Possibilities of Using Virtual Reality for Individuals with Attention-Deficit/Hyperactivity Disorder

Introduction

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that is usually diagnosed in childhood. It is characterized by impulsive behavior, difficulty maintaining attention, and increased activity, which leads to impaired functioning in various domains of life (Váryová & Andreánska, 2016). The fifth edition of the DSM (Diagnostic and Statistical Manual of Mental Disorders) distinguishes three ADHD subtypes, which present in different ways: predominantly inattentive type, predominantly hyperactive/impulsive type, and combined type. In DSM-5, ADHD is described as a lifelong disorder affecting not only children and adolescents but also adults. Nonetheless, diagnosis in adulthood in this classification manual is conditioned on the presence of certain symptoms before age 12. The tenth revision of the International Classification of Diseases (ICD-10) considers ADHD as a disorder typical of childhood. It does not address adult ADHD. In ICD-10, the equivalent of ADHD is called Hyperkinetic Disorders (Pečeňák, 2014; Ptáček & Ptáčková, 2018).

Virtual reality is a computer-generated digital environment (virtual world). Virtual reality can be understood as a simulated environment that includes virtual representations of oneself and other people as well as various sensory stimuli. In this environment, a person experiences immersion, a sense of being immersed. What distinguishes virtual reality from other technologies is that it creates a sense of presence, in English known as “the sense of being there” (Riva, 2005). This is a multisensory experience that, under certain conditions, produces in the person a sense of embodiment, in which properties of the virtual body are processed as if they belonged to one’s own biological body (Kilteni & Groten, 2012). Virtual reality offers many possibilities for psychological research and practice. It provides a safe and controllable environment, makes it possible to replicate experimental situations without modifying active stimuli, and allows the intensity and character of stimuli to be set. From a technical standpoint, virtual reality consists of various input-output components (devices). At its core is a display unit, which in most cases is worn on the participant’s head (the so-called Head-Mounted Display, HMD). As a display unit, either a VR helmet (3D virtual reality glasses) or a modern smartphone with virtual-reality support in a special holder held in front of the eyes is used most commonly. The HMD display units themselves can also include various sensors, e.g., sensors for tracking position. Additional sensors (e.g., for tracking body position, which can be placed on different parts of the body or on objects) and control devices (e.g., gloves, a controller with buttons), and other specialized devices (steering wheel, suit, treadmill) can also be used. A powerful computer is also needed for virtual reality (although some HMD devices can operate without a computer connection), especially when multiple sensors and devices are used.

Recognition of the potential of virtual reality for psychology has led to an increase in the number of research works devoted to virtual reality and to expanded application in various psychological disciplines, such as psychodiagnostics, counseling, or therapy. In therapy, virtual environments are used mainly as exposure therapy for different phobias or as a therapeutic means for body image disorders (Riva, 2005). Virtual reality is also a suitable tool for developing various skills and abilities (Xie et al., 2011). The range of psychological disorders for which virtual reality is used is gradually expanding. The aim of our contribution is to summarize what virtual reality offers in cases of ADHD and to outline further possibilities for its use.

