Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in childhood. Despite of the core symptoms of ADHD (inattention, hyperactivity and impulsivity), patients often exhibit poor social skills, problems with planning and an inability to complete tasks on time. For what concerns the intervention, recent proposals include the use of board games such as chess, neurofeedback, virtual reality (VR) or serious video games. The efficiency of Virtual Reality is based on the rapid construction of various lifelike environments for training and stimulus control. In addition, there are many advantages such as creating an environment that meets the patient's needs, providing stability between users and stimuli and a full record of patient behavior and functioning, enabling rapid feedback, and saving time and money, and providing a more entertaining tool to motivate patients to use this technology. The aim of this review is to define the effects of VR based treatment on neuropsychological symptoms of ADHD.
Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders
in childhood. In addition to its main symptoms, this disorder leads to significant difficulties in
education, social performance, and personal relationships. As it is a heterogeneous developmental
disorder, the etiology is unclear, leading to biased and extensive diagnostic assessments when
patients are examined through traditional clinical interviews and assessments of patients' behaviour
[
Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental disorder
in childhood and adolescence, affecting 4-8% of children worldwide [
Attention deficit hyperactivity disorder (ADHD) is defined as a neurodevelopmental disorder. The diagnostic classification is based on the observation of behavioral symptoms. According to the DSM5, ADHD remains a diagnosis of exclusion and should not be diagnosed if the behavioral symptoms are better explained by other mental disorders (e.g., psychotic disorders, mood or anxiety disorders, personality disorders, substance intoxication or withdrawal) [24]. However, comorbidity with other mental disorders is common. In the DSM-5, the defining symptoms of ADHD are divided into symptoms of inattention (11 symptoms) and hyperactivity/impulsivity (9 symptoms) [24]. The DSM-5 distinguishes between different manifestations of ADHD: predominantly inattentive (6 or more of 11 symptoms present), predominantly hyperactive/impulsive (6 or more of 9 symptoms present) and combined manifestations (both criteria met), as well as a partial remission category. Symptoms must be present in two or more situations for at least 6 months before the age of 12 and must limit or interfere with social, academic or occupational functioning. In adolescents over 17 years and in adults, five symptoms per dimension must be present for diagnosis [24]. In adults, the use of validated instruments such as the Wender-Utah Rating Scale is recommended [25]. In contrast, the ICD-10 classification distinguishes between childhood hyperkinetic disorder (with at least six symptoms of inattention and six symptoms of hyperactivity/impulsivity present before the age of 6 years) and hyperkinetic conduct disorder, a combination of ADHD symptoms and symptoms of oppositional defiant disorder (CD) [26]. In ICD-11 (online publication as of June 2018, printed publication expected in 2022), the latter category has been removed, as has the exact age limit ("onset during the developmental period, typically in early to middle childhood"). In addition, the ICD-11 distinguishes five ADHD subcategories, which are consistent with those of the DSM-5: ADHD in combined form, ADHD in predominantly inattentive form, ADHD in predominantly hyperactive/impulsive form and two further categories, ADHD in other form and ADHD in non-specific form. For a diagnosis, the behavioral symptoms must be outside the normal range of variation expected for the person's age and intellectual abilities [27]. 2.1.
ADHD is related to multiple underlying neurobiological pathways and heterogeneous neuropsychological (NP) profiles. Twenty-five years ago, ADHD was characterized as a disorder of inhibitory self-control [28], and an early model of dual pathways distinguished between an inhibitory/executive function pathway and a motivational/delay aversion pathway (also referred to as the "cool" and "hot" pathways of executive function in later publications), which are associated with distinct neurobiological networks [29-31]. Coghill and colleagues [32] distinguished six cognitive factors in children with ADHD (working memory, inhibition, delay aversion, decision making, timing and reaction time variability) derived from seven subtests of the Cambridge automated battery of neuropsychological tests. Attempts to classify patients empirically into subgroups with selective performance profiles that deviate from the comprehensive NP data collection were inconclusive. Lambek and colleagues [33], for example, expected to distinguish appropriate subgroups of performance profiles in children with ADHD using tasks on delay aversion, working memory and reaction time. However, their analysis revealed subgroups distinguished by severity of impairments rather than selective profiles. However, some other empirical studies searching for subgroups identified ADHD-specific performance profiles ("poor cognitive control", [34] "with attention deficits and rapid processing speed" [35]), among other profiles common to TD controls. Obviously, divergent results regarding subgrouping may also be related to the different composition of the domains tested, leading to limited comparability of these studies.
