Virtual Reality and ADHD: a review of literature

Abstract

This article critically examines the potential benefits of utilizing Virtual Reality (VR) in the rehabilitation of children diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). ADHD, prevalent among children aged 3 to 5, presents significant challenges in education, social interactions, and interpersonal relationships. Several studies indicate that VR technology serves as a valuable tool in addressing these challenges by offering adaptable solutions tailored to each child's unique needs, establishing a secure and focused environment. VR actively engages children, providing effective tools for behavioral assessments, facilitating comprehension and amelioration of cognitive deficits. It aids therapists in precise diagnosis and assessment while improving working memory, executive functions, and attention. The application of VR in the rehabilitation of children with ADHD, grounded in behavioral and physical models, is especially advantageous as it replicates virtual environments for diagnostic purposes, training sessions, ongoing monitoring, and therapeutic interventions.

Keywords

• eol>ADHD
• virtual reality
• children
• rehabilitation
• review
• 1

-

2. The Impact of Virtual Reality in ADHD Patient Rehabilitation Virtual Reality (VR) is a technology that emulates imaginary or real environments [15,16]. Allowing users to interact in three-dimensional settings, VR finds applications in education, entertainment, medical, surgical, etc. [15,17,18]. This is because this technology has the capability to easily create environments similar to real life [ 5,19,20 ]. Among various types, immersive VR, desktop VR, projective VR, and CAVE (C-Automatic Virtual Environment) are among the most common [ 4 ]. Some key advantages offered by VR include high motivation in patients, environment customization according to needs, stability between users and stimuli, complete recording of patients' behaviors and functionalities, facilitating rapid feedback, and ensuring time and cost savings [ 5,19 ]. In terms of rehabilitation, VR enables individuals with disabilities caused by brain damage to confront experiences that are difficult or impossible to experience in the real context [21,22]. However, a significant obstacle arising from the use of rehabilitation technologies in virtual environments is a psychophysiological issue [25,26]. Indeed, during a virtual reality session, users may experience discomfort such as headaches, seizures, nausea, etc. [23,24].

Virtual reality (VR) proves to be an effe ctive tool in the rehabilitation of patients with ADHD, allowing a more reliable assessment of cognitive processes through neuropsychological tests such as the Continuous Performance Test (CPT) [27,28]. Some studies indicate that the CPT integrated into VR (VRC-CPT) provides greater ecological validity and is preferred by children with ADHD compared to the traditional CPT [29]. The combination of virtual reality and interactive tests, with specific stimuli, proves useful in removing distractions and maintaining the attention and concentration of patients, contributing to the rehabilitation of children with ADHD [ 5,19,30,31,32,33 ]. Virtual reality environments enable the detection of cognitive deficits [29]. The utilization of virtual reality (VR) technologies, like computer-generated graphics emulating the actual world, diminishes disruptions in the daily routines of individuals, facilitating the transfer of skills acquired within the VR environment to real-world situations[34,35,36].