Diagnosing ADHD using virtual reality

Diagnosis of attentional problems, i.e., ADHD, is associated with childhood. Correspondingly, virtual-reality diagnostic tools mostly concern, with few exceptions (for example, Areces et al., 2019), children (Rizzo et al., 2001; Wiguna et al., 2021). One of the greatest advantages of using virtual-reality diagnostics is that it is a controllable and reproducible environment and can appear engaging for children (adolescents). Diagnosis can even take on a game-like form, which can be particularly attractive to children and adolescents (Wiguna et al., 2020). Pioneers of ADHD diagnosis using virtual reality can be considered Rizza et al. (2001), who created a special tool for assessing attention processes in virtual space. They created a virtual classroom that copied the layout of a classic classroom: it consisted of three rows of desks, a teacher’s desk, a teacher or teacheress, a window overlooking a street, and doors. Within this virtual environment, they programmed the possibility of various distracting elements—so-called distractors (for example, classmates’ activity or people on the street that participants saw through the virtual window)—and then created the possibility to assess participants’ attention performance. The authors considered the advantage of the virtual environment for testing as the systematic presentation and recording of different tasks (ibidem). Virtual reality enabled assessment of attention dimensions such as focusing, sustaining, selectivity, divided attention, and shifting. In general, the most commonly used neuropsychological attention test for assessing ADHD symptoms within the virtual classroom environment became the Continuous Performance Test (CPT) (Goharijenad et al., 2022). It is a test used for ADHD assessment in both classical computer (Žilinčík & Novotný, 2012) and virtual forms. In CPT testing, correct responses of participants, number and type of errors, reaction time and its variability are assessed. Errors can be of two kinds: 1) a participant responds (for example, by pressing a button) when they should not respond. This error is an indicator of impulsivity and is called a commission error; 2) so-called omission error indicates that the participant did not respond (did not press the corresponding button) when they should have responded (Areces et al., 2019; Parsons et al., 2019). Parsons and colleagues (2019) administered the CPT in a virtual classroom to persons diagnosed with ADHD and without diagnosis. They found that this testing format is a suitable method for distinguishing people with ADHD from neurotypical individuals in childhood. Areces et al. (2019) found that the virtual CPT test can predict ADHD symptoms in adolescents and adults as well. In their study they used a test specially developed for these purposes, the so-called Nesplora Aquarium. This is a virtual CPT test for assessing executive functions in adolescents and adults. During testing, the participant is “immersed” in a virtual aquarium where they must respond (press a button) according to specific instructions involving visual and auditory stimuli (seeing a particular fish or hearing the name of a fish). The findings of Areces et al.’s study (ibidem) showed that this virtual method, specifically the number of correct responses and omission errors, predicts current ADHD symptoms and also childhood symptoms. Wiguna et al. (2020) added artificial intelligence to virtual reality technology for ADHD diagnosis. They proposed a prototype game that uses deep learning. This is a particular type of machine learning and artificial intelligence that processes data using a multi-layered neural network. These neural networks are inspired by biological processes, whose goal is to imitate brain functioning. Diagnosis using virtual reality represents a developing field and appears to be becoming an interesting alternative to commonly used tests.

Treatment and rehabilitation of ADHD using virtual reality

In current practice, pharmacological treatment (via stimulants), psychotherapy, and various attention-training programs at schools are used to treat and rehabilitate ADHD. As an effective means of developing everyday skills (such as time management, working memory, and social skills), specially developed computer games are also being used (for example, Plan-It Commander) (Bul et al., 2016). Virtual reality offers possibilities that can serve as supplementary methods to traditional approaches. Although the number of studies devoted to virtual intervention is still small (Romero-Ayuso, 2021), the use of virtual reality for these purposes shows a growing trend. It is however highly variable (Bashiri et al., 2017). Virtual reality can be beneficial in ADHD treatment and rehabilitation in various ways. First, it can contribute to describing and understanding some forms of behavior and can be a means to eliminate risky or dangerous behavioral manifestations in children (Schwebel et al., 2008) and adolescents (Clancy et al., 2006), for example by simulating traffic situations. Another possibility is using virtual reality to improve cognitive functions. Manshaee and colleagues (2020) showed that therapeutic software can improve working memory in children diagnosed with ADHD, even to a greater extent than medication. The authors (ibid.) worked in a virtual classroom where the virtual intervention took place. They tested memory before and after the intervention and again after some time, when the positive effect was maintained. In addition to developing certain functions, virtual reality can also be used to evaluate the effectiveness of training these functions (Coleman et al., 2019). Its advantage lies in that, compared with traditional control and testing methods, it has higher ecological validity. Lee and colleagues (2001) combined virtual reality and EEG measurement, using a specially developed game with a dinosaur. They found that participants who underwent virtual-reality intervention showed a reduction in both error types in the CPT test. It should be noted, however, that participants in the experiment were not diagnosed; they were participants with suspected ADHD. Cho et al. (2002) developed an attention-increasing system (Attention Enhancement System—AES) using virtual reality and EEG biofeedback. It is a scene set in a virtual classroom. The teacher avatar, participant, and classmates are present. In addition there is a desk, blackboard, door, window, and other small objects. In this controlled environment, cognitive trainings take place. These are cognitive tasks that become progressively more difficult and are aimed at extending attention and increasing attention selectivity of the participant. The authors (ibid.) see the advantages of virtual reality primarily in the fact that distracting factors can be removed in it, special stimuli can be included, and thus concentration increased and attention episodes prolonged. Romero-Ayuso and colleagues (2021) conducted a meta-analysis of the effectiveness of interventions using virtual reality. They found that virtual reality is suitable for increasing sustained attention and vigilance, however, with respect to reducing impulsivity and inhibitory control symptoms, its effects are not convincing. It appears that the virtual environment represents a promising intervention method, yet further studies are needed to confirm its effectiveness.

