Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder that affects nearly 1 in 20 children in USA. It is characterized by inattentiveness, hyperactivity, and impulsive behavior. According to the American Psychiatric Association, ADHD is a brain disorder that usually occurs in childhood, but symptoms may continue well into adolescence and may even persist into adulthood. ADHD symptoms affect children in their daily functioning, social behaviours, and academic endeavours. At present, the rehabilitation of children with ADHD involves psychological counselling, medication, and behavioural therapies. However, the consequences of such treatments may be far from positive, such as drug side effects and no lasting behavioural improvement. Furthermore, as Faraone et al. pointed out, people who grow up with ADHD tend to have lower occupational status, poor social relationships, and are more likely to commit motoring offences and develop substance abuse. However, there is light at the end of the tunnel, through the development of a VR-based approach toward the rehabilitation of children with ADHD. By creating specially designed virtual environments for the detection, assessment and treatment of this disorder, Virtual Reality can serve both as a diagnostic tool and an effective therapeutic strategy in the rehabilitation of children with ADHD.
How can VR help children with ADHD
Children with ADHD have trouble paying attention, difficulty in concentrating on and remembering what they are told to do, and controlling impulsive behaviors, or they may be overly active, all factors which can affect their quality of life and impede academic progress. Considering that 5% of school-age American children have ADHD, the lack of standardized and reliable methods of diagnosing the disorder is evidently a cause for concern. Most assessment approaches involve indirect measure through questionnaires filled out by parents or teachers, observed Burdea and Coiffet, and these questionnaires relate to the child’s behavior over a 24-hour period (including the time spent in school). Furthermore, traditional paper and pencil tests have been shown as lacking ecological validity and generalizing their results to describe daily life cognitive functioning of individuals is often considered to be controversial. Rapid advancements in, and greater affordability of, VR technology, however, has opened the door for its use in informatics and neuroscience toward developing a more objective, precise, and ecologically valid neuropsychological assessment based on VR technology.
Virtual Reality presents a real-life situation to young learners, and potentially offers a more effective alternative to traditional modes of assessment and treatment of ADHD. The sense of immersion in a VR environment is designed to replicate the presence and exposure felt in a real environment. Both researchers and medical practitioners can therefore present the most ecologically relevant stimuli based on a significant and familiar context, allowing them to meticulously document the child’s response. More importantly, as Diaz-Orueta et al. have indicated, VR technology allows synchronization and control over distractors, stimuli, and variables, and can alter all of these depending upon the response features of the patient, enabling a more precise and detailed analysis. According to the researchers, VR has finally arrived at the necessary maturity for its application in neuroscience. Hence, we are at a stage where VR technology can be easily customized and calibrated to the specific requirements of testing conditions or therapeutic strategies for children with ADHD.
The VR-based approach to ADHD
In 2004, after nearly two decades of research, Albert Rizzo and his fellow researchers at the University of Southern California developed a VR-based diagnostic tool to detect and potentially treat ADHD. This diagnostic method recreated a virtual classroom in which the subject (child) was immersed through an HMD (head mounted device). Trackers were used for the HMD as well as the nondominant hand and the opposite knee. These trackers registered the restlessness typically present in hyperactive children. The researchers found that the motor movement (head, arm, leg) of the subjects in the experimental group was greater than that of the subjects in the control group, and the motor movement of the ADHD children was more pronounced during distracting conditions than for those in the control group. A neural network algorithm trained on the first five experimental subjects was able to accurately recognize the hyperactivity exhibited by the remaining experimental subjects. Due to its high ecological validity, Rizzo et al. concluded that VR heralded a promising modality in terms of its application and utility in the domain of neuropsychological assessment of ADHD. Three years later, the same team of researchers performed another study with the same virtual classroom, successfully replicating the results obtained in 2004. These results were also compared with a battery of classical neuropsychological tests, and the researchers’ findings established that measures obtained by the VR-based approach to testing correlated with classical instruments of evaluation.
During the course of the study, Rizzo et al. identified certain advantageous factors that set apart a VR-based evaluation system for assessing ADHD from other neuropsychological tools and they are as follows:
- The ability to systematically show dynamic and interactive 3D stimuli within a virtual environment.
- The ability to create an evaluation environment with greater ecological validity.
- The presentation of immediate performance feedbacks in a variety of forms and sensorial modalities.
- The ability to completely capture the performance and availability of a more naturalistic and intuitive registry of performance for the posterior data analysis.
- The availability of a safe and secure evaluation environment that minimized risks.
- The adaptability of the environment as per the required sensorial modality which can be integrated into the design of the virtual environment.
- The availability of engaging and immersive virtual environments that can increase motivation in the participants.
- The integration of virtually represented human avatars for enhancing social interaction in participants.
