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A Virtual Reality Application for Assessment for Attention Deficit Neuropsychiatric Disease and Treatment Dovepress open access to scientific and medical research Open Access Full Text Article ORIGINAL RESEARCH A virtual reality application for assessment for attention deficit hyperactivity disorder in school- aged children This article was published in the following Dove Press journal: Neuropsychiatric Disease and Treatment Yantong Fang 1 Background and objective: The development of objective assessment tools for attention – Dai Han1 3 deficit hyperactivity disorder (ADHD) has become a hot research topic in recent years. This Hong Luo1 study was conducted to explore the feasibility and availability of virtual reality (VR) for evaluating symptoms of ADHD. 1Children and Adolescents Mental Health Joint Clinic, The Affiliated Hospital of Methods: School-aged children were recruited. The children with ADHD or without ADHD Hangzhou Normal University, Hangzhou, were assigned into the ADHD group or Control group, respectively. They were all evaluated ’ Zhejiang, People s Republic of China; using the Conners’ Parent Rating Scale (CPRS), Child Behavior Checklist (CBCL), 2Institutes of Psychological Sciences, Hangzhou Normal University, Hangzhou, Integrated Visual and Auditory Continuous Performance Test (IVA-CPT), and a VR test. Zhejiang, People’s Republic of China; Results: The correct items, incorrect items, and the accuracy rate of the VR test of the 3Zhejiang Key Laboratory for Research in children with ADHD were significantly different with those of the children in the Control Assessment of Cognitive Impairments, Hangzhou, Zhejiang, People’s Republic of group. The correct items, incorrect items, total time, and accuracy of the VR test were China significantly correlated with the scores of IVA-CPT (auditory attention and visual attention), CPRS (impulsion/hyperactivity and ADHD index), and CBCL (attention problems and social problems), respectively. Discussion: The results supported the discriminant validity of the VR test for evaluating ADHD in school-age children suffering from learning problems. The VR test results are associated with the commonly used clinical measurements results. AVR test is interesting for children and therefore it attracts them to complete the test; whilst at the same time, it can also effectively evaluate ADHD symptoms. Keywords: attention deficit hyperactivity disorder, ADHD, virtual reality, VR, Conners’ Parent Rating Scale, CPRS, Child Behavior Checklist, CBCL, Integrated Visual and Auditory Continuous Performance Test, IVA-CPT Introduction Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood and adolescent psychiatric disorders, with prevalence rates ranging from 5–7%.1,2 In addition to the three core symptoms (inattention, hyperactivity, and impulsivity), this disorder is characterized by some secondary symptoms of impairments of cognition, Correspondence: Hong Luo emotion regulation, and other secondary symptoms.3 These primary and secondary Children and Adolescents Mental Health Joint Clinic, The Affiliated Hospital of symptoms create significant difficulties in academic attainment, executive functioning, Hangzhou Normal University, No.126 and social interactions.4 To date, the diagnosis of ADHD mainly relies on clinical Wenzhou Road, Gongshu District, Hangzhou, Zhejiang Province 311121, interviews, self/other reports, and rating scales. However, the validity and reliability of ’ People s Republic of China the diagnosis of ADHD is limited to subjective assessments. The inconsistency Tel +86 137 3809 0039 Email [email protected] between the results of objective measurements and subjective measurements have submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2019:15 1517–1523 1517 DovePress © 2019 Fang et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License (http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work http://doi.org/10.2147/NDT.S206742 you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms (https://www.dovepress.com/terms.php). Fang et al Dovepress been reported in many studies on ADHD.5–8 It has been introduce VR technology into neuropsychological assess- suggested that using objective measures may enhance assay ment of ADHD in many countries.15–17 The present study sensitivity in clinical trials on ADHD6 The study of Konrad was conducted to explore the feasibility of VR-based assess- et al9 indicated that the teacher–behavior ratings of ADHD ment in school-aged children with ADHD, who suffered with symptoms seemed to be predominantly influenced by learning problems. The