstrate that olfactory cues can exert a cross-modal influence on the judgement of a variety of non-olfactory stimulus attributes or qualities (Demattè, Österbauer, & Spence, 2007). odors, emoTions, and arousal Pleasant and unpleasant odor cues have the power to lead to, respectively, positive and negative affective states (Ehrlichman & Halpern, 1988) and moods (Alaoui-Ismaïli et al., 1997; Goel & Grasso, 2004). Specifically, it has been demonstrated that pleasant odors decrease arousal, whereas unpleasant odors have the opposite effect (Knasko, 1992; Alaoui-Ismaïli et al., 1997). Furthermore, arousal seems to be positively correlated with the strength of an odor (Royet et al., 2003; Heuberger, Hongratanaworakit, & Buchbauer, 2006). odors and pain Odors seem to have the potential to increase and decrease perceived pain. Familiar odors, such as maternal milk odorant (Mellier, Bézard, & Caston, 1997; Rattaz, Goubet, & Bullinger, 2001), can soothe up to moderate pain in infants, thereby limiting or even preventing crying and thus, limit the energy expended during somewhat painful medical procedures (Goubet, Rattaz, Pierrat, Bullinger, & Lequien, 2003). Conversely, in the presence of already existing pain, certain odors seem to superimpose additional pain, and slowly increase the level of background pain (Villemure, Wassimi, Bennett, Shir, & Bushnell, 2006). Neurophysiologically, the intensification in perceived pain can be observed by increased neural activation in several areas associated with pain (Villemure et al., 2006). However, although the unpleasantness of the odor predicts the increase in pain intensity and unpleasantness, it is the changes in mood evoked by the odors that correlates best with the perceived level of pain (Villemure et al., 2006).

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Baus and Bouchard odors and soCial inTeraCTion The perceived masculinity/femininity of photographed faces can be influenced by the presence of human sex hormone-like chemicals (Kovács et al., 2004). These findings are in line with results suggesting the influence of human pheromones on people’s judgements of the written descriptions of others (Cowley, Johnson, & Brooksbank, 1977), and on the ratings of the sexual attractiveness of pictures of women (Kirk-Smith, Booth, Carroll, & Davies, 1978; Kirk-Smith & Booth, 1990). Pheromones, which humans emit in all body fluids (Ratey, 2001), are also processed via the olfactory system (Stockhorst & Pietrowsky, 2004). Even though they may carry no consciously perceptible odor, they can cause measurable changes in the autonomic nervous system and, depending on the pheromone, they can induce mild impressions of contentment or uneasiness (Ratey, 2001). Evidence suggests that pheromones affect human sexual behavior, not through sexual activity per se (Stockhorst & Pietrowsky, 2004), but through the modification of socio-sexual mating preference, attractiveness and mood (Cutler, Friedmann, & McCoy, 1998). More specifically, they “facilitate the perception of species for reproduction (Cowley & Booksbank, 1991; Wyatt, 2003), they lead to an entrainment of the menstrual cycle (Stern & McClintock, 1998), change the physical attraction of possible sexual partners (Kohl, Atzmüller, Fink, & Grammer, 2001; Grammer, 1993) and mood (Jacob & McClintock, 2000), and they are correlated to physical attractiveness (Rikowsky & Grammer, 1999)” (Stockhorst & Pietrowsky, 2004, p.5).

37 Keverne, 1997; Haberly, 2001). This process permits the fine tuning, amplification and storage of the particularly important odors, thus allowing the subject to distinguish them from the multitude of olfactory stimuli in the environment (Hudson & Distel, 2003). Learning greatly affects the perception and processing of odors, and it allows an organism to associate a specific situation with a particular smell (Stockhorst & Pietrowsky, 2004). It may be the processes of amplification and storage of odors (identified as particularly important through "learning" during a traumatic event) that, despite the previously mentioned findings of olfactory identification deficits in PTSD patients, make the use of trauma-related odorants pertinent in the treatment of this category of clientele. As demonstrated by one trial exploring aversions to smells and tastes associated with nausea-inducing substances, olfactory learning can take place in the form of one classical conditioning trial (Stockhorst & Pietrowsky, 2004).

Research results also suggest a tendency to rate other people more positively when in the presence of a pleasant fragrance (Kirk-Smith & Booth 1990). In turn, there is a significant positive correlation between the rated sexiness of a man’s body odor and his facial attractiveness to females (Rikowski & Grammer,1999). However, Demattè et al. (2007) suggest that odors do not affect the actual perception of the visual characteristics of a subject, but that instead, they change the affective reaction to them.

Olfactory conditioning appears to first have been demonstrated on humans by Kirk-Smith, Dodd and Van Toller (1983), and by Marinkovic, Schell, and Dawson (1989), as well as by Moore and Murphy (1999). Respectively, these researchers successfully paired an odorant with an elevated level of anxiety, physiological arousal, and an eye-blink response. Olfactory stimuli may also, by virtue of an association with unconditioned drug stimuli, elicit conditioned responses in the form of increased craving, skin responses and heart rate changes (Bordnick et al., 2008). Olfactory conditioning seems to contribute to the phenomena of sick building syndrome and multiple chemical sensitivities (Magnavita, 2001). Various investigations (Van den Bergh et al., 1999) suggest that the somatic negative symptoms in reaction to certain chemicals are most likely linked to conditioned increases in olfactory sensitivity to those same chemicals (Chu, 2008), potentially leading to reactions such as pre-chemotherapy nausea (Siegel, 1999). Olfactory conditioning has also emerged as an influence in drug istration (Stockhorst et al. 1999) and cigarette smoking behavior (Lazev, Herzog, & Brandon, 1999).

odors, learning, and CondiTioning Indicators ing the role of learning in olfaction include an improving ability to discriminate between two previously unfamiliar odorants with exposure (Rabin, 1988; Jehl, Royet, & Holley, 1995), and the ability to acquire the qualities used to describe an odor (Stevenson, 2001). Olfactory learning appears to take place as early as the olfactory bulb and the pyriform cortex (Brennan &

Herz, Schlanker, and Beland (2004) have suggested that ambient odorants, initially paired with seemingly easy but actually impossible to complete tasks, could have an influence on behavior. In one of their experiments, they exposed their participants to an unfamiliar ambient odorant during a frustration mood induction. When the participants later worked on puzzle tests in a room scented with either the same odorant, a different odorant, or no odorant, par-

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ticipants in the same odorant condition spent significantly less time working on the tests than participants in the other conditions. Herz, Schlanker et al. (2004) suggest the existence of an emotional conditioning mechanism–the reduction in the time spent on the task in the presence of the conditioned odor is the result of a reduced motivation, itself resulting from the odor-triggered re-emergence of the negative emotional reaction initially experienced during the failure to complete seemingly easy tasks. But the opposite also seems to be true. Indeed, Chu (2008) demonstrated that, by classically conditioning an odorant with positive task-related experiences, subsequent performances of underachieving schoolchildren could be manipulated to significantly improve on subsequent tasks. An olfactory stimulus can also act as a conditioned stimulus in fear conditioning (Engen, 1973), and Chu (2008) suggests that stronger emotions increase the likelihood of effective olfactory associative links. odor and memory Lehrner et al. (1999) report evidence ing the existence of a discrete olfactory memory system branching into component subsystems. Olfactory memory is independent of, and different from, other modalities of memory (Vermetten & Bremner, 2003). Common and complex odorants are encoded and ed as poorly as abstract meaningless geometrical shapes (Lawless, 1978); Lawless (1978) and Engen (1991) suppose that the lack of structural information in olfactory stimuli could contribute to the poor immediate recognition of odors (in comparison to visual and verbal stimuli). Odor memory seems strongly affected by proactive interference (Engen, 1987; Lawless & Engen, 1977), barely affected by the effect of learning strategies (Zucco, 2007), and very resistant to retroactive interference (Lawless & Engen, 1977; Zucco 2007). As such, it may well be the absence of attributes that contributes to its resistance to interference (Schab, 1991). Although Engen and Ross (1973) had proposed that odors are encoded in relation to perception and independent of semantic networks, Royet et al. (1999) found that semantic and perceptual subsystems interacted during odor processing (Doop et al., 2006). According to Engen and Ross (1973), there seems to be no difference between the recognition rates of intentionally and incidentally learned odor. In addition, the memory of an odor seems unaffected by higher order abilities (Danthiir, Roberts, Pallier, & Stankov, 2001). Although Engen and Ross (1973), as well as Lawless and Cain (1975), had found no link between familiarity and odor

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memory, more recent sources have suggested that familiar odors are easier to and discriminate than unfamiliar ones (Savic & Berglund, 2000; Schab & Crowder, 1995). Royet et al.’s (1999) finding that odor familiarity strongly predicted odor naming further s the link between familiarity and odor memory. Anatomical to this result includes the observation that the judgement of odor familiarity involves the left inferior frontal gyrus (Royet et al., 1999), an area normally linked to semantic association (Ricci et al., 1999; Vandenberghe et al., 1996). Thus, familiar and unfamiliar odors may be mediated by separate neuronal circuits (Savic & Berglund, 2004). Furthermore, if familiarity and pleasantness are indeed correlated (as suggested by Bensafi et al., 2002; Sulmont et al., 2002), then odor pleasantness may also affect odor memory. While the memorization of a new odor seems more difficult than that of visual and auditory stimuli, if it is successfully stored, the memory of that odor is particularly persistent (Herz & Engen, 1996; White, 1998). During recognition tasks immediately after exposure to stimuli, visual and auditory stimuli are recognized at a rate of 90% (Zucco, 2007), while olfactory stimuli are recognized at a rate of only 70% (Herz & Engen 1996; Zucco 2003, 2005). However, over an entire year, unlike the case for verbal and visual stimuli, the forgetting curve of an acquired odor is relatively flat (Engen & Ross, 1973; Nickerson & Adams 1979). In fact, Engen and Ross (1973) observed that after one year, over and above the 30% recognition rate lost during initial memorization, the recognition rate of odorants only decreases by an additional 5%. Odor memory is excellent for odors associated with significant autobiographical experiences (Engen, 1973). This is ed by the ability of certain adults to name odors they had not smelled since childhood (Goldman & Seamon, 1992), and may be influenced by the aforementioned strong resistance to retroactive interference. Autobiographical memories are “episodic memories: recollected events that belong to an individual’s past. The events that are recalled as autobiographical memories are typically multimodal (involving vision, hearing, smell, taste, touch, and body sense or kinesthesis); they vary in spatial, temporal, emotional, and narrative content and context; they have personal relevance” (Rubin, 2005), and they are usually encoded ively (Chu & Downes, 2000a). Thus, the systems that play a role in autobiographical memory are the individual senses, a multi-modal spa-

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Baus and Bouchard tial system that notes the location of people and objects, emotion, language, a non language narrative system which tracks causal relations (Rubin, Schrauf, & Greenberg, 2003; Schrauf & Rubin, 2000), and “an explicit memory system that coordinates or binds information from the other systems” (Rubin, 2005, p. 79). When autobiographical and semantic memory retrievals are compared, the amygdala, the hippocampus and the right inferior frontal gyrus were found to be more active (Rubin, 2005), and working more closely together (Greenberg et al., 2005) during the former. Autobiographical memory retrieval is enhanced by exposure to events associated with odors (Doop et al., 2006). In an autobiographical memory recall task, twice as many memories were recalled when accompanied with the appropriate odorant than without (Maylor, Carter, & Hallett, 2002). Odor-evoked memories seem different from other memory experiences (Willander & Larsson, 2006). Although they are no more accurate than those evoked by other senses (Herz, 2004), odorant-triggered memories are rated as more pleasant, and recalled less frequently (Rubin, Groth, & Goldsmith, 1984). Odor representations can be recalled after longer periods of time than verbal or visual ones. While visually and verbally-triggered memories generate a reminiscence bump between the ages of 10 and 30 years at event (Conway & Haque, 1999; Rubin, Rahhal, & Poon, 1998), olfactory-triggered memories have been localized to the first decade of life (Chu & Downes, 2000b; Willander & Larsson, 2006). These results are in agreement with research suggesting that associative olfactory learning begins very early in life (Schaal, Marlier, & Soussignan, 2000; Van Toller & Kendal-Reed, 1995), and earlier than the formation of autobiographical memories consisting of verbal or visual information (Willander & Larsson, 2006). The strength of the relationship between the olfactory cue and the autobiographical memory is directly correlated to the emotional charge and significance of the ed event (Vermetten & Bremner, 2003). The remarkable ability of olfactory stimuli to evoke very old autobiographical memories may be attributed to weak retroactive interference (Lawless & Engen, 1977), strong proactive interference and, when compared to visual or auditory stimuli, a low probability of subsequent exposure interference (Herz, 2004). Consequently, the first odor/event association is very hard to unlearn, a subsequent association to the same odor is difficult to form (Herz, 2004), and hence, exposure to event-congruent olfactory information can give access to very old personal experiences (Willander & Larsson, 2006).

