=Paper=
{{Paper
|id=Vol-3751/short2
|storemode=property
|title=Virtual Reality and ADHD: a review of literature
|pdfUrl=https://ceur-ws.org/Vol-3751/short2.pdf
|volume=Vol-3751
|authors=Beatrice Gallai,Lucia Miranda,Carolina Mele,Angelo Rega
|dblpUrl=https://dblp.org/rec/conf/dilend/GallaiMMR24
}}
==Virtual Reality and ADHD: a review of literature==
https://ceur-ws.org/Vol-3751/short2.pdf
Virtual Reality and ADHD: a review of literature
Beatrice Gallai1, Lucia Miranda2, Carolina Mele2 and Angelo Rega2
1
Università degli Studi di Perugia, Piazza dell'Università, 1, 06123 Perugia, Italy
2
Università TelematicaPegaso, Italy
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
ADHD, virtual reality, children, rehabilitation, review.
1
1. Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Hyperactivity Disorder (ADHD), also known as hyperactivity, is a
neurodevelopmental disorder primarily characterized by the presence of symptoms related to
inattention, impulsivity, and hyperactivity [1,2,8,9]. Issues associated with ADHD, such as low self-
esteem and relational difficulties, can impact daily life, social behaviors, interpersonal relationships,
and education [1,5,6]. ADHD is considered by the Diagnostic and Statistical Manual of Mental
Disorders as one of the most common psychiatric conditions [2,10]. In fact, it is recognized that
approximately 5% of children aged 3 to 5 are affected by ADHD, with their behavioral competencies
in various aspects being lower than their neurotypical peers [11]. Rehabilitation for this condition
focuses on medical therapies, psychological counseling, and behavioral therapies [12,13,14].
Behavioral therapies include school adjustments, social skills training, and cognitive rehabilitation.
Alternative methods, such as speech therapy and family counseling, also demonstrate effectiveness
in the rehabilitation of children with ADHD [1,3,4]. The utilization of virtual reality technologies
emerges as an innovative therapeutic strategy for ADHD rehabilitation, providing simulations of
real-life situations in a safer and more effective manner compared to traditional therapies [1,4,5,6,7].
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
Proceedings of the Digital Innovations for Learning and Neurodevelopmental Disorders, May 24–25, 2024, Rome, Italy
beatrice.gallai@unipg.it (B. Gallai); lucia.miranda@studenti.unipegaso.it (L. Miranda);
carolina.mele@unipegaso.it(C. Mele); angelo.rega@unipegaso.it (A. Rega);
0000-0002-0641-7347(A. Rega);
© 2023 Copyright for this paper by its authors.
Use permitted under Creative Commons License Attribution 4.0 International (CC BY 4.0).
CEUR Workshop Proceedings (CEUR-WS.org)
CEUR
ceur-ws.org
Workshop ISSN 1613-0073
Proceedings
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 effective 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.
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 International
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.
[13] Gongsook P. Time simulator in virtual reality for children with attention 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;5:559-
64.
[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;15:120-
35.
[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, Burns 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). CEUR-
WS.
[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.