validity of the VR test was system- changes of motor activity, and did not cohere with the mea- atically investigated by comparing outcomes of the VR test surement results of computerized attention tasks. of children with ADHD with those of control children. Also, In recent years, increasing attention was paid to the the relationship between outcomes of the VR test and other development of objective evaluation tools. The frequently-used measurements of ADHD was analyzed. Continuous Performance Test (CPT) is a type of test, which requires participants to select a response to Methods a particular auditory/visual stimulus that is delivered at Participants regular intervals. Various kinds of CPTs were developed All participants were recruited from the school-aged (6–18 to evaluate children with ADHD objectively, such as years) children attending the Children and Adolescents OPATUS CPTA assessment (https://opatus.se/). Mental Health Joint Clinic of The Affiliated Hospital of Previous studies have demonstrated that the integrated Hangzhou Normal University from January 2017 to visual and auditory continuous performance testing September 2018. These children attended the clinic for (IVA-CPT) could accurately discriminate children with bad academic achievements, and were selected depending ADHD from control children.10 Quinn11 reported that on their and their parents’ willingness to participate in malingerers could fake ADHD on the subjective rating the study after they received a detailed explanation about scale, but could not on IVA-CPT. This difference it. The children who were firstly diagnosed with ADHD demonstrated the superiority of objective measurements based on the Diagnostic Interview Schedule for Children in the evaluation of ADHD. However, it is notable that Version V (DSM-V) were assigned into the ADHD group CPT is monotonous and repetitive, and requires an indi- (see Table 1). The children who did not meet the criteria vidual to focus attention for a long time. Children fre- for any mental disorders were assigned into the Control quently become bored during this kind of task. Only group (see Table 1). The children with brain damage, children with good self-control can successfully com- neurological disorders, genetic disorders, substance depen- plete it. Frequently, it is difficult for children with dence, epilepsy, an IQ of 70 or lower, or any other mental ADHD to complete all items of the CPT in the pre- disorder reported during the personal history and ana- scribed time. Consequently, both the reliability and mnesis were excluded. All participants’ parents provided validity of IVA-CPT might be influenced. It is necessary written informed consent to the content and ethics of this to assess ADHD by a more interesting test. study. All protocols were conducted in accordance with Virtual reality (VR) is a relatively new technology that the Declaration of Helsinki and approved by the Research simulates an imagined or real environment, thereby enabling Ethics Review Board of Hangzhou Normal University. users to immerse themselves in a virtual 3-dimensional envir- onment. This technology is being increasingly adopted in Table 1 The demography and VR test in the ADHD and control educational, entertainment, military, and medical areas. groups Many studies have suggested that a neuropsychological ADHD Control P/ assessment based on VR technology is more enjoyable and (n=77) (n=63) F-value can gather better behavioral data of distractibility and atten- tional deficits, compared with traditional neuropsychological Age 8.34±1.41 8.17±1.54 0.498 Sex (male/female) 57/20 49/14 0.694 tests.12,13 Negut et al14 reported the superior efficiency of VR-based CPT in children with ADHD, compared with VR test traditional CPT. The studies on the quality of experience in Correct items 36.82±5.85 38.92±3.31 0.012* Incorrect items 4.58±2.98 3.90±2.54 0.154 real environments and VR showed that virtual experience is Total time 237.6±100.84 211.33±27.37 0.047* associated with Flow, a state of consciousness characterized Accuracy (%) 87.66±12.24 91.08±5.35 0.041* by narrowed focus of attention, deep concentration.12 Note: *P<0.05. Therefore, an increased number of studies have tried to Abbreviations: ADHD, attention deficit hyperactivity disorder; VR, virtual reality. 1518 submit your manuscript | www.dovepress.com Neuropsychiatric Disease and Treatment 2019:15 DovePress Dovepress Fang et al VR test Conventional questionnaire psychological The VR test is performed using the Virtual Reality Medical test Center system (VRMC, Hangzhou Xinjing Technology
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