Rehabilitation of ADHD children with VR
Several researchers have been testing the hypothesis that VR-based neurofeedback has the potential to rectify ADHD. Based on neurofeedback (NF) training as a neurocognitive treatment in ADHD, the researchers Hudak et al. designed a randomized, controlled function, near-infrared spectroscopy (fNIRS) NF intervention embedded in an immersive virtual reality classroom in which participants learned to control the overhead lighting in the room. As the researchers explained, neurofeedback (NF) is a therapeutic technique in which participants are tasked with regulating their own brain activity, a method that is used to facilitate long-term change in abnormal brain activity. However, neurofeedback treatment is often criticized for its lack of ecological validity. Hudak et al. pointed out that strategies of brain regulation learned in a lab setting may not translate well into the real world. Enter VR. The aim of the study was to test the viability of an immersive VR NF paradigm, and the researchers found that the full classroom immersion did not detract from the ability of the participants to regulate their brain activity. They arrived at the conclusion that ‘VR NF presents a great opportunity for the treatment of behavioral disorders with known pathophysiological alterations’.
In another study, ‘Time Simulator in Virtual Reality for Children with Attention Deficit Hyperactivity Disorder’, researcher Pongpanote Gongsook investigated how effective virtual reality can be in manipulating and eventually training time perception for children with learning and/or behavior disorders. Time perception is a form of conceptual understanding that allows us to predict, anticipate, and respond to events as past or present occurring in the environment. Children with ADHD exhibit difficulties in processing, reading, and telling time. Since the use of virtual reality in education engenders an immersive and interactive form of learning in an experiential mode, Gongsook’s research confirmed the effectiveness of VR in improving the sequential time perception of children with ADHD. The researcher observed that VR simulations allow children with certain impairments to experience what could be difficult or even impossible for them to do in real life due to their condition, thus concluding that virtual reality can be an ideal candidate for the task of mitigating the effects of ADHD in children.
The upshot from such studies is that although VR holds a lot of promise, we need to be pragmatic about how this benefit will be truly useful in schools. Introducing a VR simulation alone will not suffice. Of Rizzo’s eight evaluation factors, regular, off-the-shelf VR lessons will attend to only two of these factors: increased motivation and the introduction of 3D stimuli. This means that there is only minimal value to a walk through simulation or expeditation, for learners with ADHD. However, when the VR is coupled with interactive content producing data and analytics, as the Veative system does, we now hit seven of the eight factors, making this a very significant tool for classroom use. The only factor not attended to, at the moment, is the adaptability of the environment as per the required sensorial modality. As Veative is the market leader in interactive, educational content for the VR, it is well-positioned to tackle that final factor.
For children suffering from the disorder, ADHD poses significant challenges in various aspects of their daily life, including education, social performance, and personal relationships. The use of virtual reality technology can prove to be extremely beneficial in combating these challenges. The researchers Bashiri et al. succinctly summed up the ways in which the use of immersive technologies such as VR can assist in the rehabilitation of children with ADHD: deliver a stable and controlled stimuli to make steady progress, provide feedback-focused interaction, offer flexibility in terms of patients’ requirements, provide safe learning environments that minimize errors, reduce time and costs involved in the evaluation and treatment processes, improve users’ motivation through the creation of engaging and user-friendly environments, embed different neuropsychological tests as required by therapists, manage different stimuli and enable clinicians to develop diagnosis, assessment, and rehabilitation strategies, and improve behavioral and cognitive skills in young learners. However, choosing a VR solution in and of itself is not enough. It must be the right solution, which attends to the greatest number of factors for all children, whether suffering from ADHD or not.
Quality of life and a good education should not be seen as the luxury of a few, but must be regarded as a necessity for all. And in the endeavour to do so, no child should be left behind, especially not those who deserve more of our time, patience and creative solutions to their problems than others. As advancements in immersive technologies gain momentum, it is important for us as parents, teachers, doctors, and developers to recognize and harness the power of a VR-based approach and enable a profound transformation in the lives of children with ADHD.
Bashiri, Azadeh, Marjan Ghazisaeedi, and Leila Shahmoradi. ‘The Opportunities of Virtual Reality in the Rehabilitation of Children with Attention Deficit Hyperactivity Disorder: A Literature Review.’ Korean Journal of Pediatrics 60.11, 2017.
Burdea, Grigore C. and Philippe Coiffet. Virtual Reality Technology. John Wiley & Sons, 2017.
Diaz-Orueta, Unai et al. ‘Virtual Reality for Neuropsychological Assessment’. Virtual, Augmented Reality and Serious Games for Healthcare edited by Minhua Ma, Lakhmi C. Jain, Paul Anderson. Springer Science & Business, 2014.
Faraone, Stephen V et al. ‘The worldwide prevalence of ADHD: is it an American condition?’ World Psychiatry : official journal of the World Psychiatric Association (WPA) vol. 2,2, 2003, pp.104-13.
Gongsook, Pongpanote. ‘Time Simulator in Virtual Reality for Children with Attention Deficit Hyperactivity Disorder’.
Hudak, Justin et al. ‘Near-Infrared Spectroscopy-Based Frontal Lobe Neurofeedback Integrated in Virtual Reality Modulates Brain and Behavior in Highly Impulsive Adults.’ Frontiers in Human Neuroscience 11, 2017.