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39 In addition to being more potent autobiographical memory cues than stimuli presented to other senses (Chu & Downes, 2000), research suggests that olfactory-triggered memories generate a stronger feeling of being brought back in time than verbally or visually-triggered ones (Herz, 2004; Willander & Larsson, 2006). Indeed, crossmodal laboratory and autobiographical studies of episodic memory have shown that olfactory-triggered memories are more vivid than memories evoked by corresponding words (Chu & Downes, 2002), and more emotional than those triggered by alternate sensory variants, including auditory stimuli (Royet et al., 2000) of the same item (Herz, 2004; Herz, Eliassen, Beland, & Souza, 2004). In fact, specific trauma-related olfactory cues can lead to anxiety, fear-related memories, flashbacks (Vermetten & Bremner, 2003) and panic attacks (Hinton, et al., 2004) in PTSD patients. These reactions may, in turn, lead to avoidance behavior. In the case of PTSD, the conditioned responses rooted in the autobiographical memory do not extinguish with time (Vermetten & Bremner, 2003). These observations are congruent with the direct synapsing from the olfactory area to the amygdala-hippocampal complex– the neural substrate of emotional memory (Cahill, Babinsky, Markowitsch, & McGaugh, 1995; Herz, Eliassen, et al., 2004)–and the greater activation in the amygdala-hippocampal complex in reaction to personally relevant odors (Herz, Eliassen, et al, 2004). effeCT of sub-ConsCiously proCessed odors The research presented above suggests that olfactory processed signals can affect organisms, but it is important to recognize that these signals need not be consciously processed to create an effect. Indeed, subliminal odors, as little as seven ppt, (Shepherd, 2004) can influence implicit odor memory (Degel & Köster, 1999; Köster, Degel, & Piper, 2002), social likeability judgements, and autonomic responses in a valence-consistent manner (Li, Moallem, Paller, & Gottfried, 2007). In fact, contrary to autonomic responses which are independent of the level of awareness of an odor, the effects on social likeability emerge best when the odor is subliminal (Li et al., 2007). As bottom-up sensory input often induces top-down regulation, thereby resulting in synthesized processes (Schneider & Chein, 2003), it has been suggested that it is the absence of the conscious awareness of the odor, and thus, the absence of a top-down regulation, that allows the subliminal odor to exert a greater effect than supraliminal odors (Li et al, 2007). In summary, the presence of an odorant is associated with numerous effects, and some of the ways these effects

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could be exploited in VEs will be addressed in the discussion section. While pleasant odors seem to lead to positive affects and decrease arousal, unpleasant ones seem to increase arousal and lead to negative affects. Furthermore, arousal is inversely related to pleasantness, but positively related to odor strength. The presence of odors can increase or decrease the pain perceived by an individual. The indications that an odor can influence how another person is perceived are of particular interest to social presence in a VE. These results seem to speak in favor of asg individual olfactory signatures to each virtual human in a particular VE. Olfactory learning enables the discrimination of odorants in the environment, and this ability can be improved through exposure. Olfactory conditioning– the association between an olfactory stimulus and a particular situation–can not only elicit physiological and physical responses, but it can also affect performance. The olfactory system seems to have its own memory system, and although the establishment of the memory of an odor is more difficult than that of a visual stimulus, if it is successfully established, it becomes particularly persistent. There seems to be no difference between the recognition rates of intentionally and incidentally learned odors, and the memory of an odor seems unaffected by higher order abilities. Odor memory is excellent for odors associated with significant autobiographic experiences, and the retrieval of an autobiographical memory is enhanced by exposure to event-associated odors. The strong resistance to retroactive interference allows olfactory cues to trigger memories originating in the first 10 years of life. These memories are vivid, and result in a strong feeling of being brought back in time. The conscious awareness of the odor is not necessarily required to enable its potential effects. disCussion The sense of olfaction is used constantly and often subconsciously (Drummond et al., 2007). It contributes to personal safety by helping to test the quality of the air (Drummond et al., 2007), detect the presence of food and individuals (Drummond et al., 2007), determine the edibility of food (Holland, Hendriks, & Aarts, 2005), sense the flavors of food (Ratey, 2001; Shepherd, 2006), to the pleasures of eating (Simpson & Sweazy, 2006), and thus, it also influences future consumption. The olfactory sense’s significant role in human social behavior is ed by the observation that, contrary to congenitally blind, mute or deaf people, individuals with congenital anosmia do not have intact reproductive–social behavior (Naftolin, Harris, & Bobrow, 1971). The olfactory sense contributes to the identification of, not only an individual, but also his/her

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gender (Russel, 1976), as well as certain emotional states (Stockhorst & Pietrowsky, 2004). Subconsciously, it affects mating behavior (Herz & Inzlicht, 2002; Sergeant et al., 2005). Specifically, it influences attraction and sexual partnering by affecting mood states (Jacob & McClintock, 2001), detecting immune system characteristics (Jacob, McClintock, Zelano, & Ober, 2002; Thornhill & Gangestad, 1999), genetic similarities (Eggert, Müller-Ruchholtz, & Ferstl, 1999), and female fertility (Poran, 1995). As presented earlier in this document, research results suggest that through the association of an olfactory cue with an emotion (the more intense the emotion, the stronger the association), that same olfactory cue can later evoke the conditioned emotion, thereby affecting the abilities and behavior of the subject. Thus, it could be expected that the use of olfactory cues would be common in experimental as well as in clinical psychology–yet, it isn’t so. Several factors may have contributed to this situation. First and foremost, as olfaction often acts subliminally, its importance in day-to-day life may be underestimated (Albrecht & Wiesmann, 2006). Secondly, due to their complex composition and transient character, controlled exposure to olfactory stimuli is more complex than that to visual or acoustical stimuli (Stockhorst & Pietrowsky, 2004) and it is still impossible, from one exposure to another, to stimulate the exact same combination of olfactory receptors (Hudson & Distel, 2003). Thirdly, the odor perceived by each subject is highly subjective, and thus, generalization involving one particular odorant is likely to be difficult. These factors may have contributed to the knowledge gap between olfaction and the more researched senses such as vision and audition. This knowledge gap also applies to the technology behind devices reproducing and dispensing olfactory stimuli. More recently, however, due to the potential of this relatively neglected sense and, in particular, its ability to evoke vivid memories, this trend has begun to change (Chu & Downes, 2000a). Today, in the field of scent machines, dispensing and controlling odorants in VEs (previously identified, as the primary obstacle to a generalized integration of olfactory stimuli in VEs; Sadowski, 1999) are being addressed by a variety odor delivery systems, such as the SDS100 by Biopac Systems Inc., the Scent Collar by the Institute for Creative Technologies in collaboration with AnthroTronix Inc., and the Scent Projector by ATR Media Information Science Laboratories. These systems allow exposure to a variety of orthonasally-delivered olfactory stimuli. In the field of applied research, the interest

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Baus and Bouchard in aromachology, the study of the influence of odors on behavior, now grows annually, and the topics covered by this research include the effect of odorants on emotions, physiology, cognitive abilities and behavior (Chu & Downes, 2000a). It has been suggested that a jasmine scent can enhance individuals' performance on problemsolving tasks, as well as lead to higher levels of interest and motivation to a task (Rottman, 1989), and that the scents of rose and mustard seed differentially modulate attention to brightness (Michael, Jacquot, Millot, & Brand, 2003). A stimulating peppermint fragrance seems to contribute to increased pain tolerance (Raudenbush, Koon, Meyer, & Flower, 2002), to enhance athletic performance (Raudenbush, Meyer, & Eppich, 2002; Raudenbush, Corley, & Eppich, 2001), to induce physiological arousal (Raudenbush, Koon, et al., 2002), and to enhance attention to visual stimuli. The latter also seems true for muguet (Warm, Dember, & Parasuraman, 1991). Finally, a rosemary scent seems to contribute to, at the cost of slower performance, increased memory recall accuracy (Moss, Cook, Wesnes, & Duckett, 2003), while a cinnamon scent seems to contribute to enhanced cognitive performances such as attention processes, virtual recognition memory, working memory, and visual-motor response speed (Zoladz & Raudenbush, 2005). Some of the physiological changes resulting from pleasant ambient scents may, in turn, contribute to behaviors such as increased gambling in casinos (Hirsch, 1995), increased time spent on a decision task (Bone & Ellen,1999; Mitchell, Kahn, & Knasko, 1995), and intentions to visit a store (Spangenberg, Crowley, & Henderson, 1996). At the opposite end of the spectrum, the persistent scents of air pollution seem to contribute to aggression in school-aged children (Ratey, 2001). Other results indicate that odors can impair the memory for faces that are presented simultaneously with an odorant (Walla et al., 2003), and that when an odor is semantically (Platek, Thomson, & Gallup, 2004) or hedonically (Ehrlichman & Halpern, 1988) congruent with a picture or a word, it facilitates the detection of that picture, or the production of that word. Furthermore, stimulating odorants seem to have the ability to increase alertness (Goel & Lao, 2006; Weber & Heuberger, 2008). In clinical applications, aromatherapy aims to capitalize on the ability of olfactory stimuli to elicit specific emotional responses. It relies on the hypothesis that, due to the rapid connection between the olfactory system and the limbic system, the appropriate olfactory stimulus could calm or stimulate an individual, assist sleep, influence eating habits, reduce pain (via the release of enkephalins), or

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41 heighten sexual arousal (via the release of endorphins) (Ratey, 2001). For example, the natural scent of blooming plants seems to be able to increase calmness, alertness, and mood (Weber & Heuberger, 2008), while a lemon scent seems to lead to fewer reports of health symptoms (Knasko, 1992). Whether in clinical or experimental research, VEs have, so far, failed to fully integrate the potential of olfactory stimulation, but there are exceptions. In clinical scenarios, some interesting VR research utilizing olfactory stimuli is being pursued in the field of behavioral and physiological reactivity to drug and alcohol triggers/cues (Bordnick et al., 2008). In such scenarios, the power of combining visual and olfactory cues to induce drug cravings and undesired behavior can be employed as a tool for behavior modification. Clinical scenarios for treating PTSD utilize the tendency of prevailing olfactory cues to become strongly associated to a highly emotional event occurring at the same time, such the odor of burning human flesh during a Rocket Propelled Grenade attack on a convoy. In these virtual world scenarios, olfactory cues, along with visual and acoustic ones, are meant to ease access to, and thus facilitate the processing of, traumatic memories (Gerardi, Rothbaum, Ressler, Heekin, & Rizzo, 2008). However, the use of olfactory cues in VEs is more often the exception than the rule, and more extensive applications of olfactory cues seem possible. For example, VEs are presently used for pain distraction (Hoffman, Patterson, & Carrougher, 2000), and odors seem to have the potential to decrease perceived pain. It would be interesting to the effect of integrating them in these types of applications. Furthermore, Kawai and Noro (1996) have suggested that odorants, combined with stereoscopic 3D images may, through their ability to affect arousal and emotions, be useful in relaxation procedures. It seems that, as an extension of this application, the investigation of the use of olfactory cues as an element of treating mood disorders in VEs would also be pertinent. In training scenarios, VR olfactory conditioning could turn out to be useful in triggering more appropriate responses to emergency situations–for example, the use of the smell of smoke during the practice of a fire drill in a VE may lead to more appropriate behavior, including better control of emotions, in the presence of this stimulus during an actual fire. Olfactory cues in a VE may also turn out to be useful to establish an association between a distinct odorant and “virtually-evoked” positive emotions. Such

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an association may possibly find use in relaxation training, or the treatment of certain mood and anxiety disorders. Furthermore, the ability of a VE to expose a great number of s to a complex, yet perfectly identical scenario, would seem to make it a good tool for investigating the fundamental interactions between olfactory cues, perception, cognition, emotion, and behavior. The results of such investigations are of major interest, because they could reveal whether the integration of olfactory stimuli in training devices, such as combat simulators, would enhance the virtual experience, and if so, how and to what degree. In sum, research has demonstrated the importance of olfactory stimuli in the human experience, and the results

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Journal of CyberTherapy & Rehabilitation S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

Can We Combine learning WiTh augmenTed realiTy physiCal aCTiViTy? Kuei-Fang Hsiao1

Augmented Reality (AR) technology is being applied in an increasingly large range of applications for improved educational efficiency. In this study, a new approach to the implementation of AR in the educational environment was taken by creating a Chemistry Augmented Reality Learning System (CARLS), using the existing teaching curriculum, together with physical activity. This system combined learning with three types of physical activity–aerobic fitness, muscle strength and flexibility fitness. A large sample of students (n=673) from five high schools was divided into four groups. The first three groups used the CARLS learning system while a control group used a keyboard and a mouse to operate the computer. We explored changes in academic achievement, as well as attitudes towards learning about science, resulting from the implementation of CARLS. This study reveals that the students using all three types of physical activity together with CARLS result in significantly higher academic performance compared to the traditional Keyboard-Mouse CAI (KMCAI). The improvement is most evident for the non-memorized knowledge component of science. Moreover, the students in the AR group with "muscle strength" physical activity had a significantly more positive learning attitude change toward science than those in the KMCAI group. An additional benefit of our approach is that students also obtained better physical fitness while learning. Keywords: Augmented Reality, Physical Activity, Information Technology, Academic Achievement, Learning Attitude

inTroduCTion Numerous researchers have reported the importance of physical activity not only for physical and mental health, but such studies have also indicated a potential positive impact on intelligence (Chomitz et al., 2009; Hillman, Erickson, & Kramer, 2008), and cognitive development (Neubauer, 2008; Sibley & Etnier, 2003). Further, physical activity was even proven to positively correlate to students’ academic performance (Hillman, Erickson, & Kramer, 2008; Castelli et al., 2007; Coe et al., 2006). Recent research done on fourth-eighth grade students revealed that both mathematics and English test scores increased as the ed number of fitness tests increased (Chomitz et al., 2009). Other research conducted on third and fifth grade students (Castelli et al., 2007), found that "aerobic fitness" was positively associated with total academic achievement, including reading and mathematics.

Moreover, students’ body mass index (BMI) was negatively associated with their total academic achievement. Therefore, Chomitz et al. pointed out that “promoting fitness by increasing opportunities for physical activity during Physical Education (PE), recess, and out of school time may academic achievement” (Chomitz et al., 2009). While the importance placed on standardized testing is increasing, many schools in the United States have tried to diminish or even eliminate PE programs, although no empirical evidence suggests that this elimination could result in higher academic performance (Hillman, Erickson, & Kramer, 2008). A similar situation is also apparent in Taiwan. Contrary to the "Health Related Physical Fitness" policies of the Ministry of Education in Taiwan (Ministry of Education, 2007a, 2007b), many schools have diminished

Corresponding Author: Dr. Kuei-Fang HSIAO, Department of Information Management, Ming-Chuan University, No. 5, Teh-Ming Rd., Gwei-Shan,Taoyuan County 333, Taiwan, Tel: +886-933-981105, Fax: +886-3-3294449, E-mail: [email protected] 1

Department of Information Management, Ming-Chuan University, Taiwan

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non-academic programs in order to maximize the time for academic programs in order to meet parents’ expectations. In Taiwan, most parents expect their children to spend most of their time on academic programs instead of other nonacademic endeavors, though, as mentioned above, spending more time on academic programs does not guarantee higher scores. Nonetheless, many Chinese parents are profoundly influenced by the Chinese philosophy that says, “Regardless of the result, just throw all your endeavors into studying” (Hsiao, 2005). Because of their parent’s high expectations with respect to studying, students may feel it is inappropriate to spend time on physical activity instead of studying academic subjects. This old Chinese philosophy has triggered the innovative idea of "learning while exercising" that will be discussed in this study. One of the main research objectives of this study was to develop a learning system that can facilitate students' "learning while exercising." A new information technology termed "Augmented Reality" (AR) was employed to achieve this objective. Most previous studies involving AR learning systems used 3-D features to assist students to learn in a way that is more realistic than 2-D instructional tools (Yee, Ning, & Lipson, 2009; Chen & Wang, 2008). Kaufmann reported that AR is a variation of Virtual Reality (VR) (Kaufmann, 2002). Recent research provided fruitful results by using VR, MR or AR to help sufferers of mental (Mühlberger et al., 2008; Manzoni et al., 2008) or physical health disorders. Regarding mental healthcare, a recent study reported exciting results using VR applications for patients with schizophrenia (Kim et al., 2008). Concerning physical health, Schaik et al. reported that participants strongly preferred virtual augmented physical activity over traditional physical exercise and the adherence rate was 100% (Schaik et al., 2008). Wiederhold and Wiederhold pointed out that VR has made a significant impact on behavioral healthcare with its multiple effective uses over the past decade (Wiederhold & Wiederhold, 2008). In addition to healthcare by the applications of VR, MR or AR, Schaik et al. also found that fitness level was not associated with the performance of solving simple puzzles and hitting targets in the game. Further, the correlation of preference for type of games with performance in the game was not significant. In this study, a new approach was taken by creating an AR system for educational purposes using the current-day curriculum, not only for simple puzzles or simple arithmetic puzzles, together with three types of physical activity. Moreover, the potential of AR environments would be explored for adolescent high school students.