Virtual reality as a means of reducing myths and prejudice toward people with ADHD

Use of virtual reality to reduce racial prejudice is a topic discussed fairly often. This work is based mainly on intergroup contact theory, in which virtual reality makes simulated intergroup encounters possible (Tassinari et al., 2021). This is a situation in which a participant in a virtual environment experiences a meeting with a virtual representative of a minority group (Lemmer & Wagner, 2015), or in which the participant’s virtual representative is a member of a minority group. The participant becomes, for a short time, a representative of a minority through the embodiment experience, gains that perspective, which can lead to a reduction of their negative attitudes and prejudices (Peck et al., 2013). In virtual reality, it is possible to set the appearance of another person, simulate their perspective, and modify the physical environment. The combination of these factors allows simulation of various mental disorders, or psychotic states, as well. Lee and colleagues (2020), for example, created a simulation of schizophrenia, which they recommend using in training and education of healthcare workers. Their simulation is similar to the three-dimensional computer simulation created by Yelowlees and Cook already in 2006 for education about visual and auditory hallucinations. In both cases, the purpose of the software is to enable better understanding of the given disorder by third parties. In our view, simulation of mental disorders may be an effective method for correcting myths, reducing stigmatization of people with mental disorders, and reducing prejudice toward them. To our knowledge, virtual reality has not yet been used for this purpose in the case of people with ADHD. We believe that creating software that would simulate the experience of students with ADHD in a university lecture (for example, impaired concentration while distractors are present) would be beneficial because it would help us better understand their perspective. Simulating the ADHD experience could also be beneficial when preparing teachers and psychologists for work with students and pupils with attention-deficit/hyperactivity disorders. Using adapted software (according to the type of school and setting) could also be helpful in the acceptance of students with ADHD by their peers.

Conclusion

Virtual reality offers many advantages in diagnosis and intervention for individuals with ADHD, such as controllability, repeatability, and the possibility of modifying the environment. Alongside these advantages, we must not forget disadvantages—for example, some individuals may feel nauseous when using virtual-reality equipment. The virtual environment itself is unnatural, and characters can appear artificial or “robotic,” reducing ecological validity in research and potentially leading to distorted experiences that do not occur in reality. A challenge remains in testing large groups of participants and in the questionable generalizability of conclusions. Overall, it can be concluded that virtual reality possesses many advantages. It is still necessary to continue research validation of its possible uses and to work on improving virtual environment visualizations and scenarios.

Authors: Mgr. et Mgr. Annamária Antalová Ústav aplikovanej psychológie, Fakulta sociálnych a ekonomických vied, Univerzita Komenského v Bratislave Ing. Eugen Antal, PhD. Ústav informatiky a matematiky, Fakulta elektrotechniky a informatiky, Slovenská technická univerzita v Bratislave doc. Mgr. Lenka Sokolová, PhD. Ústav aplikovanej psychológie, Fakulta sociálnych a ekonomických vied, Univerzita Komenského v Bratislave

Príspevok vznikol vďaka podpore grantu UK/199/2021 Využitie virtuálnej reality na redukciu predsudkov na Slovensku. Príspevok je čiastkovým výstupom grantu VEGA 1/0119/21 Poruchy učenia a pozornosti u študentov a študentiek v terciárnom vzdelávaní: Prevalencia, symptomatológia, copingové a učebné stratégie (2021 – 2024).

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