BIRMINGHAM, Ala. — After a shift stocking coffee beans at grocery stores around Birmingham, Sarah Stewart sits in her mother’s office chair and logs into a virtual world.
She straps on virtual reality goggles and chooses a program, created by Floreo, that asks her to put groceries away in their correct places in the pantry and fridge.
Sarah, who is 27, has multiple disabilities including autism, and uses Floreo to rehearse common skills and challenges.
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“Learning how to deal with these challenges is an important life skill as an adult,” Sarah’s mother, Margaret Stewart, said.
In a Floreo program, a student wears a VR headset and completes tasks or replies to questions. A coach monitors their progress in real time and can adjust prompts and difficulty of questions.
Virtual reality is an increasingly common and accessible tool for people with autism.
Some research suggests that certain programs, when applied with positive reinforcement and best practices, can help people improve social skills and life skills.
Margaret worked through Alabama’s Medicaid waiver process to get Floreo paid by the state.
But she said other families she knows haven’t been able to use or pay for the program using state funds.
It can be hard for people with autism in Alabama to get certain services, as families navigate long wait times, low reimbursement rates and complicated waiver processes.
While Floreo qualifies for reimbursement under Medicaid waiver programs in some states, families must still make a case for why the classes are necessary.
Vijay Ravindran founded Floreo after his son was diagnosed with autism. The company offers a wide range of lessons and programs intended to help people with autism build confidence as they navigate real-world challenges.
“One of the elements of some forms of therapy is rewards-based motivation, but the rewards can be disconnected,” Ravindran said.
“Here, you can get immediate feedback within the animation or from the coach.”
Floreo has added programs after feedback from families about issues people with autism may encounter, such as police stops, bullying and online safety.
“They are age appropriate, but they are also developmentally appropriate,” Ravindran said. “That’s where the expertise of the caregiver, teacher, therapist comes in, and their sense of where they are at developmentally.”
“A lesson that might take one kid 30 seconds might take another kid 6 minutes, and that’s okay,” he said.
Right now, Sarah is working on lessons about crossing the street at the correct time and interacting with police officers.
She also enjoys games where she matches animals, learns about Jane Goodall and practices asking questions in order to solve a problem.
Logan Harrell, a direct support professional, assists Sarah throughout the day. She said she has found Floreo useful as they work on job and social skills.
“Are you ready to be in the driver’s seat?” Harrell said, queuing up another lesson as she sits across the desk from Sarah.
“Rock and roll,” Sarah said.
“I’ve overheard her using some of those same phrases she learned, successfully,” Margaret said.
“She comes into the kitchen and sees me unloading groceries and says oh, that goes there. That’s been really encouraging.”
Sarah loves to be around other people. She serves on her church’s hospitality team. She shares candy and small talk with people she meets. She has joined a bowling league.
Her parents look for ways she can expand her abilities and practice independence.
“There are some programs that simulate work experiences, which, although she already has a job, a lot of the skills she does in there can help her be more successful,” her mother, Margaret, said.
“We can’t assume that she can’t do something, if we don’t try to give her all of the support she needs to be successful.”
Floreo is available on the market, but the company also is working to get a specific product, called FloreoRX, approved by the U.S. Food and Drug Administration as an investigational device.
FloreoRX has a specific sequence of lessons delivered over 12 weeks, intended to focus on increased social skills and social connection.
The company previously did a clinical trial for FloreoRX with 125 patients, which found that people who used the program made more improvements than people who used a sham control.
It was one of the largest prospective, multi-site randomized controlled trials of a VR-based intervention conducted in children with autism, according to the company.
“There’s obviously a lot of scrutiny,” Ravindran said, of the broad spectrum of autism therapy and behavioral services, some of which can be low-quality.
“We’re building something that is science-backed that can accelerate outcomes.”
Other interventions for people with autism can include watching training videos, but they are typically passive and can be hard to apply in real-world scenarios.
In-person therapy is important, but not every family can get to hours of intervention each week. And some programs, such as applied behavioral analysis, have been criticized and aren’t a good fit for everyone.
While some virtual reality programs can improve social skills and training, researchers say some people report sensory overload and fatigue after using them.
Ravindran said his team has tried to work with families, clinicians and people with autism to make sure the programs are as effective as possible.
“Asking parents to do even more work with their kids is asking a lot. They’re already pushed to the limit in so many ways,” Ravindran said.
“So it’s important that solutions are comprehensive and really address the three-pronged nature of support for children with developmental delays and special needs — that it’s clinical, that it’s educational and that it’s home-based, and all three have to work together and reinforce each other.”
Ravindran said the product is not designed to be entertainment or to replace a therapist or special education teacher.
Instead, he said, it is an additional intervention and tool that can be tailored for an individual’s needs.
“We’re trying to give them superpowers,” he said, of families and caregivers for people with autism.
“We’re trying to take the thing they care about doing, which is teaching skills to individuals, and supersize it, accelerate it.”
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