Learning with AR Physical Activity

In addition to creating an AR learning system including exercise, another objective of this study was to compare the academic performance and learning attitude towards science between high school-age groups using CARLS and a group using KMCAI. In of assessment for educational objectives, Bloom classified six categories of cognitive domains–Knowledge, Comprehension, Application, Analysis, Synthesis and Evaluation (Bloom et al., 2009). Among these six categories, "Knowledge" was defined as “recalling or ing something without necessarily understanding, using, or changing it.” The revised taxonomy of the cognitive domains by Anderson and Krathwohl included ing, Understanding, Applying, Analyzing, Evaluating and Creating (Pickard, 2007; Anderson & Krathwohl, 2001). The subject specialists involved in the research divided the assessment for the unit of chemistry in high school science into two categories–memorized type and non-memorized type. The memorized type referred to the content, which students only needed to recall or without necessarily understanding. The memorized type corresponded with the basic level "Knowledge" in Bloom’s classification of cognitive skills and "ing" in Anderson’s & Krathwohl’s Revised Bloom’s Taxonomy (RBT). For the rest of the assessment, the non-memorized type was identified with the other five categories of cognition domains except ing knowledge. Our final goal in this study was to compare the impact of the three types of physical activity in CARLS on the memorized type and non-memorized type of knowledge in high school science. meThods subJeCTs In this study, the participants consisted of 687 seventh and eighth grade students, aged between 13-14 years old, from 22 classes in five high schools located in Northern Taiwan during the spring term of 2009. Approximately half of the participants were male and the other half were female. A total of 673 valid data samples were collected. All students were divided into four groups–Group AR-Jump, Group AR-Stretch, Group AR-Box and Group KMCAI. In these four groups, only the first three groups used the AR learning system. Each group used a different type of AR physical activity. Group AR-Jump practiced aerobic fitness, Group AR-Stretch practiced flexibility fitness and Group AR-Box practiced muscle strength. The reference Group KMCAI used a keyboard and a mouse to operate the computer. The gender distribution ratios, male versus female, among the above-mentioned four groups are 84 (53.5%) versus 73 (46.5%), 77 (48.4%) versus 82 (51.6%), 79

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(49.4%) versus 81 (50.6%), and 99 (50.3%) versus 98 (49.7%) for Group AR-Jump, Group AR-Stretch, Group AR-Box, and Group KMCAI respectively. The initial academic performance of the students for the subject of science or other subjects was not available. Due to the Information Protection Act of students’ personal information, only the class tutors and students’ parents are allowed

to obtain students’ initial academic performance. Students from all four groups followed the conventional instructions, using textbooks and CAI materials to implement the first part of the teaching activity, then adopted four different approaches to carry out the second part, "practice." Table 1 presents the different features of the learning activities for students in the four groups.

Table 1 The different features of learning activity in the four groups group ar-Jump

group ar-stretch

group ar-box

group KmCai

numbers

157

159

160

197

Teach

textbooks and CAI material

textbooks and CAI material

textbooks and CAI material

textbooks and CAI material

practice

CARLS- Jump system CARLS- Stretch sys- CARLS- Box system tem

interactions with materials

By body movement like jumping

media delivery

Text, graphics, sound effects and AR technology (with aerobic fitness function)

By body movement like stretching

By wrist movement

Text, graphics, sound Text, graphics, sound Text, graphics, sound effects and AR tech- effects and AR techeffects nology (with flexibil- nology (with muscle ity fitness function) strength function)

insTrumenTs In order to explore academic achievement in high school science, pre-test and post-test paper-and-pencil examinations were designed to be used in this study. There were eight items pertaining to the memorized type and seven items pertaining to the non-memorized type for each examination. Among these 15 items, eight items were the same in both of the pre-test and post-test examinations and the other seven items were different, but of the same level of difficulty. The examination items were identified by four subject teachers from four high schools and by one director of Teaching Affairs. In addition, the scale for measuring attitude towards leaning science was revised from the previous studies of Germann and also of Osborne et al. (Germann, 1988; Osborne, Simon, & Collins, 2003). After the Factor Analy-

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A keyboard and mouse

sis in this study, there were 13 items left in the revised scale. All items were measured using a five-point Likerttype scale, ranging from 1 meaning "strongly disagree" to 5 meaning "strongly agree." Regarding the content validity, the questionnaire was refined by a pilot study, which focused on question wording, clarity and validity. In the pilot study, the four subject teachers and director mentioned above provided comments on the questionnaire as a basis for revisions. The reliability (alpha) coefficient for the scale was 0.925. In this study, all teachers and students using the AR learning system received two 50-minute training lessons to become familiar with the operations of CARLS. During the training week, the students in the three AR groups and the control group KMCAI spent approximately 20 minutes for the pre-test and 15 minutes for the pre-attitude test to-

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Learning with AR Physical Activity

ward learning about science. Afterwards, all students in the four groups received one 50-minute lesson for conventional instruction using textbooks and CAI materials and the other 50-minute lesson for the second part, "practice," by using four different approaches in the following three weeks. After the completion of learning the unit of Elements and Compounds, all students in the four groups spent 20 minutes for the post-test and 15 minutes for the post-attitude test toward learning about science. The posttest and post-attitude test were applied a week after finishing all activity with AR in order to examine students’ learning retention. Thus, in addition to a four-week intervention with AR, the fifth week was used for the exam and the questionnaire. In order to avoid anxiety and resistance towards the new AR technology from parents and teachers, the four-week intervention using AR technology and one week for the exam and questionnaire in this study were authorized by the schools. Relating to the intervention time of this study, the following realistic and practical problems did exist at the beginning stage of deg the experiment: (1) AR is new to most schools in Taiwan so there are a great number of doubts and resistance towards new technology. (2) This study involves a large sample of students (n= 673) from 22 classes in five high schools. To avoid uncertain academic results for students, most schools would not allow the long-term experiment to be conducted on their students, particularly for the pioneer or exploratory study. To examine the differences in students’ academic achievement including both memorized and non-memorized types, as well as students’ attitude change towards learning, a series of statistical analyses was conducted among

the five groups. Since the group means differed both pretest and post-test in academic achievement and learning attitude, covariance analysis was applied to the following statistical analyses. Furthermore, in order to explore a richer, in-depth context of students’ learning with AR, extensive interviews and observations were also carried out in this study. ChemisTry ar learning sysTem (Carls) In this study, AR technology was employed to facilitate students "learning by exercising." By modifying the content of chemistry for seventh and eighth grade high school students, CARLS was developed as an assisted tool for students’ science learning. Thus, CARLS can be viewed as another type of a Computer Assisted Instruction (CAI) tool, but differentiated from conventional KMCAI. In of AR technology, the most well-known definition of AR was provided by Milgram and Kishino, who defined it as “a continuum of real to virtual environments in which AR is one area within the general area of Mixed Reality (MR)” (Milgram et al., 1994). In Azuma’s work, AR was defined as a system with three characteristics: (1) a combination of real and virtual environments; (2) interactive in real time; and (3) ed in 3-D (Azuma, 1997). However, Malik et al. argued that AR uses virtual objects, including text, 2-D images or 3-D models, to enhance s' insight into the real world (Malik, Roth, & McDonald, 2002). Kaufmann reported that AR is a variation of VR (Kaufmann, 2002). VR immerses a in a virtual environment but, in contrast, AR allows a to see the real world combined with virtual objects in the same space at the same time.

Figure 1. Equipment setup and ’s location in CARLS.

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In this study, CARLS adopted a webcam to capture students’ gestures and body movements from the real world and combined them with designed virtual images to create an interactive image. These virtual interactions were displayed onto a screen by a projector (see Figure 1, previous page). In CARLS, when students touch the "answer area" in the virtual environment, their positions and gestures can be captured by the webcam and CARLS will generate re-

actions according to the students’ intended answers. The results and from CARLS will be displayed on a large screen-wall in the real world. CARLS combined learning with three types of physical activity–aerobic fitness or jumping (see Figure 2a), flexibility fitness or stretching (see Figure 2b) and muscle strength or boxing (Figure 2c).

Figure 2. AR Physical activity including jumping, boxing and stretching in CARLS.

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56

Learning with AR Physical Activity

CARLS allowed the students to have direct interactions with the system through their body gestures, such as waving their hands to "catch" the answer in the virtual environment. For instance, in the boxing physical activity, the students have to wear "boxing gloves" to hit the correct answers a certain number of times instead of only hitting once. The system designer programmed the number of hits required from the in order to reach particular physical exercise levels in CARLS. For the other types of physical activity, like jumping, CARLS can be programmed to request students to jump to reach a certain height, and a certain number of times, in order to reach the desired exercise levels. In Taiwan, most high schools have at least one computer and a projector in each classroom, making it is feasible to implement CARLS in any high school. All that is required in addition is a low-cost webcam. With regards to the curriculum design in CARLS, a conventional high school science teacher in Taiwan would normally be expected to teach by presenting fundamental concepts from textbooks, and then providing practice exercises to students. The first part of the teaching activity is a one-way instruction. However, the practice compo-

nent contains interactive communication and discussion between a teacher and the students. In this study, CARLS was used for students as an assisted learning tool in the second part of teaching activity, "practice." All students received conventional instruction using textbooks and CAI materials on the fundamental concepts of chemistry, in particular the unit dealing with elements and compounds. The content in the CARLS segment corresponded with the National Curriculum in Science in Taiwan (Ministry of Education, 2003) and consisted of 216 items from the elements and compounds unit. All items were identified as memorized or non-memorized types by four subject teachers involved in this study. resulTs In of examining the differences in students’ academic achievement including memorized and non-memorized types of learning, as well as students’ attitude towards learning change, since the group means differed both pre-test and post-test in academic achievement and learning attitude, a series of ANCOVA test analyses were applied. Table 2 shows students’ estimated marginal means and standard errors of non-memorized,

Table 2 The descriptive data of non-memorized, memorized science knowledge and learning attitude changes toward science for four groups (ANCOVA) non-memorized

memorized

learning attitude changes

Mean

S.E.

n

Mean

S.E.

n

Mean

S.E.

n

group ar-Jump

3.697

0.114

139

3.504

0.144

139

3.391

0.058

97

group ar-stretch

3.726

0.113

141

3.887

0.143

141

3.277

0.059

93

group ar-box

3.649

0.114

139

3.519

0.144

139

3.432

0.060

90

group KmCai

3.246

0.096

197

4.121

0.121

197

3.248

0.048

144

Covariates appearing in the model are evaluated at the following value: pre-test=

3.10

3.48

3.11

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memorized science knowledge and learning attitude changes toward science from four groups (by ANCOVA). In term of the non-memorized type academic achievement, the students in all three AR groups, ARJump, AR-Stretch, and AR-Box (mean = 3.697, mean = 3.726, and mean = 3.649, respectively), have higher average scores than those in the control group KMCAI (mean = 3.246). Regarding the memorized science knowledge, the students in the control group KMCAI (mean = 4.121) scored higher than those in the ARJump, AR-Stretch, and AR-Box groups (mean = 3.504, mean = 3.887, and mean = 3.519, respectively). Concerning the learning attitude changes towards science, the students in the AR-Box group scored highest on the relevance scale (mean = 3.432), indicating that they have the highest positive learning attitude changes to-

wards science. non-memorized and

memorized sCienCe

KnoWledge

Table 3 presents differences in the non-memorized portion of science academic achievement between the four groups, F (3, 615) =4.921, p<0.01. The table was integrated from a series of Pairwise Comparisons based on estimated marginal means in the ANCOVA test analysis. It revealed there were significant differences in the non-memorized type achievement between the students in Group AR-Jump and Group KMCAI (p<0.01), Group AR-Stretch and Group KMCAI (p<0.01), and Group AR-Box and Group KMCAI (p<0.01). The results also clearly showed that all students in the three AR groups have better academic achievement in science than those in Group KMCAI.

Table 3 The differences in non-memorized science knowledge between four groups group ar-Jump (mean=3.697)

group ar-stretch (mean=3.726)

group ar-box (mean=3.649)

group KmCai (mean=3.246)

group ar-Jump group ar-stretch

-0.029

group ar-box

0.049

0.078

group KmCai

0.451**

0.480**

0.403**

F (3, 615)= 4.921, ** p< 0.01 Table 4 shows the differences in the memorized type academic achievement between the four groups, F (3, 615) =5.170, p<0.01. The table was integrated from a series of Pairwise Comparisons based on estimated marginal means in the ANCOVA test analysis as well. The results shown in Table 4 indicated that there were significant differences

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in the memorized academic achievement between Group AR-Jump and Group KMCAI (p<0.01) and between Group AR-Box and Group KMCAI (p<0.01) after students studied. It revealed that the students in Group KMCAI have a better performance than those in both Group AR-Jump and Group AR-Box.

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Learning with AR Physical Activity

Table 4 The differences in memorized science knowledge between four groups group ar-Jump (mean=3.504)

group ar-stretch (mean=3.887)

group ar-box (mean=3.519)

group KmCai (mean=4.121)

group ar-Jump group ar-stretch

-0.382

group ar-box

-0.014

0.368

group KmCai

-0.616**

-0.234

-0.602**

F (3, 615)= 5.170, ** p< 0.01

learning aTTiTude Change ToWard sCienCe In of the learning attitude change toward science following the course study, there was a significant difference between the students in Group AR-Box and Group

KMCAI, F (3, 423) =2.581, p<0.05 (Table 5). The students in Group AR-Box had a more positive learning attitude change toward science than those in Group KMCAI (p<0.05).