A meta-analysis conducted by Bashiri et al. ( 2017) revealed that many professionals, including doctors and therapists, are adopting VR systems for clinical rehabilitation. Rehabilitation therapies based on virtual reality employ strategies that take into account interaction, system usability, and user perceptions. They offer specific stimuli that can be utilized to eliminate distractions and create safe environments that capture the subjects' attention, thereby enhancing their concentration abilities [32,33]. Regarding challenges in cognitive performance, such as working memory, executive function, and attention in children with ADHD, literature highlights that VR technologies are extremely useful for assessing, providing instruction, and improving these conditions. They offer a stable virtual environment that allows patients to adapt their lifestyle through cognitive training [15,28,37,38,39]. Often, children with ADHD experience difficulties in problem-solving, behavior management, and cognitive adaptability [19]. Behavioral models play a crucial role in the rehabilitation process for individuals with ADHD, demonstrating significant importance in virtual reality-involved therapies. VR technologies facilitate action-based responses in these children, helping to reduce behavioral symptoms and problems [34,40]. Other studies have indicated VR's ability to enhance memory functionality, sensory processing, and the five levels of attention, including focused, sustained, selective, alternating, and divided attention in individuals with ADHD [ 1,15 ].Some research, concerning the ecological relevance of neuropsychological tests, suggests that integrating these tests into virtual reality contexts increases both ecological validity and the ability to transfer skills and knowledge acquired from the virtual environment to the real world [ 5,19,29,30,32,33 ]. A key point underscoring the importance of virtual reality technologies is that using medication within virtual contexts proves more effective than in non-virtual environments, contributing to reducing omission errors and reaction times during the assessment of children with ADHD [41]. Based on these results, it appears that VR games express a wide range of human emotions and are particularly effective in rehabilitating children with ADHD [45]. Furthermore, the use of a virtual classroom in VR, simulating the school environment, and the inclusion of neuropsychological tests, such as the CPT, exhibit higher ecological validity in this context [19,30,31,42]. Despite the various opportunities offered by VR technologies, potential side effects pose a challenge that can threaten the health and safety of children with ADHD. However, this issue is partially manageable through the customization of VR according to user needs, proper calibration, and the use of suitable user interfaces and head-mounted displays [23,25,43,44]. 3. Conclusion In conclusion, ADHD presents challenges that significantly impact the daily lives and development of affected individuals. Traditional rehabilitation approaches involve medical therapies, psychological counseling, and behavioral interventions, but emerging technologies, particularly VR, offer innovative strategies for ADHD rehabilitation [45]. VR, with its diverse applications, provides a unique platform for creating immersive environments that cater to individual needs, enhancing motivation, and offering a more reliable assessment of cognitive processes. The integration of neuropsychological tests into VR environments, such as the Virtual Reality Continuous Performance Test (VRC-CPT), not only proves more engaging for children with ADHD but also demonstrates greater ecological validity compared to traditional methods. The interactive nature of VR environments facilitates focused attention and concentration, contributing to the reduction of behavioral symptoms and the improvement of cognitive functions. Despite the evident benefits, challenges such as psychophysiological issues and potential side effects need careful consideration. Nonetheless, advancements in customization, calibration, and suitable interfaces offer promising avenues to manage these concerns [47]. The potential of VR technologies to bridge the gap between virtual and real-world scenarios, coupled with their ability to enhance memory functionality and attention levels, underscores their significance in the rehabilitation of children with ADHD. As professionals increasingly adopt VR systems for clinical rehabilitation, it is crucial to navigate the balance between therapeutic efficacy and ensuring the health and safety of individuals with ADHD in virtual environments. [13] Gongsook P. Time simulator in virtual reality for children with a ttention deficit hyperactivity disorder. Berlin: Springer; 2012:490-3. [14] Barkley RA, Koplowitz S, Anderson T, McMurray MB. Sense of time in children with ADHD: effects of duration, distraction, and stimulant medication. J Int Neuropsychol Soc 1997;3:359-69. [15] Schwebel DC, Gaines J, Severson J. Validation of virtual reality as a tool to understand and prevent child pedestrian injury. Accid Anal Prev 2008; 40:1394-400. [16] Reid D. Virtual reality and the person-environment experience. CyberpsycholBehav2002;5:55964. [17] Satava RM. Medical virtual reality. The current status of the future. Stud Health Technol

Inform 1996;29:100-6. [18] Johnson D, editor. Virtual environments in army aviation training. In: Proceedings of the 8th

Annual Training Technology Technical Group Meeting; Mountain View (CA), USA. 1994. [19] Parsons TD, Bowerly T, Buckwalter JG, Rizzo AA. A controlled clinical comparison of attention performance in children with ADHD in a virtual reality classroom compared to standard neuropsychological methods. Child Neuropsychol2007;13:363-81. [20] Rizzo AA, Buckwalter JG. Virtual reality and cognitive assessment and rehabilitation: the state of the art. Stud Health Technol Inform 1997;44:123-45. [21] Rose FD, Attree EA, Brooks BM, Andrews TK. Learning and memory in virtual environments: A role in neurorehabilitation? Questions (and occasional answers) from the University of East London. Presence: Teleoper Virtual Environ 2001;10:345-58. [22] Gongsook P, editor. Time simulator in virtual reality for children with attention deficit hyperactivity disorder. In: Herrlich M, Malaka R, Masuch M, editors. Entertainment Computing - ICEC 2012. ICEC 2012. Lecture Notes in Computer Science, vol 7522. Berlin; Springer; 2012 [23] Barrett J. Side effects of virtual environments: a review of the literature. Edinburgh S (Australia): DSTO Information Sciences Laboratory; 2004. [24] Schneider SM, Hood LE. Virtual reality: a distraction intervention for chemotherapy. Oncol

Nurs Forum 2007;34:39-46. [25] Brooks JO, Goodenough RR, Crisler MC, Klein ND, Alley RL, Koon BL, et al. Simulator sickness during driving simulation studies. Accid Anal Prev2010;42:788-96. [26] Lawson BD. Motion sickness symptomatology and origins. In: Hale KS, Stanney KM, editors.