Virtual reality, also called computer-simulated reality or video-generated environments, is a computer technology that simulates an imaginary or real environment such as a classroom [36, 37]. Using this technology, users can interact and behave in 3-dimensional environments as they would in the real world [38]. The application of this technology has developed in education and training, entertainment, military, medicine, and surgery [36,39,40]. Immersive VR, desktop VR, projective VR and CAVE (C-Automatic Virtual Environment) are the most used types of virtual reality. The capability of this technology is based on the rapid construction of various lifelike environments for training and stimulus control [41-43]. There are many advantages to developing VR systems, such as creating an environment that meets the patient's needs, providing stability between users and stimuli and a full record of patient behavior and functioning, enabling rapid feedback, and saving time and money, and providing a more entertaining tool to motivate patients to use this technology [41,42]. In the rehabilitation field, VR technologies enable people with impairments and disabilities due to brain damage to experience everything that is difficult or impossible for them in reality [44,45].
Nevertheless, health guidelines list possible side effects of VR such as headaches, seizures, nausea, fatigue, drowsiness, disorientation, apathy and dizziness. These symptoms are associated with cyberdisease or virtual reality disease. Cyber-sickness as a complex problem is the psychophysiological response to exposure to VR environments [46,47]. Studies have shown that cybersickness is a barrier to the use of training or rehabilitation tools in virtual reality environments [48,49].
The aim of this review is to determine the effectiveness of VR -based interventions for ADHD children and adolescents. Our online search revealed that there are few studies of VR -based interventions targeting cognitive rehabilitation in ADHD children. Most VR studies in ADHD populations have focused on validating the assessment of attention in a virtual classroom setting [5054]. Furthermore, there is no consensus on the outcome measures used in the different studies, so there are few studies that can be compared [55]. However, we have tried to include studies with the same outcome measures. The type of vigilance and sustained attention requirements imposed in the studies was significantly lower. It is striking that this is the case when children with ADHD have significant executive deficits in addition to attentional deficits, such as in planning, executing, and monitoring actions, which requires the development of self-regulation. In addition, these children's deficits also affect the scope of activities of daily living, social activities, and leisure time activities
In summary, despite the limited number of studies, the results suggest that VR -based interventions help to improve the cognitive performance of children and adolescents with ADHD on vigilance and sustained attention tasks, reducing the number of omissions and increasing the number of correct responses to target stimuli with large effect sizes [56]. In contrast, a medium effect on performance was observed for reaction time to target stimuli and the number of errors per task. This suggests that the effect is more due to vigilance and less due to improvement in impulsivity or inhibitory control. These results are of interest because they suggest that VR -based interventions could improve inattention symptoms and could therefore be very useful in children with ADHD of the inattention subtype, in whom a greater number of omissions and fewer correct responses were observed [57]. On the other hand, the results of the Bioulac study [58] showed that children who received VR -based interventions were better at inhibiting distractors. Moreover, they also showed less impulsivity (with a lower number of orders). The authors of this study also pointed out the good acceptance of this type of intervention. However, no improvements were observed by the parents, showing that although there was an improvement in the parameters of the attention tasks, there was no transfer to activities of daily living [59], suggesting that there is a need to increase the ecological validity of this type of intervention, as mentioned by the authors themselves. The simple fact that the environment of the task is changed does not mean that the task has ecological validity (pressing a button when a stimulus appears). It is necessary to distinguish between tasks and environment and to carefully analyze and adapt the task so that it has ecological validity in accordance with age-appropriate requirements and with meaningful value for the child [60].
Some authors reported improvements from the training programs and academic performance and a decrease in ADHD symptoms [61]. In addition, a reduction in performance time in individuals with ADHD [62] was associated with better performance on attention and executive tasks [41]. In addition, some studies [63,64] have found that, despite rehabilitation, VR can be useful in identifying attention difficulties in children with ADHD and improving the reliability of neuropsychological assessments.
As it has been described above, the heterogeneity of the results between the studies found in the literature can be seen. Nevertheless, it is not possible to deny the effectiveness of Virtual Reality in the rehabilitation of the symptoms present in ADHD. Moreover, the literature reports advantages not only relative to an improvement of the symptomatology but to a use of the Virtual Reality also in the assessment regarding the cognitive functions that can increase the effectiveness of the traditional instruments. The generalization of the results with respect to the patient’s daily life remains unclear. Studies that provide virtual environments more specific to the patient’s needs are recommended.
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