Table 5 The differences in learning attitude change toward science between four groups group ar-Jump (mean=3.391)

group ar-stretch (mean=3.277)

group ar-box (mean=3.432)

group KmCai (mean=3.248)

group ar-Jump group ar-stretch

0.115

group ar-box

-0.041

-0.155

group KmCai

0.143

0.028

0.184*

F (3,423)=2.581, * p< 0.05

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Hsiao disCussion This study developed an AR learning system, CARLS, to facilitate students learning about science by including three types of physical activity–aerobic fitness, flexibility fitness and muscle strength–at the same time. Further, the performance in academic achievement in science, including both memorized and non-memorized types of knowledge and learning attitude change toward science between the four groups, Group AR-Jump, Group AR-Stretch, Group AR-Box and Group KMCAI, have been compared. In comparison to the previous research which reported that "aerobic fitness" was positively associated with total academic achievement, including reading and mathematics (Castelli et al., 2007), the findings derived from this study the notion that students combining all three types of physical activity in CARLS obtained significantly higher scores of the non-memorized type knowledge of science than those in the control group KMCAI. The findings concur with those revealed by previous studies that there was no negative link between distraction from physical exercise and performance of cognitive activity (Schaik et al., 2008). This study also found evidence for the benefits of AR physical activity with cognitive activity, irrespective of physical activity type. Meanwhile, the students in the control group KMCAI tended to attain significantly better performances on the memorized type of knowledge than those in Group ARJump and Group AR-Box. These results imply that both conventional KMCAI and our new AR technology approach were both helpful to students’ learning, but in different types of knowledge. In of memorized knowledge, based on the revised taxonomy of the cognitive domain by Anderson and Krathwohl (Anderson & Krathwohl, 2001), "ing" is the basic level of cognitive domain where students "do not need to understand, use or change" knowledge. However, non-memorized knowledge includes other cognitive domains such as understanding, applying, analyzing, evaluating or creating. All of these could be seen as very essential abilities in the field of science. In addition to quantitative evidence on academic achievement, qualitative interviews and observations were carried out to obtain a better picture of the educational setting and learning process. Relating to higher-level learning beyond memorizing of the concepts of chemistry, especially the unit dealing with elements and compounds, students from all three types of physical activity in CARLS ex-

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59 pressed their personal experiences about the new approach using AR: “After learning with the use of CARLS, I know the fundamental concepts of Elements and Compounds better now.” (Interviews, June 2009, opinions from Student 281020-C). “After learning with the use of CARLS, I could clearly understand the differences between Elements and Compounds and the characteristics of Elements and Compounds.” (Interviews, June 2009, opinions from Student 2-81035-A, 3-80332-A, 4-71001-A,2-80215-B, 280426-B, 2-80609-B, 2-81013-C, and 2-80235-C). In of the change in attitude toward learning about science, this study revealed that the students in Group ARBox using the "muscle strength" physical activity obtained a significantly more positive attitude change than those in the control group KMCAI. Thygerson and Larson (Thygerson & Larson, 2006) suggested that muscle fitness could improve the peoples' ability to manage and function well under pressure or anxiety. Further, it also promoted people’s intention and willingness to carry out their tasks. The findings of Thygerson and Larson imply that muscle fitness might improve peoples' attitude toward certain objects or situations since Loyd and Loyd suggested that attitude includes four components–anxiety, confidence, liking and usefulness (Loyd & Loyd, 1985). Moreover, Gibson et al. defined attitude as the positive or negative mental state toward objects or situations (Gibson, Ivancevich, & Donnelly, 1991). Thus, the findings in this study corresponded with previous studies and also explained why the students in the muscle fitness exercise group had the highest positive learning attitude change toward science. In addition to quantitative evidence on learning attitude, the qualitative interviews also provided some clues. Among three groups with AR physical activity, the students in both Group AR-Box and Group AR-Jump obtained higher scores in learning attitude change than Group AR-Stretch, though only the students in Group ARBox obtained significant results in comparison with those in the control group KMCAI. Based on the analysis of collected data between the quantitative survey and qualitative interviews, we provide outlines to explain this situation. Firstly, the design of three types of physical activity in CARLS might cause students to progress less concerning learning attitude. The physical activity design for both ARBox and AR-Jump is quite "simple" and "straightforward."

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The students only need to jump a certain height to touch the answer, or to box the answer there is only a "short" distance between their hands and the answer. However, the physical activity design for AR-Stretch is slightly more complicated than the other two. Students have to move the correct answer from location A to location B carefully and stretch their body in a difficult manner. The students from Group AR-Stretch which resulted in less progress regarding positive attitude change towards learning stated: “It is a bit difficult to move the answer to the target location. Even though I know the answer, I am not able to move the answer to reach the assigned location.” (Interviews, June 2009, opinions from Student 2-81003-B, 3-80322B, and 3-80419-B) “The system should be improved to be easier for and the route for moving should be re-designed.” (Interviews, June 2009, opinions from Student 2-80831-B and 380110-B) However, in order to reach the aim of the "stretch" exercise, the route between location A and location B was deliberately designed to be longer and more winding in comparison with the other two types of physical activity. Future research may look more closely at the relationship between the precise functions of exercise and the effect on learning. ConClusions This study provides a new approach to increasing students’ physical activity without diminishing students’ academic performance since many schools have tried to decrease PE programs in many countries due to a variety of reasons. In addition, better academic achievement in non-memorized knowledge of science and a more positive attitude toward learning about science were also promoted by using CARLS. In this study we have shown that by using CARLS it is possible to promote better academic achievement in non-memorized knowledge in science, and a more positive attitude toward science while students also participated in extra physical fitness exercises while learning. In spite of the above findings, as the exploratory study that pioneers in combining learning with AR and physical activity, some suggestions and research constraints are needed for future researchers and teachers adopting new AR technology in the classroom. First, the content used

Learning with AR Physical Activity

in the AR learning system was taken from a certain unit in high school science so that the findings could not be generalized to other fields or subjects. Moreover, the students who were involved in this study only used the CARLS system to specially learn the unit dealing with elements and compounds for a relatively short period of time. One week of training was used to provide familiarity with the AR system and three weeks were spent learning with CARLS. There may possibly have been a novelty effect effecting students’ performances or behaviors, which is partially in response to increased interest in, or attention to, the AR technology, instead of the curriculum. The findings might vary when CARLS is used in learning for a longer period of time. Therefore, instead of drawing too much attention to the novelty of the new technology, future researchers and teachers should be encouraged to emphasize more valuable characteristics of AR, i.e. exploring learning material through the combinations of the real and virtual objects in the 3-D space so that it would help to display more concrete demonstrations to learners. Furthermore, students obtain more physical activity while learning compared to the sedentary learning style. Finally, although this study revealed that the students participating in all three types of physical activity in CARLS obtained higher scores on the non-memorized science knowledge, this study did not directly prove that any specific physical activity in CARLS promoted any specific students’ abilities in the above-mentioned five non-memorized cognitive domains. Future studies might prove fruitful in providing more details of the likely causes of the results by utilizing more sophisticated medical equipment. For teachers adopting the new AR technology in the classroom, we suggest that they pay close attention to the safety of students since physical activity typically takes place in the classroom. Further, the amount of physical activity should be individualized for different students’ health conditions. Physical activity should ideally take place within a normal school schedule, however, if student exercise has been limited by school budgets or any variety of reasons as has happened in different countries, an AR learning system with physical activity functions, like CARLS, might provide an alternative solution. Acknowledgements This research work has benefitted from the technical by Professor SY Huang and an AR work team in Ming-Chuan University, Taiwan.

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61 Hillman, C.H., Erickson, K.I., & Kramer, A.F. (2008). Be smart, exercise your heart: exercise effects on brain and cognition. Nat. Rev. Neurosci., 9, 5865.

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Castelli, D.M., Hillman, C.H., Buck, S.M., & Erwin, H.E. (2007). Physical fitness and academic achievement in third- and fifth-grade students, J Sport Exerc. Psychol., 29, 239-252.

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Chen, R., & Wang, X. (2008). An Empirical Study on Tangible Augmented Reality Learning Space for Design Skill Transfer. Tsinghua Science and Technology, 13 (S1), 13-18. Chomitz, V.R., Slining, M.M., McGowan, R.J., Mitchell, S.E., Dawson, G.F., & Hacker, K.A. (2009). Is there a relationship between physical fitness and academic achievement? Positive results from public school children in the northeastern United States. J. Sch. Health, 79 (1), 30-37.

Hsiao, K.F., & Sung, H.Y. (2009). Gender Differences in the Learning Performance and Attitude within the use of the Ecosystem Augmented Reality Learning System. Proceedings of International Academic Conference, MCU, Taiwan Kaufmann, H. (2002). Construct3D: an augmented reality application for mathematics and geometry education. Proceedings of the tenth ACM international conference on Multimedia, 656-657.

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Gibson, J.L., Ivancevich, J.M., & Donnelly, J.H. (1991). Organizational behavior. Boston, MA: Irwin.

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Malik S, Roth G, McDonald C. (2002), Robust 2D Tracking for Real-Time Augmented Reality. The 15th International Conference on Vision Interface, Calgary, Canada.

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Manzoni, G.M., Gorini, A., Preziosa, A., Pagnini, F., Castelnuovo, G., Molinari, E., Riva, G. (2008). New Technologies and Relaxation: An Explorative Study on Obese Patients with Emotional Eating. Journal of CyberTherapy and Rehabilitation, 1 (2), 182-192. Milgram, P., Takemura, H., Utsumi, A., & Kishino, F. (1994). Augmented Reality: A class of displays on the reality-virtuality continuum. Telemanipulator and Telepresence Technologies, 2351, 282-292. Ministry of Education, (2003). The instructor’s handbook of the National Curriculum in Science. Taipei: MOE. Ministry of Education, Division of Physical Education. (2007a). Report of the extension of bicycling sports in the youth. Retrieved from website: http://epaper.edu.tw/ news/960727/960727c.htm. Ministry of Education, Division of Physical Education. (2007b). The plan of ’Happy Life’ in high schools. Retrieved from: http://www.edu.tw/ EDU_WEB/Web/publicFun/tmpurl.php?sid=1 8906&fileid=158077&open. Mühlberger, A., Sperber, M., Wieser, M.J. & Pauli, P. (2008). A Virtual Reality Behavior Avoidance Test (VR-BAT) for the Assessment of Spider Phobia. Journal of CyberTherapy and Rehabilitation, 1 (2), 147-158. Neubauer, D. (2008). Exercise Improves Your Brain. Retrieved from: http://health.yahoo.com/experts/

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depression/11913/exercise-improves-yourbrain. Osborne, J., Simon, S., & Collins, S. (2003), Attitudes towards science: a review of the literature and its implications. Int. J. Sci. Educ. 1464-5289, 25(9), 1049-1079. Pickard, M.J. (2007). The new Bloom’s taxonomy: An overview for family and consumer sciences. Journal of Family and Consumer Sciences Education (JFCSE), 25 (1), 45-55. Schaik, P.V., Blake, J., Pernet, F., Spears, I., & Fencott, C. (2008). Virtual Augmented Exercise Gaming for Older Adults. CyberPsychology & Behavior, 11, 103-106. Sibley, B.A., & Etnier, J.L. (2003). The relationship between physical activity and cognition in children: A meta-analysis. Pediatr. Exerc. Sci., 15, 243-256 Thygerson, A. & Larson, K. (2006). Fit to be well. Boston: Jones and Bartlett Publishers. Wiederhold, B.K., & Wiederhold, M.D. (2008). Virtual Reality for Posttraumatic Stress Disorder and Stress Inoculation Training. Journal of CyberTherapy and Rehabilitation, 1 (1), 23-36. Yee, B., Ning, Y., & Lipson, H. (2009). Augmented Reality In-Situ 3D Sketching of Physical Objects. Proceedings in IUI 2009 Workshop on Sketch Recognition, Sanibel Island, Florida.

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Journal of CyberTherapy & Rehabilitation S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

sex and raCe differenCes in raTing oThers’ pain, pain-relaTed negaTiVe mood, pain Coping, and reCommending mediCal help Ashraf F. Alqudah1, Adam T. Hirsh2, Lauren A. Stutts3, Cindy D. Scipio3, and Michael E. Robinson3

This study examined the influence of Virtual Humans' (VH) sex and race on participants’ ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommendations for medical help. Seventy-five undergraduates viewed a series of VHs and provided computerized visual analog scale (VAS) ratings for the five domains listed above. Mixed model ANOVA analyses showed that participants of both sexes and races viewed female VHs as experiencing greater pain intensity, greater pain unpleasantness, a greater number of pain-related negative moods, poorer coping skills, and a greater need to seek medical help for their pain. Participants of both races rated Caucasian VHs as experiencing more negative moods and poorer coping skills do deal with their pain. The novel computerized VH technology used herein allowed for the standardization of pain expression across sexes and races of VH stimuli, thus allowing us to remove the influence of biases when creating the study stimuli. This is a notable advantage over other research methodologies in this line of inquiry. Several future research and education applications of this VH technology are discussed. Keywords: Pain Assessment, Virtual Technology, Mood, Coping, Medical Help

inTroduCTion Empirical investigations the presence of sex differences in pain (Dao & LeResche, 2000; Ellemeier & Westphal, 1995; Frot, Feine, & Bushnell, 2004; Hawthorn & Redmond, 2000; Robinson, Riley, Myers, Papas, Wise, Waxenberg et al., 2001; Robinson & Wise, 2003; Robinson & Wise, 2004; Unruh, 1996; Vallerand & Polomano, 2000). Some studies have shown that females perceive and express higher levels of pain than males in clinical settings (Hawthorn & Redmond, 2000). Sex-related differences in pain perception have also been found in experimental pain settings (Frot, et al., 2004). These sex differences extend to the observation of pain in others, with one study finding that par-

ticipants rated female subjects as experiencing greater pain intensity in an experimental pain task compared to males (Robinson & Wise, 2004). Sex-specific relationships between pain and negative affect have been reported in both community and clinical samples (Riley, Robinson, Wade, Myers, & Price, 2001). In the National Health and Nutrition Examination Survey, pain and depression were more prevalent in females than in males (Magni, Caldieron, Rigatti-Luchini, & Merksey, 1990). In clinical pain samples, the prevalence of depression and anxiety is typically higher for females (Unruh, 1996). Although little is known about the differences between males and females in coping with pain, Unruh, Ritchie, & Merskey (1999)

Corresponding Author: Michael E. Robinson, P.O. Box 100165, Gainesville, FL 32610-0165, Tel: +1 352-273-6153, Fax: 352-273-6156 University of Jordan, Department of Psychology, Amman, Jordan University of Washington, Department of Rehabilitation Medicine, Seattle, Washington, U.S.A. 3 University of Florida, Department of Clinical and Health Psychology, Gainesville, Florida, U.S.A. 1 2

64

Sex and Race Differences in Rating Pain

found that females use a wider range of coping strategies than men do. However, Keogh & Herdenfeldt (2002) suggested that the use of a wider range of strategies could reflect the failure of coping strategies to effectively reduce pain.

sible with traditional research methodologies, such as those that involve historical chart reviews. It was hypothesized that a VH stimulus would elicit the same sex and race differences previously published in traditional self-report and observational studies.

A number of studies have also suggested that there are racial differences in pain perception, pain-related negative affect, and pain coping. In one study, African Americans with rheumatoid arthritis reported significantly higher use of distraction and praying/hoping as coping strategies, whereas, Caucasians reported greater use of ignoring pain and coping statements (Jordan, Lumley, & Liesen, 1998). Campbell, Edwards, & Fillingim (2005) examined racial differences in responses to multiple experimental pain stimuli, including heat pain, cold pressor pain, and ischemic pain and found that African Americans reported greater use of ive pain coping. Moreover, research on pain-related mood has shown that African Americans with chronic pain had higher pain-related depression and disability when compared to Caucasians (Carmen, Green, Ndao-Brumblay, Nagrant, Baker, & Rothman, 2004). Riley, Wade, Myers, Sheffield, Papas, & Price (2002) also found that African Americans experience greater emotional suffering compared to Caucasians with similar levels of pain intensity.

meThods parTiCipanTs Seventy-five University of Florida undergraduate students (53 females, 22 males) were recruited through fliers and posters requesting volunteers to participate in this study. The participant sample was 83% Caucasian and 17% African American.