Handbook of virtual environments: design, implementation, and applications. 2nd ed. Boca Raton (FL): CRC Press, 2014:531-600. [27] Rizzo AA, Buckwalter JG, Bowerly T, Van Der Zaag C, Humphrey L, Neumann U, et al. The virtual classroom: a virtual reality environment for the assessment and rehabilitation of attention deficits. Cyber Psychol Behav2000;3:483-99. [28] Rose FD, Brooks BM, Rizzo AA. Virtual reality in brain damage rehabilitation: review.

CyberpsycholBehav2005;8:241-62. [29] Pollak Y, Weiss PL, Rizzo AA, Weizer M, Shriki L, Shalev RS, et al. The utility of a continuous performance test embedded in virtual reality in measuring ADHD-related deficits. J Dev BehavPediatr2009;30:2-6. [30] Adams R, Finn P, Moes E, Flannery K, Rizzo AS. Distractibility in Attention/Deficit/ Hyperactivity Disorder (ADHD): the virtual reality classroom. Child Neuropsychol2009;15:12035. [31] Díaz-Orueta U, Garcia-López C, Crespo-Eguílaz N, Sánchez-Carpintero R, Climent G, Narbona J. AULA virtual reality test as an attention measure: convergent validity with Conners' Continuous Performance Test. Child Neuropsychol 2014;20:328-42. [32] Kim IY, Cho BH, Jang DP, Lee JH, Lee JM, Kim JS, et al., editors. Attention enhancement system using virtual reality and EEG biofeedback. In: Proceedings of the IEEE Virtual Reality Conference 2002; 2002 Mar 24 – 28; Orlando (FL), USA. [33] Gaitatzes A, Papaioannou G, Christopoulos D, editors. Virtual reality systems and applications.

In: Proceedings of the ACM symposium on Virtual reality software and technology 2006; 2006 Nov 1–3; Limassol, Cyprus. [34] Dehn MJ. Working memory and academic learning: Assessment and intervention. Hoboken (NJ): John Wiley & Sons, 2011. [35] Self T, Scudder RR, Weheba G, Crumrine D. A virtual approach to teaching safety skills to children with autism spectrum disorder. Top Lan Disord2007;27:242-53. [36] Riva G, Mantovani F, Gaggioli A. Presence and rehabilitation: toward second-generation virtual reality applications in neuropsychology. J NeuroengRehabil2004;1:9. [37] Othmer S, Kaiser D. Implementation of virtual reality in EEG biofeedback.

