VRET and Minors: Ethical and Clinical Considerations

Why Pediatric VR Is Not Just Scaled-Down Adult VR

The difference between applying VRET with a 35-year-old adult and with a 13-year-old adolescent is not just a matter of adjusting the headset strap. Three dimensions change substantially.

1. Physical dimension. Human binocular development (the ability to visually fuse the two images) continues maturing until approximately age 8-12, according to the ophthalmology literature. The vestibular system, responsible for balance, completes its fine-tuning in the same range. A session of prolonged VR in children under 10, with these systems still developing, is not clinically equivalent to the same session in an adult.

2. Cognitive dimension. The ability to reliably quantify SUDS, identify and verbalize automatic thoughts, and sustain attention within a clinical scenario depends on cognitive development. Below age 7-8, standard tools (the 0-10 scale) usually need adapting to visual analog scales (faces, emotion thermometer).

3. Legal dimension. In Spain, a minor patient cannot sign their own informed consent until age 16 (Article 9 of Spain's Law 41/2002 on patient autonomy, with some nuances). Clinical decisions are made by the legal guardian; but clinically, without the minor's explicit assent, the therapeutic alliance is fragile.

Minimum Age: What Manufacturers Recommend and What the Literature Suggests

A sound framework combines manufacturer warnings with training criteria and clinical practice. Both should be kept in mind.

Recommendations from major manufacturers. Meta states that Meta Quest should not be used by children under 10. Sony sets a minimum age of 12 for PSVR2. ByteDance/Pico recommends against using the Pico 4 in children under 13. These figures are indicative; manufacturers do not define them as clinical thresholds but as consumer-use warnings.

Clinical recommendations. The applied literature on pediatric VRET works mostly with children age 8 and up for very specific presentations (supported autism spectrum disorder, specific phobia, pediatric pain) and with short sessions (5-15 minutes). For full CBT-style exposure protocols, the best-documented range in psychology practices in Spain and Europe is 12 to 17 years.

A reasonable operating consensus for a private practice in Spain.

Under age 8: VRET only within clinical research or very isolated interventions under close supervision. This is not the case for a general practice.

Age 8-12: possible in very controlled scenarios (specific phobia, pediatric mindfulness), short sessions (10-15 minutes with the headset on), and active monitoring for motion sickness or fatigue. Guardian present in the room.

Age 13-17: a protocol similar to the adult one, with adjustments to language, hierarchy, and somewhat shorter sessions. The minor's explicit assent is needed in addition to the guardian's consent.

Pre-Session Screening Specific to Minors

Before proposing VRET to a minor, it is advisable to add some specific questions to the general adult screening, directed at the guardian and, when appropriate, at the minor.

For the guardian.

1. Ophthalmological history: strabismus, amblyopia (lazy eye), uncorrected hyperopia, previous eye surgery? Any of these warrants an ophthalmology consultation before starting.

2. Neurological history: personal or first-degree family history of epilepsy, migraines with aura, positional vertigo, balance disorders.

3. Sensory sensitivity: in children with autism spectrum disorder or suspected ASD, how do they tolerate similar headgear (other headsets, tight caps, music headphones)? Some children with ASD tolerate VR very well, while for others it is intolerable.

4. Prior screen time: excessive phone or console use is not a contraindication in itself, but it changes the educational framing (VR should not be trivialized as just another screen).

For the minor (with language adapted to age).

1. Have you ever used virtual reality goggles? How did it feel?

2. Do cars or boats make you feel sick?

3. Do you want to try this, or are you doing it because your parents are telling you to?

The last question is the one that assesses genuine assent. If the minor says they do not want to try it, the plan is adjusted. It is never forced.

Guardian Consent and Minor Assent

Spanish law distinguishes three brackets: mature minor (16-17), minor (12-15), and minor without capacity to understand (under approximately 12, with individual assessment). For personal data processing in digital services, the GDPR (as implemented in Spain via the LOPDGDD) adds a specific parental consent requirement for minors under 14.

For VRET in private practice, the recommended process is as follows.

1. Written informed consent from the legal guardian (both parents in cases of joint custody, unless a court ruling states otherwise). It must include: the therapeutic goal, a description of the VR procedure, known risks (cybersickness, visual fatigue, potentially activating content), processing of personal and biometric data, the right to withdraw, and the duration of consent.