Most research studies investigating sex and race differences in pain perception and evaluation focused on how both sexes and different races perceive and evaluate their own pain. The current study focuses on the differences in perceiving and evaluating others’ pain. Furthermore, studies investigating differences in perceiving and evaluating pain in others relied mainly on recorded videos and still pictures of actual pain patients expressing pain. This methodology, however, is not sensitive to the possible variance that might already exist amongst video-taped pain patients. The current study controls this possible variance through a novel computerized technology which reduces the variance to almost zero. The purpose of this study was to employ a novel computer-generated virtual human (VH) technology to investigate sex and racial differences in the observation of pain, pain coping, pain-related negative affect, and recommendations to seek treatment. The use of a VH technology allows for the standardization of the amount of pain expression independent of the sex and race characteristics that are of interest as dependent variables. This level of experimental control is not pos-

inClusion/exClusion CriTeria Eligibility requirements for participation were being at least 18 years old, English speaking, and of African American or Caucasian background. Participation was also contingent upon ability to give consent. proCedure Each participant was asked to read a description of the study including the time required to complete the study and a reminder that the study is voluntary. After reading the study description, all participants read and signed a computerized consent form acknowledging that the study procedures were explained and that they could withdraw, without prejudice, from the study at any time. Next, they completed a brief demographic questionnaire that collected participants’ age, race, and sex. Participants then read a set of instructions that provided information on how to approach the task and how to use Visual Analogue Scales (VASs) to give ratings. A series of 16 vignettes were produced using computerized VH technology via a commercially available software package (People Puttytm). A novel feature of this approach was the ability to standardize the amount of pain expressed in the VH face across different sexes and races of VHs. This was accomplished by employing the Facial Action Coding System (FACS). The FACS is based on an anatomic analysis of facial muscle movements and distinguishes 44 different action units (AUs). An abbreviated version of the FACS was used in this study focusing on the four primary action units that are involved in the facial expression of pain and produced validated facial expressions showing pain– brow lowering, tightening of the orbital muscles surrounding the eye, nose wrinkling/upper lip raising, and eye closure.

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Alqudah et al. Each stimulus the participants observed consisted of a vignette and a VH patient. Each VH contained three cues–sex (two levels: male or female), race (two levels: Caucasian or African American), and pain (two levels: low amount or high amount of pain) which was reflected on the VHs facial expressions. Participants were instructed to completely respond to VHs in the order presented, complete the ratings for one VH before going on to the next, and they were not allowed to revisit a previously viewed VH. For each VH, participants used computerized VASs to rate the level of pain intensity observed, the level of pain unpleasantness observed, the level of pain-related negative mood observed, how well the observed VH was coping with the pain experience, and the extent to which they would recommend the observed VH to seek pain-related medical help. Participants also completed a computerized version of the Gender Role Expectations of Pain questionnaire (GREP) (see appendix A) using computerized VASs to assess the degree to which gender role expectations of pain may contribute to their ratings. The Gender Role Expectations of Pain questionnaire (GREP) consists of visual analog scales to assess participants’ view of the typical male and female regarding pain sensitivity, pain endurance, and willingness to report pain. It also assesses the participants’ personal attribution of his/her pain sensitivity, pain endurance, and willingness to report pain relative to the typical male and female. The psychometric properties of the GREP factor structure are close to the theoretical formulation of the scales, ing for 76% of the variance in scores. The questionnaire has good test–retest reliability with individual item correlations ranging from 0.53 to 0.93. The sex differences in the endorsement of items on the GREP were large, with the largest differences (46% of variance) shown for willingness to report pain items. Wise, Price, Myers, Heft and Robinson found that the GREP was a significant predictor of experimental pain ratings in undergraduate males and females, and that a significant proportion of sex differences in pain report was ed for by gender role expectations. Task duration for the current study was approximately one hour. Following the completion of the task, participants were asked to respond, in writing, to a task validity probe, in which they were asked to guess the study hypotheses. Then, participants were briefed regarding the variables of interest and the study hypotheses.

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65 analysis All data analyses were performed using SPSS for Windows (Version 15). Mixed model ANOVA analyses were performed where sex and race of participants and VHs served as independent variables, and ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and the extent to which the VHs were recommended to seek medical help for their pain served as dependent variables. We had no a priori hypotheses regarding a number of the interaction (e.g. sex of participant, by race of participant, by sex of video, by race of video), therefore, we approached the analyses by looking at only the main effects and specified two-way interactions for which a priori hypotheses were available. Willingness to report pain and pain endurance, taken from the GREP, were investigated to determine whether they met the criteria to serve as covariates in the analyses involving participants’ ratings of pain intensity and pain unpleasantness. resulTs CoVarianCe analysis Willingness to report pain and pain endurance are two factors of the GREP that were considered for inclusion in the models as covariates. Correlation analyses were conducted on these two factors as well as male and female participants’ ratings of pain intensity and pain unpleasantness for male and female VHs. Results of the correlation analyses were not significant, thereby indicating that the two GREP factors did not meet the assumptions of covariance analysis. Therefore, willingness to report pain and pain endurance were not included in the following models. assoCiaTions among The dependenT Variables A correlation analysis was conducted between the dependent variables. All dependent variables in this study (ratings of pain intensity, pain unpleasantness, pain-related negative mood, pain coping, and recommending medical help) were significantly correlated. The magnitude of the correlations ranged from 0.35 (pain coping and recommending medical help) to 0.87 (pain intensity and pain unpleasantness.) See Table 1 below. analysis of pain inTensiTy raTings sEx EffEcts Both male and female participants rated pain intensity for female VHs as significantly higher than that for

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Sex and Race Differences in Rating Pain

Table 1 Correlations between the dependent variables pain intensity

pain unpleasantness

pain-related negative mood

pain coping

recommending medical help

pain intensity

1

–

–

–

–

pain unpleasantness

0.87

1

–

–

–

pain-related negative mood

0.72

0.82

1

–

–

pain coping

0.68

0.75

0.71

1

–

recommending medical help

0.53

0.51

0.42

0.35

1

male VHs, F (1, 73) = 4.92, p < 0.05. Both Caucasian and African American participants rated pain intensity for female VHs significantly higher than that for male VHs, F (1, 73) = 6.93, p < 0.05.

racE EffEcts There was no main effect of race of VHs on ratings of pain intensity. Table 2 below summarizes the results of the pain intensity ratings.

Table 2 Means and standard deviations of pain intensity ratings

analysis of pain unpleasanTness raTings sEx EffEcts Both male and female participants rated pain unpleasantness for female VHs significantly higher than that for male VHs, F (1, 73) = 7.61, p < 0.01. Both Caucasian and African American participants rated pain unpleasantness for female VHs as significantly higher than that for male VHs, F (1, 73) = 4.17, p < 0.05. These results mirrored the pain intensity effects presented above.

Vh

pain intensity

male

38.65* (14.54)

female

41.14* (13.87)

Caucasian

39.94 (13.98)

african american

39.72 (14.45)

* < .05 significant difference between participants on pain intensity ratings

racE EffEcts There was no main effect of race of VHs on ratings of pain intensity. Table 3 below summarizes the results of the pain unpleasantness ratings. a nalysis of pain -r elaTed n egaTiVe mood r aTings sEx EffEcts Both male and female participants rated pain-related negative mood for female VHs as significantly higher than that for male VHs, F (1, 73) = 6.76, p < 0.05. A

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Table 3 Means and standard deviations of pain unpleasantness ratings

Table 4 Means and standard deviations of pain-related negative mood ratings

Vh

pain unpleasantness

Vh

negative mood

male

32.42* (15.17)

male

37.87* (15.44)

female

44.77* (14.54)

female

40.23* (15.11)

Caucasian

44.30 (14.28)

Caucasian

39.84* (14.97)

african american

42.90 (15.27)

african american

38.12* (16.02)

* < .05 significant difference between participants on pain unpleasantness ratings

* < .05 significant difference between participants on pain-related negative mood ratings

main effect was found for race of participants where Caucasian participants’ ratings for both male and female VHs pain-related negative mood (M=40.59, SE=1.84) were significantly higher than African American participants’ ratings (M=31.75, SE=4.02), F (1, 73) = 3.99, p = 0.05. An interaction of the sex of the VHs by race of participants was also found–Caucasian participants' ratings for female VHs (M=42.17, SD=14.28) were significantly higher than African American participants' ratings for female VHs (M=31.02, SD=16.16), F (1, 73) = 4.11, p < 0.05.

race Effects Both Caucasian and African American participants viewed Caucasian VHs as coping more poorly with their pain (M=34.47, SE=13.56) than African American VHs (M=32.79, SE=14.07), F (1, 73) = 6.86, p < 0.05. Table 5 below summarizes the results of the pain-coping ratings.

racE EffEcts Both Caucasian and African American participants viewed Caucasian VHs as having significantly higher levels of pain-related negative mood (M=39.84, SD=14.97) compared to African American VHs (M=38.12, SD=16.02), F (1, 73) = 5.34, p < 0.05. Table 4 above summarizes the results of the pain-related negative mood ratings. analysis of pain-Coping raTings sEx EffEcts Both male and female participants viewed female VHs as coping more poorly than male VHs, F (1, 73) = 6.37, p < 0.05. No significant main effect for sex of VHs on the race of participants was found.

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Table 5 Means and standard deviations of pain-coping ratings Vh

Coping

male

32.47* (13.63)

female

34.76* (13.80)

Caucasian

34.47* (13.56)

african american

23.79* (13.07)

* < .05 significant difference between participants on pain-coping ratings

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Sex and Race Differences in Rating Pain

analysis of reCommending mediCal help raTings sEx EffEcts A main effect for sex of VHs on sex of participants was found. Both male and female participants’ ratings for recommending medical help were significantly higher for female VHs than that for male VHs, F (1, 73) = 5.98, p < 0.05. The sex of participants was also found as a main effect, indicating that male participants’ ratings for recommending medical help (M=52.86, SE=4.31) were significantly higher than female participants’ ratings (M=42.50, SE=2.78), F (1, 73) = 4.02, p < 0.05. Race of the participant did not have an effect on ratings of recommending medical help. racE EffEcts Male participants’ ratings for both Caucasian and African American VHs (M=52.86, SE=4.31) were significantly higher than that of female participants (M=42.50, SE=2.78), F (1, 73) = 4.06, p < 0.05. Table 6 below summarizes the results of recommending medical help ratings. Table 6 Means and standard deviations of recommending medical help ratings Vh

recommending medical help

male

44.05* (21.16)

female

47.15* (20.94)

Caucasian

45.80 (21.35)

african american

45.28 (20.71)

* < .05 significant difference between participants on recommending medical help ratings

summary of resulTs In summary, male and female participants both rated female VHs’ pain intensity, pain unpleasantness, pain-related negative mood, and poorer pain coping, as higher than male VHs. Male and female participants were also more likely to recommend that female VHs seek medical help than male VHs. However, Caucasian and African

American participants’ ratings for female VHs were higher than that for male VHs only on pain intensity and pain unpleasantness. Caucasian VHs were viewed as having higher pain-related negative mood and as coping more poorly with their pain than African American VHs. African American VHs’ pain intensity was rated higher only by African American participants. Ratings made by male participants tended to be higher than ratings made by female participants. disCussion Although pain levels–as expressed by the faces of the VHs–were digitally controlled to be equivalent across different sexes and races, results indicated that participants of both sexes and races still viewed female VHs’ pain, both the sensory (intensity) and affective (unpleasantness) components, as significantly higher than that for male VHs. This is consistent with other research findings. In a study of experimentally-induced pain, Robinson et al. found that viewers rated females’ pain as higher than males’. One explanation for why female VHs were viewed as having higher pain is the difference in pain expectations. Females are expected to report higher levels of pain than males in general. Although willingness to report pain and pain endurance (as measured by the GREP) did not correlate significantly with pain ratings in this study, a sizable literature shows that both males and females expect females to experience greater amounts of pain (Robinson et al., 2001; Unruh, 1996). Additional research is needed to determine whether such expectations are also elicited by computer-generated VH characters. The International Association for the Study of Pain’s definition of pain highlights the importance of understanding the emotional experiences of pain. It is important to note the effects of negative mood accompanying pain. Although all facial expressions of pain were digitally controlled to be similar for males and females in this study, female VHs’ pain-related negative mood was rated as significantly higher than that for male VHs’ by participants of both sexes. This result could be explained by the positive relationship between pain and negative mood and is consistent with the findings of the National Health and Nutrition Examination Survey, where pain and depressive symptoms were more evident in females than in males (Magni et al.,1990). Caucasian VHs were rated by both African American and Caucasian participants as experiencing greater pain-related negative moods. These results suggest that assess-

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Alqudah et al. ment of the pain-related negative mood is, at least, partly determined by the race of the individual experiencing pain. Consistent with the pain-related negative mood results, participants of both sexes rated female VHs as coping more poorly with their pain, and participants of both races rated Caucasian VHs as coping more poorlywith their pain. These results mirror those for pain-related negative mood, and suggest that when females and Caucasians are viewed as having higher pain than males and African Americans, respectively, they are also more likely to be viewed as experiencing higher levels of pain-related negative mood and poorer pain-related coping. When an individual’s pain level, pain-related negative mood, and maladaptive pain coping is rated as high, it is expected that he/she is more likely to be recommended to seek medical help for his/her pain. In this study, female VHs were rated higher on all these variables than male VHs. They were also recommended to seek medical help for their pain significantly more often than male VHs. However, it was not expected for male participants’ recommendations to be higher than female participants’. Male participants recommended that VHs of both sexes and races should seek medical help for their pain significantly more than female participants. This is consistent with studies showing sex differences in health-seeking behaviors. Males have been found to request more drugs than females after surgery when given access to patient controlled analgesia (Macintyre & Jarvis, 1995). Burns, Hodsman, McLintock, Gillies, Kenny, & McArdle (1989) and Stinshoff, Lang, Berbaum, Lutgendorf, Logan & Berbaum (2004) also found that males tend to seek more medication for their pain compared to females. Based on the current findings, it also appears that males are more likely to recommend that others seek care for their own pain complaints. Several other interpretations are possible. For example, perhaps males consider themselves to be less equipped than females to help others with their medical concerns. Males may also be less tolerant of expressions of distress from others, which results in them being more likely than females to encourage that medical care be sought. These speculations could be investigated in future studies. The ratings of pain intensity, pain unpleasantness, painrelated negative mood, pain coping, and recommending

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69 medical help showed significant intercorrelations. Relationships between these dependent variables have a pattern that might add to the explanation of some of the current results. For example, the high correlation between pain intensity, pain unpleasantness, pain-related negative mood, and pain coping might add to the explanation of why female virtual videos were rated higher on all variables, if pain ratings influenced the other ratings. The results of this study have several implications that are worth noting. First, the use of computerized VHs with digitally controlled facial expressions of pain across sexes and races is an innovative technique that enabled greater standardization of pain expression than real humans would allow. This standardization allows for greater confidence in interpreting the results as being determined by the sex and race biases that participants brought to the ratings. Furthermore, the VH technology used in this study has the potential to be an educational assessment and intervention tool. Students, healthcare providers, and other individuals can use this technology to assess their own biases in interpreting pain or other emotions expressed by others. This technology can also be accessible to almost anyone in the world via the Internet. This study did have some limitations, however. First, there was only one African American male participant in the sample. Future investigations with more diverse samples would be necessary to provide additional evidence of the sex and race findings of the present study. Second, the participants in this study were undergraduate students and it would be important to replicate these findings in other populations. Finally, the VH characters only showed the head region and, thus, did not address the many other nonverbal expressions of pain that are communicated throughout the entire body. Future work could examine whether the sex and race effects observed herein are also found when full body characters are used and other nonverbal expressions are manipulated. Acknowledgement The present work was ed by grants from the National Institute of Dental and Craniofacial Research (R01DE013208), National Institute of Neurological Disorders and Stroke (F31NS049675), and National Center for Rehabilitation Research (T32HD007424).