CyberpsychoBehav2000;3:415-20. [38] Slate SE, Meyer TL, B urns WJ, Montgomery DD. Computerized cognitive training for severely emotionally disturbed children with ADHD. BehavModif1998;22:415-37. [39] Hale KS, Stanney KM, Stone RJ, Hannigan FP. Applications of virtual environments: an overview. In: Hale KS, Stanney KM, editors. Handbook of virtual environments: design, implementation, and applications. 2nd ed. Boca Raton (FL): CRC Press, 2014. p. 883-957. [40] Wang M, Reid D. Virtual reality in pediatric neurorehabilitation: attention deficit hyperactivity disorder, autism and cerebral palsy. Neuroepidemiology 2011;36:2-18. [41] Pollak Y, Shomaly HB, Weiss PL, Rizzo AA, Gross-Tsur V. Methylphenidate effect in children with ADHD can be measured by an https://doi.org/10.3345/kjp.2017.60.11.337 343 ecologically valid continuous performance test embedded in virtual reality. CNS Spectr2010;15:125-30. [42] Moreau G, Guay M, Achim A, Rizzo A, Lageix P. The virtual classroom: An ecological version of the continuous performance test–A pilot study. Annual Rev CybertherTelemed2006;4:59-66. [43] Hu S, Davis MS, Klose AH, Zabinsky EM, Meux SP, Jacobsen HA, et al. Effects of spatial frequency of a vertically striped rotating drum on vection-induced motion sickness. Aviat Space Environ Med 1997;68: 306-11. [44] Toplak ME, Dockstader C, Tannock R. Temporal information processing in ADHD: findings to date and new methods. J Neurosci Methods 2006;151:15-29. [45] Vita, S., Morra, C., & Rega, A. (2021). Virtual reality and emotion regulation: A systematic review. In O. Gigliotta& M. Ponticorvo (Eds.), CEUR Workshop Proceedings (Vol. 3100). CEURWS. [46] Frolli, A., Cerciello, F., Esposito, C., Ricci, M. C., Laccone, R. P., & Bisogni, F. (2023). Universal Design for Learning for Children with ADHD. Children (Basel, Switzerland), 10(8), 1350. https://doi.org/10.3390/children10081350 [47] Somma, F., Rega, A., &Gigliotta, O. (2019). Artificial Intelligence-powered cognitive training applications for children with attention deficit hyperactivity disorder: A brief review. CEUR Workshop Proceedings, 2524.

References

[1] Lee JM , Cho BH , Ku JH , Kim JS , Lee JH , Kim IY , et al., editors. ( 2001 ). A study on the system for treatment of ADHD using virtual reality . In: Proceedings of the 23rd Annual Internationa l Conference of the IEEE; 2001 Oct 25 - 28 ; Istanbul, Turkey. Piscataway (NJ): IEEE Engineering in Medicine and Biology Society.

[2] American Psychiatric Association. ( 2013 ). Diagnostic and statistical manual of mental disorders: DSM-5 . Washington, DC: American Psychiatric Publishing.

[3] Strickland DC , McAllister D , Coles CD , Osborne S. ( 2007 ). An Evolution of Virtual Reality Training Designs for Children With Autism and Fetal Alcohol Spectrum Disorders . Top Lang Disord; 27 : 226 - 41 .

[4] Bashiri , A. , Ghazisaeedi , M. , & Shahmoradi , L. ( 2017 ). The opportunities of virtual reality in the rehabilitation of children with attention deficit hyperactivity disorder: a literature review . Korean journal of pediatrics , 60 ( 11 ), 337 .

[5] Yeh SC , Tsai CF , Fan YC , Liu PC , Rizzo A , editors. An innovative ADHD assessment system using virtual reality . In: 2012 IEEE EMBS International Conference on Biomedical Engineering and Sciences; 2012 Dec 17 -19; Langkawi, Malaysia.

[6] Hurks PP , Hendriksen JG . ( 2011 ). Retrospective and prospective time deficits in childhood ADHD: the effects of task modality, duration, and symptom dimensions . Child Neuropsychol; 17 : 34 - 50 .

[7] Kim J , Lee Y , Han D , Min K , Kim D , Lee C. ( 2015 ). The utility of quantitative electroencephalography and Integrated Visual and Auditory Continuous Performance Test as auxiliary tools for the Attention Deficit Hyperactivity Disorder diagnosis . Clin Neurophysiol ; 126 : 532 - 40 .

[8] Goldstein S. Handbook of neurodevelopmental and genetic disorders in children . 2nd ed. New York: Guilford Publication, 2010 .

[9] Kim JW , Sharma V , Ryan ND . Predicting methylphenidate response in ADHD using machine learning approaches . Int J Neuropsychopharmacol 2015 ; 18 : pyv052 .

[10] Schweitzer JB , Cummins TK , Kant CA . ( 2001 ). Attention-deficit/hyperactivity disorder . Med Clin North Am; 85 : 757 - 77 .

[11] Bioulac S , Lallemand S , Rizzo A , Philip P , Fabrigoule C , Bouvard MP . ( 2012 ). Impact of time on task on ADHD patient's performances in a virtual classroom . Eur J PaediatrNeurol ; 16 : 514 - 21 .

[12] Brown SJ , inventor. Health Hero Network, Inc. Method for diagnosis and treatment of psychological and emotional conditions using a microprocessor-based virtual reality simulator . United States patent US6186145 B1 . 1996 June 21.