2. The minor's assent, ideally in writing from age 12 and always verbal from age 7 up. It is advisable to prepare an information sheet in age-appropriate language and ask the minor to sign or mark that they understand it.

3. Document both in the clinical record. Keep a signed copy in line with the usual clinical retention periods in Spain (5-15 years, depending on the region).

4. Possibility of withdrawal. Both the guardian and the minor can withdraw consent or assent at any time, with no need to justify it. Document the withdrawal and the stated reason (if the patient wishes to give one).

For special cases (contentious joint custody, a minor in foster care, a minor with a designated legal representative), it is advisable to consult the professional licensing board or a legal advisor before starting. A quick consultation up front saves problems later.

Pediatric Presentations That Benefit Most From VRET

Accumulated clinical evidence and practice in private psychology practices point to certain presentations where VRET fits pediatric care best.

1. Specific phobias. Dog phobia, fear of the dark, fear of injections, fear of the dentist, fear of flying. The clear hierarchy and the possibility of controlled exposure make VR a natural complement to in-vivo exposure. Sessions of 15-25 minutes in adolescents, 10-15 minutes in children over age 9-10.

2. Separation anxiety and school refusal. Virtual classroom, playground, and school-entrance scenarios allow progressive exposure without the need to travel. Work is combined with the family and, when possible, with school counseling.

3. Pediatric PTSD (with caution). The literature (ISTSS guidelines for treatment of PTSD in children and adolescents) places narrative exposure and trauma-focused CBT as first-line treatments. VR is a complement, not a substitute, and is applied only in stabilized minors, with a supportive family network and experienced clinical supervision.

4. Pediatric pain and medical procedures (oncology, dermatology, dentistry). VR as distraction during invasive procedures has consistent supporting literature. Here VR is not exposure; it is adjuvant psychological analgesia.

5. Autism spectrum disorder with associated anxiety. In children with ASD who tolerate the headset, the possibility of pre-exposure to new social settings (a movie theater, a birthday party, a school trip) reduces anticipatory anxiety. This requires prior clinical experience with ASD.

Presentations and Situations Where Pediatric VRET Should NOT Be Applied

There are profiles where pediatric VR is not the tool of choice, at least not as the central piece of the treatment plan.

1. Neurodevelopmental disorders with severe cognitive impairment. The inability to understand the procedure and to communicate SUDS or other signals makes clinical monitoring unfeasible.

2. Active psychotic episodes or high psychotic risk. Although psychosis is less common in the pediatric population, in ASD with psychotic symptoms or in adolescents with prodromal symptoms, VR is not indicated.

3. Severe dissociation or clinically significant depersonalization. VR immersion can worsen the condition by adding a layer of sensory unreality.

4. Recent history of epilepsy or seizures, until neurological assessment is completed.

5. Minor without assent. Even if the guardian has signed, if the minor does not want to put on the headset, it is not used. There is no useful therapy without alliance.

For all these cases, the treatment plan is built without VR as its central piece. There may be room for occasional relaxation or mindfulness scenarios, but VR exposure is excluded.

Practical Adaptations Compared to the Adult Protocol

The first pediatric VRET session keeps the adult structure (framing, acclimatization, brief exposure, closing) with several concrete adjustments.

1. Shorter session. 45-60 minutes for minors, versus 60-75 for adults. Time with the headset on: maximum 10-15 minutes for ages 8-12, 15-20 minutes for ages 13-17, in the first session.

2. Adapted SUDS scale. For children under 12, replace the 0-10 scale with a visual thermometer or a 5-level faces scale. Print the scale on paper and keep it in view of the minor before starting.

3. Guardian in the room or in an adjoining room. For children under 12, the guardian is present in the room (positioned so as not to interfere with the session). For adolescents, the guardian can wait outside unless the adolescent asks otherwise.

4. Language. Replace 'exposure' with 'practice' or 'training.' 'Today we're going to practice getting closer to a dog in the headset, slowly, so that next time you feel more comfortable when you see one.'

5. Adapted between-session tasks. For ages 8-12, simple tasks (draw the dog you saw, count how many dogs you saw at the park on Saturday). For adolescents, logs similar to the adult ones.

6. Coordination with the family. A call or email to guardians after each session, with a brief summary and plan, without disclosing confidential details about the minor beyond what is necessary.

This article is for informational purposes for psychology professionals. It is not clinical advice for any individual case and does not replace the judgment of the licensed psychologist in charge. VRET is professional clinical-support software, not a CE-marked medical device.