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referenCes Burns, J., Hodsman, N., McLintock, T., Gillies, G., Kenny, G., & McArdle, C. (1989). The influence of patient characteristics on the requirements for postoperative analgesia. Anaesthesia, 44, 2-6. Campbell, C. M., Edwards, R. R., & Fillingim, R. B. (2005). Racial differences in responses to multiple experimental pain stimuli. Pain, 113(1-2), 20-26. Carmen, R., Green, S., Ndao-Brumblay, K., Nagrant, A. M., Baker, T. A., & Rothman, E. (2004). Race, age, and sex influences among clusters of African American and White patients with chronic pain. The Journal of Pain, 5(3), 171-182.

Sex and Race Differences in Rating Pain

An analysis of the 1st National Health and Nutrition Examination Survey data. Pain, 43, 299307. Riley, J. L., Robinson, M. E., Wade, J. B., Myers, C. D., & Price, D. D. (2001). Sex Differences in Negative Emotional Responses to Chronic Pain. The Journal of Pain, 2(6), 354-359. Riley, J. L., Wade, J. B., Myers, C. D., Sheffield, D., Papas, R. K., & Price, D. D. (2002). Racial/racial differences in the experience of chronic pain. Pain, 100(3), 291-298.

Dao, T. T. & LeResche, L. (2000). Sex differences in pain. Journal of Orofacial Pain,14, 169-184.

Robinson, M. E., Riley, J. L., Myers, C. D., Papas, R. K., Wise, E. A., Waxenberg, L. B., & Fillingim, R.B. (2001). Sex role expectations of pain: Relationship to sex differences in pain. Journal of Pain, 2, 251-257.

Ellermeier, W. & Westphal, W. (1995). Sex differences in pain ratings and pupil reactions to painful pressure stimuli. Pain, 61(3), 435-439.

Robinson, M. E. &Wise, E. A. (2003). Sex bias in the observation of experimental pain. Pain 104(1-2), 259-264.

Frot, M., Feine, J.S., & Bushnell, M.C. (2004). Sex differences in pain perception and anxiety. A psychophysical study with topical capsaicin. Pain, 108 (3), 230-236.

Robinson, M. E. & Wise, E. A. (2004). Prior pain experience: influence on the observation of experimental pain in men and women. The Journal of Pain, 5(5), 264-269.

Hawthorn, J. & Redmond, K. (1998). Pain: Causes and Management. Malden, Mass. Blackwell Science.

Stinshoff, V. J., Lang, E. V., Berbaum, K. S., Lutgendorf, S., Logan, H., & Berbaum, M. (2004). Effect of sex and gender on drug-seeking behavior during invasive medical procedures. Academic Radiology, 11(4), 390-397.

Jordan, M., Lumley, M., & Leisen, J. (1998). The relationships of cognitive coping and pain control beliefs to pain and adjustment among African-American and Caucasian women with rheumatoid arthritis. Arthritis Care and Research, 11, 80-88. Keogh, E. & Herdenfeldt, M. (2002). Sex, coping and the perception of pain. Pain, 97(3), 195-201. Macintyre, P. & Jarvis, D. (1995). Age is the best provider of postoperative morphine requirements. Pain, 64, 357–364. Magni, G., Caldieron, C., Rigatti-Luchini, S., & Merksey, H. (1990). Chronic musculoskeletal pain and depressive symptoms in the general population:

Unruh, A.M. (1996). Sex variations in clinical pain experience. Pain, 65(2-3), 123–167. Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does sex affect appraisal of pain and pain coping strategies? Clinical Journal of Pain, 15, 31–40. Vallerand, A.H. & Polomano, R.C. (2000). The relationship of sex to pain. Pain Management Nursing, 1(3), 8-15. Wise, E. A., Price, D. D., Myers, C. D., Heft, M. W., & Robinson, M. E. (2002). Gender role expectations of pain: relationship to experimental pain perception. Pain, 96, 335-342.

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Journal of CyberTherapy & Rehabilitation S p r i n g 2 0 1 0 , Vo l u m e 3 , I s s u e 1 © Vi r t u a l R e a l i t y M e d i c a l I n s t i t u t e

The effeCT of aCTiViTies in VirTual Worlds as a CommuniCaTion enVironmenT To undersTand eaCh oTher Hyungsung Park1

The purpose of this study is to explore the possibility of using virtual worlds such as Second Life as a tool to develop an understanding of male and female gender roles in the classroom and in social life. Specifically, virtual worlds offer possibilities for s to experience role playing with other people, of different ethnicities and gender roles, which may allow them to better recognize characteristics of male/female gender roles and give them a different perspective of men and women in the real world. Through these activities in Second Life, we found that s had positive attitudes about gender identification and developed an increase in respect towards other people. At the same time, also explored the benefits of using virtual worlds for educational applications. Keywords: Virtual World, Communication, Learning Environment, Second Life, Role Playing

inTroduCTion Our future society is an age of knowledge and information. In this new period, entrenched stereotypes and prejudices may yield to a more balanced sense of social values based on rationality and dignity. This will be a direct result of empowering the individual, without the distinction of sexual, ethnic, or class discrimination. Talented individuals who may otherwise be stifled will have a better chance to be realize their own potential and become socially recognized. Jonassen et al. (1999) argues that technologies can be applications of human knowledge to solve real-world problems. Such technological tools can human needs and expand the individual’s functional capacities. This knowledge can be constructive, aid in informational resource management, and requires producing communication connectivity. In the same context, Second Life is a social virtual environment tool and new media for exploring communication environments may improve mutual understanding between men and women concerning gender roles. Virtual worlds continue to grow as a significant component of many children’s and adults’ leisure time. They are being used in education worldwide, and they

play an increasingly important part of our culture as a whole. Different societies reflect cultural values that vary, alter and evolve with given social, political and environmental locations. Male and female gender roles, and the interaction between the two, have long been a key determinant of social-cultural values. In other words, expectations of male and female behavior are set according to gender differences and variance. However, such expectant interpretive analysis is within accordance to age modification variants. A gender role is set within a particular social, political, and environmental context shared between male and female subjects. However, such expectant interpretive analysis is within accordance to age modification variants. This is social science and humanity’s framework for the desired analysis. Gender is the primary component of the gender system in human society, which refers to the set of arrangements by which a society transforms biological sexuality into products of human activity, and in which these transformed needs are satisfied (Reiter, 1975). Thorne (1999) classified four kinds of meaning for gender playing. Of the gender playing used in this research, one

Corresponding Author: Hyungsung Park, LG Apt. 103-2002, Dangjeong-dong, Gunpo-si, Gyeonggi-do, Tel: 82-10-5602-0122, E-mail: [email protected] 1

Kyonggi University, Republic of Korea, San 94-6 Iui-dong, Paldal-gu, Suwon-si, Gyeonggi-do, 443-760, Republic of Korea

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is community activity through role playing with gender classifications, gender identities, and gender areas. He argued that gender role playing is an important activity to understand one's own gender identity and to understand the opposite gender role. It has been determined that gender roles are decided by social and cultural factors more than biological factors. This makes online communities an interesting site to explore how gender is perceived in virtual spaces. The online player community serves the function of interaction and socialization for many players, and one virtual world in particular, is the so-called Second Life. This Second Life is rich in scenery with players interacting with other characters through text-based chat, virtual environment and social activities. Virtual Reality (VR) is an emerging computer interface that strives to make simulations believable and realistic. Highly realistic and believable simulations are accomplished using high-speed supercomputers and three-dimensional graphic accelerators (Ken & Teixeira, 1995). The important distinguishing features of VR is that it is highly immersive, interactive, colorful and visually oriented, fun and generally exciting. VR technology is increasingly being recognized as a potential tool for the assessment and rehabilitation of cognitive and functional processes in humans (Foreman et al, 1997; Pugnetti et al, 1995; Rizzo & Buckwalter, 1997; Rose, 1996). Virtual environments (VE) allow the creation of dynamic stimulus environments in which all responding behaviors can verifiably be recorded. Such advanced technology could potentially offer testing and training options that are unavailable with the use of conventional neuropsychological methods. It is proposed that computer-generated interactive simulated environments can be used to assess and rehabilitate cognitive abilities, much like an aircraft simulator tests and trains piloting abilities. Second Life is a social virtual environment entirely built and owned by its residents. Since opening to the public in 2003, it has grown explosively, and today over 12 million unique s have been created world-wide (Secondlife.com, 2008). Second Life has the capacity to contain game content, but it is not a game, rather, it is a social virtual world within itself. It is also a representation of the first generation of this type of free open source technology. Unlike games, it is a VE without a back story and educators. Also, s have the opportunity to write their own narratives in a social virtual world. Through the willing suspension of disbelief, s initially enter the virtual world and experience it as visually appealing in a ive

Communication in Virtual Worlds

sense. However, through continued participation, the transitions from feeling like an outsider or a viewer into an active “resident” who is “living” in the virtual world, performing social positions and role play. The purpose of this study is to explore the possibilities offered by virtual worlds such as Second Life as a tool for understanding gender roles. Virtual worlds have many uses for testing s’ experiences about and understanding of other people, recognition of gender roles, and how their experiences in these virtual worlds may change the way they think about men and women. Through these activities, we believe that s will develop positive values concerning gender identification and respect for other people. At the same time, we can explore the broader possibilities of using virtual worlds for education. seCond life as a CommuniCaTion enVironmenT To undersTand opposiTe gender roles All societies and cultures have unique expectations and rules about men and women. Because of sociocultural factors, the performance of gender roles has a tremendous influence on an individual's life. Gender roles are internalized through the socialization process, many times unconsciously. Gender roles also determine many social expectations of men and women, such as family and occupation roles, political roles, self-efficacy, and psychological factors. As social customs have changed, present-day gender roles require a deeper understanding about men and women. In modern times, the meaning of gender roles has been shown to be far more independent of physiological and anatomical differences than previously believed. This permits individuals to utilize interactive social technology within a controlled environment to explore the complicated patterns of behavior that modern society has adapted in response to both men and women’s traditional gender roles. According to psychologists (Chodorow, 1978; Dinnerstein, 1977; Johnson, 1988), gender identity results from distinguishing gender identity differences between males and females since birth. Also, Whiting and Edward (1988) stated that gender identity is a result of biological difference. Nood and Attema (2006) said that Second Life is a VE where one can interact with the environment, made up of a realistic graphic representation of our physical world. The first thing a new visitor sees is a modifiable puppet, called an "avatar" that enables the to move through the virtual world. With this avatar, the can fly, tele-

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Park port, or walk to practically any place within Second Life. Moreover, the can meet others, create objects, go to parties, buy kitchens, and, through the introduction of commerce, earn money in a currency called the "Linden Dollar"(L$), and perform many other activities. Virtual worlds can supplement education, modeling ideas that are abstract and making them interesting, relevant, and concrete (Williamson & Facer, 2004). Virtual worlds might also provide safe places where children can interact and socialize, without worrying about unknown dangers in an educational context (Alvarez, 2006). However, they still include some physical dangers, predator behavior, resulting negative emotions and so on. Another main appeal of Second Life is that new activities can be tried in an almost risk-free environment. This can encourage experimentation in a way that is not possible in the real world. There can be some very real, human aspects to this, such as people with social disorders practicing talking to others behind the safety of a computer screen (Johnson, 2007). We need to change our teaching methods to enhance the skills that future citizens will need in a digital society. Children and young people are introduced to virtual worlds via video games, and the ways that they interact with technology may change methods of learning, and the accumulation of knowledge (Gros, 2007). At the same time, Garau (2003) commented about the role of virtual worlds that recent works of cyber fiction have depicted, in a not-so-distant future where the Internet has developed into a fully three-dimensional and immersive data-scope, simultaneously accessible by millions of network s. This virtual world is described as having spatial properties similar to the physical world and its virtual cities are populated by digital proxies of people. Slater et al. (2000) argues that practical applications of VR are normally in the realms of engineering, product design, and skill rehearsal. s can enter into a VE such as Second Life in order to learn something new about a real situation, to which the simulation corresponds, or to improve or learn a new skill. Participants can create their avatar and explore, meet other people, own land, play games or sports, have discussions, dance, create, run a business, enhance their education and so on, through a VR such as Second Life. s can perform actions in real life as well as something that is impossible in real life. In fact, the culture in Second Life is characterized by its combination of real actions as well as virtual life representations and activities.

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73 researCh meThods researCh QuesTions For this research, we had to consider the following questions: -Do virtual worlds provide a learning environment for role playing to understand the opposite gender? -Do s change their recognition of gender roles via virtual worlds? The research questions are formed to reflect the main objectives of this research and they are statistically tested in this study. parTiCipanTs of The sTudy The sample for this study was drawn from university students consisting of one hundred twenty female students in the author's three classes titled, "Instruction Method and Technology." The the sample consisted of thirty participants. Most of the students are women, with just three male students. The men were excluded in this research to avoid biases. The students’ ages ranged from 21-23 years old. Participants did not meet prior to the experiment to avoid the possibility of any first impressions influencing their thoughts on gender in the conversation of the virtual world. The experiment took place for twelve weeks to give participants ample opportunity to develop an awareness of gender roles in the virtual environment. design The study took place at the school of the participants. The instructional interventions were divided into three main phases–pre-testing, treatment, and post-testing. Treatments were carried out over three months based on the 3rd-4th grade female students since a pre-service teacher was taking "Instruction method and Technology" at the university. Participants experienced their gender role for two hours per day in a controlled environment within Second Life. Assessment methods were the same for all students who participated in the three groups. The first group served as a control group, performing a female gender role in the real world. The other groups performed in the virtual world of Second life as male and female roles, respectively. Gender roles were set as dependent variables. In order to answer the research questions, we calculated ANOVA to examine the statistical effect. researCh proCedure and aCTiViTy During the sessions, four experimental tasks were employed in order to evaluate the degree of gender role experienced by the participants as they engaged in the virtual world of Second Life. The Second Life allows a to

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Communication in Virtual Worlds

select their personalized avatar, either male or female, when the was created for the study. Also, participants engaged in discussions related to social topics such as gender equality, and employment of males and females. They also visited the male "places" in second life during the session as cyber characters. The sessions consisted of two hours a day for three months. Grouping according to random assignment ↓ Pre-test on the Learner’s BSRISF ↓ Activity in Second Life via interaction with other people related on discussion and visiting the land ↓ Reflection activity via reflection paper about opposite gender ↓ Post-test on the Learner’s BSRISF Figure 2. Fig 1. Research Procedure

insTrumenT The questionnaire was based on the adults Bem Sex Role Inventory Short Form (BSRISF) by Bem (1981,

2007). The test is comprised of 30 item adaptations of Bem’s original inventory designed to investigate masculinity and femininity as independent dimensions of sex role identity. Respondents are asked to rate themselves as to how well ten stereotypically masculine adjectives, ten stereotypically feminine adjectives and ten neutral adjectives describe themselves. In this study, we used the masculinity and femininity items. Respondents were also asked to specify ratings on a 5-point scale, with 1 meaning "never" to 5 meaning "always." Scores on the BSRISF are purported to measure the respondents’ degree of masculine and feminine identification (Singh & Agrawal, 2007). resulTs Table 1 and Table 2 summarize the overall ANOVA results for each of the three group’s pre-test analyses, listing the response variable, explanatory variables with p-values, the means value and standard deviation for each group’s analysis. As you can see in the ANOVA Table 1 and Table 2, between the groups there is no significant difference for masculine adjectives (F=.115, p>.05) and feminine adjectives (F=.050, p>.05). In other words, participants had the same group for masculine adjectives and feminine adjectives.

Table 1 Result of pre-test recognition of gender role of between real world and virtual world Measure

Masculine Adjectives

Feminine Adjectives

Women-Women (Real World) n=30

Women-Women (Virtual World) n=30

Women-Men (Virtual World) n=26

M

4.58

4.51

4.49

SD

.75

.73

.72

M

4.82

4.80

4.76

SD

.60

.76

.72

As you can see in Tables 3 and 4, differences between the groups did occur. According to results, studying the recognition of gender roles shows that virtual worlds offer a mutual understanding via the ability to choose other gender roles for their avatar. In this way, we can recognize the importance and potential of virtual worlds such as Second Life. After the experimental session, groups which chose a male avatar in the virtual world increased their post-test

mean square of masculine adjectives (M=5.18) compared to the pre-test mean square (M=4.49). Also, there were significant differences within masculine adjectives via the mean square (F=6.320, p=0.003). At the same time, prefeminine adjectives of this group decreased after experiencing activities in the virtual world as a male avatar (M=3.89). As shown in Table 4, there were differences between the groups.

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Table 2 Analysis of variance measure

Masculine Adjectives

Feminine Adjectives

ss

df

Ms

f

p

Between Group

.123

2

.062

.115

.892

Within Group

44.674

83

.538

Total

44.798

85

Between Group

.048

2

.024

.050

.951

Within Group

40.028

83

.482

Total

40.077

85

Table 3 Result of posttest recognition of gender role between real world and virtual world Measure

Masculine Adjectives

Feminine Adjectives

Women-Women (Real-Real) n=30

Women-Women (Real-Virtual) n=30

Women-Men (Real-Virtual) n=26

M

4.57

4.47

5.18

SD

.68

.89

.82

M

4.51

4.58

3.89

SD

.65

.81

1.00

Table 4 Analysis of variance measure

Masculine Adjectives

Feminine Adjectives

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ss

df

Ms

f

p

Between Group

8.039

2

4.019

6.320

.003

Within Group

52.786

83

.636

Total

60.825

85

Between Group

7.830

2

3.915

5.773

.004

Within Group

56.286

83

.678

Total

64.115

85

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Communication in Virtual Worlds

Enforced post multiple comparisons were calculated using Tukey methods to determine whether differences which were kept in mind between any groups were concrete. As a result, there were differences between the groups which had chosen other gender roles in the virtual world than their own, such as women choosing male avatars. As shown in the table, gender role recognition of experimental groups (women-men) had significantly increased. Mean square of pre-masculine adjectives of the experimental group (woman-man) who chose a male avatar in the virtual world significantly increased. On the other hand, feminine adjectives decreased. Figure 1. Masculine adjectives’ change

Figure 2. Feminine adjectives’ change

Group (real World-Virtual World)

In general, the results of this study show that VR interactions can be an important factor in developing a mutual understanding of gender roles. Through activities in virtual worlds, especially through role-playing in a gender role other than one’s own, individuals can develop a deeper understanding of the special characteristics and advantages of their own gender, as well as increase recognition of characteristics of the opposite gender. Also, in this context, VR can become an important learning environment and tool for developing increased understanding, respect for, and comfort interacting with the opposite gender. ConClusion In recent years, there has been a rapid increase in the capability of VR technology. VR technology has been widely promoted as a major technological advancement

Women-Women

Women-Women

*

Masculine Adjectives Women-Women Women-Men

** *

Women-Women

** *

Feminine Adjectives Women-Women Women-Men

Women-Men

** *

**

Result of post hoc multiple comparisons by Tukey

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Park that can offer significant for education. There are several ways in which VR technology is expected to facilitate learning. One of its unique capabilities is the ability to allow students to visit environments and to interact in events that real-life distance, time, or safety factors make unavailable. The type of activities ed by this capability facilitate current educational thinking that students are better able to master, retain, and generalize new knowledge when they are actively involved in constructing knowledge through learning by doing. Learners are represented in the virtual world by their characters, called an “avatar.” In graphic-based virtual world environments, like Second Life, it is possible for a to choose an avatar that is the opposite gender from their real life gender. Thus, this opens up many possibilities for research and exploration. Indeed, the way gender shapes basic human interaction in virtual worlds is often noticed and reflected upon, and has been studied in game-based virtual worlds. According to Svatos (2007), during game play a ’s character gains experience points through activities he or she does in the virtual world, and these experience points drive the character’s evolution and external form. Though Second Life is not a game, there are many similarities between these virtual worlds and video games, just as a video game character gains “experience” that changes their avatar’s evolution and form. It may be possible for learners to gain “experiences” about gender in virtual worlds in ways that can change their perceptions of gender in the real world.

referenCes Alvarez, M. (2006). Second Life and School: The Use of Virtual Worlds in High School Education. Retrieved June 13, 2008, from http://www.trinity.edu/adelwich/worlds/articles/trinity.manny.a lvarez.pdf. Bem, S. L. (1981). Bem Sex Role Inventory: Professional Manual. Palo Alto, CA: Consulting Psychologists Press. Bem, S. L. (2007). Sex role inventory test. Retrieved August 9, 2007, from http://www.okcupid.com /tests/take?testid=9417365772332679709. Chodorow, N. (1978). The reproduction of mothering. Berkeley: University of California Press.

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77 The analytical statistical results of this study indicate that virtual world environments offer the possibility of a clear understanding of gender roles and their placement and functionality within the context of a social environment. This in itself further provides opportune foundational criteria for such information to become the building blocks of further educational processing analyses. This research analysis provides concrete and useful data pertaining to the functionality of gender roles' impact and variation when it comes to formal educational values, strategies, methods, measurable results and treatments. This research provides a measure of gender recognition, and shows that such target placement can be variable with a s’ variant activity experience within the context of a virtual world in an educational context. Furthermore, it demonstrates the capability and capacity for educational virtual worlds to be accurate means of promoting practical and theoretical data which is key to understanding the time-worn, infinite complexities of male/female social relations and educational placement within a given social context. This study has the limitation that can also reflect the characteristics of gender role in the real world–during the session, females in the real world had to have a male or female avatar in a virtual world such as Second Life. To reduce this point, we explained to the participants that they had to focus on understanding the opposite gender. Also, given the topic for discussion, they had to come up with a solution through rational decision making and positive thinking activities during the session.

Foreman, N., Wilson, P., & Stanton, D. (1997). VR and spatial awareness in disabled children. Communications of the ACM, 40(8), 76-77. Garau, M. (2003). The Impact of Avatar Fidelity on Social Interaction in Virtual Environments. Ph D thesis, University College London. Gros, B. (2007). Digital Games in Education: The Design of Games-Based Learning Environments. Journal of Research on Technology in Education, 40(1), pp. 23-38. Johnson, M. (1988). Strong mothers, weak wives. Berkeley: University of California Press. Johnson, N. (2006). The educational potential of Second Life. Ohio State University. Digital Union.

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Jonassen, D. H., Peck, K. L., & Wilson, B. G. (1999). Learning with technology: A constructivist perspective. NJ: Phoenix Color Corp. Ken, P., & Teixeira, K. (1995). Virtual Reality: Through the New Looking Glass, second edition, Windcrest Books. Nood, D., & Attema, J. (2006). The Second Life of Virtual Reality. EPN REPORT. Retrieved June 24, 2008, from https://docs.rice.edu/confluence/ /attachments/5111868/EPN-REPORT-The_Second_Life_of_VR1.pdf?version=1. Pugnetti, L., Mendozzi, L., Motta, A., Cattaneo, A., Barbieri, E., & Brancotti, B. (1995), Evaluation and retraining of adults’ cognitive impairments: Which role for virtual reality technology?, Computers in Biology and Medicine, 25(2), 213- 227. Reiter, R. (1975) ed. Toward and Anthropology of Women. Monthly Review Press: New York. Rizzo, A. A., Buckwalter, J. G., & Neumann, U. (1997). Virtual reality and cognitive rehabilitation: A brief review of the future. The Journal of Head Trauma Rehabilitation, 12(6), 1-15. Rose, F. D. (1996). Virtual reality in rehabilitation following traumatic brain injury. Proceedings of the European Conference on Disability, Virtual Reality and Associated Technology (pp. 5-12). Cognitive, Clinical, and Methodological Issues

Communication in Virtual Worlds

in Assessment and Rehabilitation (G. Riva, Ed.), IOS Press, Amsterdam, 123-146. Savtos, O. (2007). The Potential of Online Virtual Worlds. Retrieved Oct. 9, 2007, from http://almorea. com/papers/PotentialofVW.pdf. Singh, K., & Agrawal, P. (2007). Perceived Sex Role and Fear of Success: A Study on Urban Working Women. Journal of Social Sciences, 15(1), 6569. Slater, M., Howell, J., Steed, A., Pertaub, D-P., Garau, M., & Springel, S. (2000). Acting in Virtual Reality. Proceeding of the Third International Conference on Collaborative Virtual Environments, San Francisco, U.S.A. Terdiman, D. (2003). SL Intrudes On First One. Retrieved March 9, 2008, from http://www.wired. com/news/games/0,2101,59675,00.html. Thorne, B. (1999). Gender play: Girls and boys in school (6th ed.). New Brunswick: Rutgers University Press. Whiting, B., & Edward, C. (1988). Children of difference worlds. Cambridge: Harvard University Press. Williamson, B., & Facer, K. (2004). More than ‘just a game’: the implications for schools of children’s computer games communities. Education, Communication & Information, 4, 255-270.

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CyberproJeCTs IN THIS FEATURE, we will try to describe the characteristics of current cyberpsychology and rehabilitation research. In particular, CyberProjects aims at describing the leading research groups and projects, actually running around the world, with a special focus on European research. geTTing families and friends TogeTher again–VirTually A fireside chat, sharing photos with granddad, a family get-together to play Monopoly on a Sunday afternoon… Digital media designed for the individual has hastened the demise of collective social events, but it could also enable their revival. By marrying state-of-the-art video and audio communications technology with digital media, interactive devices and ambient intelligence, a team of European researchers hopes to give people of all ages the opportunity to get together, play games, share experiences and generally communicate, interact and have fun together, even if they are thousands of kilometers apart. Their goal is to break down the barriers between people – technological and social. “E-mail, the Internet, cellphones, Internet video calls… they are all designed for one person using one machine. They are not designed to families or groups of people communicating,” suggests Nikolaus Färber, a researcher at the Fraunhofer Institute for Integrated Circuits IIS in . “People have become isolated by technology,” he adds. Coupled with people moving and traveling more frequently for work and study, it is a situation that has led families and friends to spend less time together. Even in the same home many people now tend to entertain and educate themselves alone, whether it is the teenager playing computer games in her room, the father listening to music on his MP3 player in the lounge or the mother studying on her laptop in the kitchen. Technology has encouraged this isolation, but advances in that same technology could now reverse this trend.

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TelepresenCe and more Working in the EU-funded TA2 (Together anywhere, together anytime) project, Färber and a team of researchers from seven European countries are aiming to turn the tables on technology by simply and affordably bringing telepresence into normal households. Their vision consists of groups of friends and family seeing each other on their TVs, hearing each other through their stereo systems, sharing photos and videos and playing games almost as naturally as if they were in the same room. “My brother lives in Switzerland and we have kids about the same age, but they only get to see each other twice a year. With the system we are developing they would be able to play together whenever they wanted to without having to leave their homes,” Färber notes. To make that possible, the TA2 researchers are developing the components necessary to build an affordable and easy to install in-home telepresence system. The components can then be used to build complete telepresence systems without the need for special rooms or big screens to bring people together virtually. A television set, sound system, cameras and microphones placed in a living room suffice to create a sufficiently interactive and immersive experience, while state-of-the-art software, which is transparent to the end , manages the communications backbone. “Audio and video quality is of essence… it needs to be sharp and responsive,” Färber says. “At the same time, TA2 is aware that high audiovisual quality is not the only thing that matters. Applications like games, photo sharing, or virtual pin boards are necessary to frame and trigger the communication.” Fraunhofer IIS has developed an Audio Communication Engine to provide low-delay, hi-fi quality sound that vastly improves upon current shaky and echo-prone Internet calls. Other project partners, among them Philips, BT and Alcatel-Lucent, are working on enhancing video communications, linking interactive devices together and implementing ambient intelligence.

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Two or more families playing a board game, for example, would be able to see and hear each other over their TV sets, with artificial intelligence used to focus in-home cameras on the person speaking or whoever's turn it is. A touch screen embedded in a table might serve as a board game interface, while ambient intelligence from in-home sensors will let the system and other players know where participants are and what they are doing. “Ambient intelligence could also improve communications by letting friends and family know when someone is available for a call or if they are busy, depending of course on how much information the person wants to disclose,” Färber says. Children and the elderly, who often find themselves more isolated than other social groups in the modern world, could particularly benefit from the technology. One scenario, which will be used as a demonstration to highlight the project results, envisions a grandparent and grandchild playing a picture-matching game called "pairs" in which old photos could be used to trigger conversations and stories down through generations. “At IFA in Berlin (the world’s largest consumer electronics fair) we set up a demonstration consisting of two rooms, two TV screens and two tables with integrated touch screens on which people could play games. People

CyberProjects

were playing with each other as if they were really together in the same room… Many people were interested in the system, particularly those with families and friends in different parts of the world,” notes Matthias Rose, the head of marketing communications for audio and multimedia at Fraunhofer IIS. Fraunhofer is already working on integrating its audio technology into commercial products, and commercial applications are also likely to stem from other areas of research in the TA2 project, which is being funded by the EU’s Seventh Framework Programme. “Obviously, once the project ends, it would be interesting to find investors and partners to create a commercial product out of the whole system that would allow everyone to incorporate telepresence into their homes and bring families and friends closer together,” Färber says. For more information visit http://www.ta2-project.eu/. Compiled by Giuseppe Riva, Ph.D. and Simona Raspelli, Ph.D. Istituto Auxologico Italiano Data provided by ICT Results (http://cordis.europa.eu/ictresults).

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CyberfoCus New technologies are developing at a rapid pace. To help you stay abreast of the latest trends in advanced technologies and healthcare, this feature showcases , 2009- 2010 events, which will provide you with the opportunity to connect with leading experts worldwide and remain on the cutting edge of the most recent developments. The CyberFocus column welcomes your contributions. To supply relevant information for this feature, please send an e-mail to: [email protected]. Cyberpsychology & CyberTherapy 15 June 13 - 15, 2010 Seoul, Korea www.interactivemediainstitute.com The Journal of CyberTherapy & Rehabilitation is the official journal of the CyberTherapy Conference. The 15th Annual International CyberTherapy Conference (CT15) brings together researchers, clinicians, policy makers and funding agencies to share and discuss advancements in the growing discipline of CyberTherapy & Rehabilitation, which includes training, education, prevention, rehabilitation, and therapy. The focus of this year’s conference is two-fold–first, “Technologies as Enabling Tools” will explore the use of advanced technologies in diagnosis, assessment and prevention of mental and physical disorders. In addition, attention will be drawn to the role of interactive media in training, education, rehabilitation and therapeutic interventions. Secondly, CT15 will investigate the “Impact of New Technologies” and how they are influencing behavior and society through cyberadvertising, cyberfashion and cyberstalking, among others. Technologies featured at the conference include VR simulations, video games, telehealth, the Internet, robotics, brain-computer interfaces, and non-invasive physiological monitoring devices. Conference attendees have the opportunity to play a role in deg the future of mental healthcare. CT15 features interactive exhibits at the Cyberarium allowing participants to experience the technologies firsthand as well as the opportunity to display their exhibits in a forum-type setting. 2010 Conferences raVe 2010 - real actions in Virtual environments March 3 Barcelona, Spain www.raveconference.com ----------------------------------------------------------------------------------------------------------------------------------------The World of health iT Conference & exhibition March 15 - 18 Barcelona, Spain http://www.worldofhealthit.org/ ----------------------------------------------------------------------------------------------------------------------------------------ieee Vr 2010 March 20 - 24 Waltham, Massachusetts, USA http://conferences.computer.org/vr/2010/

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----------------------------------------------------------------------------------------------------------------------------------------applied psychophysiology & bio 2010 March 24 - 27 San Diego, California, USA http://www.aapb.org/ ----------------------------------------------------------------------------------------------------------------------------------------2010 haptics symposium March 25-26, 2010 Boston, Massachusetts, USA http://www.hapticssymposium.org/ ----------------------------------------------------------------------------------------------------------------------------------------spie defense, security, and sensing April 5 - 9 Orlando, Florida, USA http://spie.org/x1375.xml ----------------------------------------------------------------------------------------------------------------------------------------society of behavioral medicine: 2010 April 7 - 10 Seattle, WA http://www.sbm.org/meetings/ ----------------------------------------------------------------------------------------------------------------------------------------laval Virtual 2010: 12th Virtual reality international Conference April 7 - 11 Laval, http://www.laval-virtual.org/ ----------------------------------------------------------------------------------------------------------------------------------------The 7th annual World health Care Congress April 12 - 14 Washington D.C., USA http://www.worldcongress.com/events/ ----------------------------------------------------------------------------------------------------------------------------------------med-e-Tel April 14 - 16 Luxembourg http://www.medetel.lu/index.php

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87 ----------------------------------------------------------------------------------------------------------------------------------------19th international World Wide Web Conference: WWW2010 April 26 - 30 Raleigh, North Carolina, USA http://www2010.org/www/ ----------------------------------------------------------------------------------------------------------------------------------------human systems interaction Conference May 13-15 Poland http://hsi.wsiz.rzeszow.pl/ ----------------------------------------------------------------------------------------------------------------------------------------american Telemedicine association 2010: 15th annual international meeting and exposition May 16 - 18 San Antonio, Texas, USA http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3629 ----------------------------------------------------------------------------------------------------------------------------------------The 6th annual World health Care Congress – europe May 19 - 20 Brussels, Belgium http://www.worldcongress.com/events/HR10015/ ----------------------------------------------------------------------------------------------------------------------------------------The xii symposium on Virtual and augmented reality – sVr 2010 May 24 - 27 Rio Grande Do Norte, Brazil http://www.dimap.ufrn.br/svr2010/ ----------------------------------------------------------------------------------------------------------------------------------------WCbCT 2010-World Congress of behavioral and Cognitive Therapies June 2 - 5 Boston, Massachusetts, USA http://www.wcbct2010.org/ ----------------------------------------------------------------------------------------------------------------------------------------Cyberpsychology & CyberTherapy 15 June 13 - 15 Seoul, Korea www.e-therapy2010.org

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----------------------------------------------------------------------------------------------------------------------------------------siggraph 2010 July 25 - 29 Los Angeles, California, USA http://www.siggraph.org/s2010/ ----------------------------------------------------------------------------------------------------------------------------------------3rd international symposium on intelligent interactive multimedia: systems and services July 28 - 30 Baltimore, Maryland, USA http://iimss-10.kesinternational.org/ ----------------------------------------------------------------------------------------------------------------------------------------2010 american psychological association Conference August 12 - 15 San Diego, California, USA http://www.apa.org/convention/ ----------------------------------------------------------------------------------------------------------------------------------------8th iCdVraT with artabilitation August 31 - September 2 Valparaiso, Chile http://www.icdvrat.rdg.ac.uk/ ----------------------------------------------------------------------------------------------------------------------------------------The 5th international Conference on interactive mobile and Computer aided learning September 16 - 17 Hasselt University, Belgium http://www.imcl-conference.org/ ----------------------------------------------------------------------------------------------------------------------------------------10th international Conference on intelligent Virtual agents (iVa 2010) September 20 -22 Philadelphia, Pennsylvania, USA http://iva2010.org/ ----------------------------------------------------------------------------------------------------------------------------------------40th european association for behavioural and Cognitive Therapies annual Conference October 7 - 10 Milan, Italy http://www.eabct2010-milan.it/

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89 ----------------------------------------------------------------------------------------------------------------------------------------association for behavioral and Cognitive Therapies (abCT 2010) November 18 - 21 San Francisco, California, USA http://www.abct.org/d/?m=m&fa=Convention

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for auThors To submiT Please submit electronic copies of your manuscript by visiting www.vrphobia.eu and clicking on the “Submit Paper” link on the right. manusCripT sTyle. The language of the journal is American English. Submissions should follow American Psychological Association (APA) format. Format questions not addressed in the checklist below can be sent to the Managing Editor at [email protected]. CopyrighT. Submission of a manuscript will be held to imply that it contains original unpublished work and is not being submitted for publication elsewhere at the same time. If selected for publication, authors must sign and return a Copyright Transfer Form (available on the Web site or from the Publisher.) Submitted ma-

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93 postal address, e-mail address, telephone number, and fax number for future correspondence and a statement that the manuscript is original, not previously published, and not under concurrent consideration elsewhere.

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general informaTion Journal of CyberTherapy & Rehabilitation ISSN: 1784-9934 GTIN-13 (EAN): 9771784993017 Journal of CyberTherapy & Rehabilitation is published quarterly by the Virtual Reality Medical Institute, Rue de la Loi, 28/7, B-1040 Brussels, Belgium. The journal explores the uses of advanced technologies for therapy, training, education, prevention, and rehabilitation. Areas of interest include, but are not limited to, psychiatry, psychology, physical medicine and rehabilitation, neurology, occupational therapy, physical therapy, cognitive rehabilitation, neurorehabilitation, oncology, obesity, eating disorders, and autism, among many others. publishing house Virtual Reality Medical Institute Rue de la Loi, 28/7 B-1040 Brussels, Belgium Telephone: +32 2 286 8505 Fax: +32/2/286 8508 E-mail: [email protected] Website: www.vrphobia.eu

adVerTising For advertising information, rates, and specifications please Virtual Reality Medical Institute, Rue de la Loi, 28/7, B-1040 Brussels, Belgium, Telephone: +32 2 286 8505; Fax: +32/2/286 8508; E-mail: [email protected]. reprinTs Individual article reprints are available from corresponding authors. Please the publisher for rates on special orders of 100 or more. manusCripTs Please submit electronic copies of your manuscript by visiting www.vrphobia.eu and clicking on the “Submit Paper” link on the right. Information about manuscript submission requirements and formatting can be found at the back of each issue or on the Web site.

publisher Brenda K. Wiederhold, Ph.D., MBA, BCIA

CopyrighT Copyright © 2010 by Virtual Reality Medical Institute. All rights reserved. Journal of CyberTherapy & Rehabilitation is owned by Virtual Reality Medical Institute BVBA and published by the Virtual Reality Medical Institute BVBA. Printed in Hungary.

subsCripTion informaTion Rates for subscription are for a volume of four issues. Print Europe: €115 International: €145

With the exception of fair dealing for the purposes of research or private study, or criticism or review, no part of this publication may be reproduced, stored, or transmitted in any form or by any means without prior permission in writing from the copyright holder.

Online and Print Europe: €135 International: €165

For permission to photocopy an article for internal purposes, please request permission and pay the appropriate fee by ing [email protected].

Online Only All locations: €75

The accuracy of contents in Journal of CyberTherapy & Rehabilitation are the responsibility of the author(s) and do not constitute opinions, findings, conclusions, or recommendations of the Publisher or editorial staff. In addition, the Publisher is not responsible for the accuracy of claims or information presented in advertising portions of this publication.

Subscriptions begin with the first issue of the current volume. No cancellations or refunds are available after the volume’s first issue is published. There are also no refunds on single issue purchases.

The Journal of CyberTherapy & Rehabilitation is indexed in PsycINFO, Gale and EBSCO, and is currently under review with SCOPUS, EMBASE and Medline.

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insTruCTions for ConTinuing eduCaTion Quiz The quiz is an open-book exam. Clearly mark answers by circling the correct letter. You may photocopy the exam or work directly on the journal page. Mail the completed exam and appropriate payment (see fees,

next page) to Interactive Media Institute, 6155 Cornerstone Court East, Suite 210, San Diego, California 92121, U.S.A. If you wish to receive a receipt of payment or a copy of the correct quiz answer, please include a self-addressed, stamped envelope.

eValuaTion Please rate this article, “The Sense of Olfaction: Its Characteristics and Its Possible Applications in Virtual Environments” (Baus & Bouchard, pg. 31), on a scale of 1 to 5 (1=true, 5=false). _____The information in this article was presented well _____The information is applicable to my line of work _____The article covered all relevant aspects of the topic _____I read this article because it addresses my work _____I read this article to gain the CE credits _____I would recommend the article to colleagues To judge your responses to the previous article, please evaluate a second article as well, on a scale of 1 to 5 (1=true, 5=false). The article title is:____________________________________________________________________ _____The information in this article was presented well _____The information is applicable to my line of work _____The article covered all relevant aspects of the topic _____I read this article because it addresses my work _____I read this article to gain the CE credits _____I would recommend the article to colleagues The CE credit quiz is open for one year after the issue’s publication date. The Interactive Media Institute is approved by the American Psychological Association to offer continuing education and is solely responsible for the content of articles and the examination process. Please print clearly and mail with payment to the address listed above: Name________________________________________ Address______________________________________ City______________________________________State and Zip Code (if in U.S.)__________ Country______________________________________ I certify that I have read the article and completed the test without receiving any outside help. Signed_________________________________________________________Date_____________ For iACToR and personal subscribers, payment is US $20. For others, payment is US $40. Check ____ Visa ____ MasterCard ____ Card # _______________________________________Exp.___________ Signed________________________________________

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ConTinuing eduCaTion Quiz Prepared by Alessandra Gorini, Ph.D.

The sense of olfaction: its Characteristics and its possible applications in Virtual environments (baus & bouchard, pg. 31) If you answer 10 out of 12 questions correctly, you will be awarded one CE credit. 1. Olfactory sense has been considered of minor interest in VR applications because: a)the incorporation of olfaction stimuli in the VR experience would not enhance it b)the odor perceived by each subject is highly subjective, and thus, generalization involving one particular odorant is likely to be difficult c)due to their complex composition and transient character, controlled exposure to olfactory stimuli is more complex than that to visual or acoustic stimuli d)all of the above 2. Up to date, the rare VR applications that include some forms of olfaction stimulation regard: a) the treatment of specific phobias b) the treatment of eating disorders c) drug addiction research d) the treatment of psychotic disorders 3. When exposed to multi-sensory alcohol related cues presented in virtual environments, individuals with alcohol use disorders: a) increase their level of presence b) become more relaxed c) report significantly higher cravings for alcohol than non-binge drinkers d) both A and C 4. One of the differences between the olfactory system and the other senses is that: a) the olfactory bulb projects without being mediated by the thalamus onto the amygdala b) the olfactory bulb projects crossed onto the amygdala c) the olfactory bulb goes through a series of cortical

relays before reaching the limbic system d) none of the above 5. Which of the following cerebral structures are involved in the olfactory system: a) the olfactory bulb b) the amygdala c) the orbitrofrontal cortex d) all of the above 6. Compared to other animals, humans: a) have a poor ability to localize the source of an odorant b) have an olfactory acuity inferior to that of most animal species c) use olfaction for socialization d) none of the above 7. In order to be effective, the presentation of an odor in a virtual environment should be: a) provided using many remote sources to release the olfactory cues b) ed by a visual cue related to the odor c) randomly provided d) none of the above 8. In a VR experience including odor stimulation: a) the hedonicity of an odor contributes to the determination of its intended virtual source b) the level of familiarity leads to a more rapid association with the cues presented via other modalities c) varying odorant intensities may be useful in cueing the about the position, and rate of position change, relative to the intended virtual source of that odor d) all of the above

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9. The presence of an odorant in the environment can be associated with: a) positive affects and increased arousal, if the odor is pleasant b) an alteration in the level of pain perceived by an individual c) negative affects and decreased arousal if the odor is unpleasant d) the pleasantness of the experience 10. Contrary to congenitally blind, mute or deaf people, individuals with congenital anosmia: a) experience less pain b) are more prone to illness c) do not have intact reproductive–social behavior d) all of the above

ConTinuing eduCaTion CrediTs To qualify for CE credits, readers will need to do the following: • After reading an article, answer the questions above. • Send the completed answer sheet, along with payment, to Interactive Media Institute, 6155 Cornerstone Court East, Suite 210 San Diego, CA 92121, U.S.A.

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11. Clinical scenarios for treating PTSD utilize odors to: a) make the virtual experience more fascinating b) make the experience more realistic c) facilitate the processing of traumatic memories d) none of the above 12. In training scenarios, olfactory stimulation could be useful to: a) trigger appropriate responses to emergency situations b) establish an association between a distinct odorant and “virtually-evoked” positive emotions c) enhance the virtual experience d) all of the above

• If you wish to receive a receipt of payment or a copy of the correct quiz answer, please include a self-addressed, stamped envelope. • The fee is $20 for iACToR or subscribers and $40 for non-subscribers. • All CE exams are open-book. • Credits assigned are based on the length of time required to read each article.

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The Journal of CyberTherapy & Re ha bilitation (JCR) is the official journal of the International Association of CyberPsychology, Tra i n i ng & Re ha bil itation (iACToR ). Its m ission is to explore the uses of adva nced tech nolog ies for ed ucation, tra i n i ng, prevention, thera py, a nd reha bil itation .

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