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Son HM, Calub CA, Fan B, Dixon JF, Rezaei S, Borden J, Schweitzer JB, Liu X. A quantitative analysis of fidgeting in ADHD and its relation to performance and sustained attention on a cognitive task. Front Psychiatry 2024; 15:1394096. [PMID: 39011341 PMCID: PMC11246969 DOI: 10.3389/fpsyt.2024.1394096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/31/2024] [Indexed: 07/17/2024] Open
Abstract
Introduction Attention-Deficit/Hyperactivity Disorder (ADHD) is a neurodevelopmental disorder where hyperactivity often manifests as fidgeting, a non-goal-directed motoric action. Many studies demonstrate fidgeting varies under different conditions as a self-regulating mechanism for attention and alertness during cognitively demanding tasks. Fidgeting has also been associated with reaction time variability. However, a lack of standard variables to define and quantify fidgeting can lead to discrepancies in data and interpretability issues across studies. Furthermore, little is known about fidgeting in adults with ADHD compared to youth. This study aims to design a framework to quantify meaningful fidgeting variables and to apply them to test the relation between fidgeting and performance on a cognitive task, the Flanker, in adults with ADHD. Method Our study included 70 adult participants diagnosed with ADHD, aged 18-50 years (30.5 ± 7.2 years). Screening included a structured clinical interview, childhood, current self and current observer ratings of ADHD symptoms. Actigraphy devices were attached to the left wrist and right ankle during completion of a cognitive control, attention task (the Flanker). Laboratory testing was subsequently completed on a single day. The relation between task performance, reaction time variability and fidgeting was examined. Results and Discussion Our analysis revealed increased fidgeting during correct trials as defined by our new variables, consistent with previous observations. Furthermore, differences in fidgeting were observed between early and later trials while the percentage of correct trials were not significantly different. This suggests a relation between the role of fidgeting and sustaining attention. Participants with low reaction time variability, that is, those with more consistent reaction times, fidgeted more during later trials. This observation supports the theory that fidgeting aids arousal and improves sustained attention. Finally, a correlation analysis using ADHD-symptom rating scales validated the relevance of the fidget variables in relation to ADHD symptom severity. These findings suggest fidgeting may be a compensatory mechanism that aids in sustained attention for those with ADHD, although alternative explanations exist. Conclusion Our study suggests that fidgeting may aid in sustained attention during the attention-demanding, cognitive control processes for adults with ADHD, with more fidgeting observed during correct trials and among participants with lower reaction time variability. Furthermore, the newly defined fidget variables were validated through a significant correlation with ADHD rating scales. By sharing our implementation of fidget variables, we hope to standardize and encourage further quantitative research into the role of fidgeting in ADHD.
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Affiliation(s)
- Ha Min Son
- Department of Computer Science, University of California, Davis, Davis, CA, United States
| | - Catrina Andaya Calub
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, United States
- MIND Institute, University of California, Davis, Sacramento, CA, United States
| | - Boyang Fan
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, United States
- MIND Institute, University of California, Davis, Sacramento, CA, United States
| | - J Faye Dixon
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, United States
- MIND Institute, University of California, Davis, Sacramento, CA, United States
| | - Shahbaz Rezaei
- Department of Computer Science, University of California, Davis, Davis, CA, United States
| | - Jared Borden
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, United States
- MIND Institute, University of California, Davis, Sacramento, CA, United States
| | - Julie B Schweitzer
- Department of Psychiatry and Behavioral Sciences, University of California, Davis, Sacramento, CA, United States
- MIND Institute, University of California, Davis, Sacramento, CA, United States
| | - Xin Liu
- Department of Computer Science, University of California, Davis, Davis, CA, United States
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Mancuso V, Sarcinella ED, Bruni F, Arlati S, Di Santo SG, Cavallo M, Cipresso P, Pedroli E. Systematic review of memory assessment in virtual reality: evaluating convergent and divergent validity with traditional neuropsychological measures. Front Hum Neurosci 2024; 18:1380575. [PMID: 38818031 PMCID: PMC11137286 DOI: 10.3389/fnhum.2024.1380575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 05/03/2024] [Indexed: 06/01/2024] Open
Abstract
Introduction The evaluation of memory is a crucial aspect of both cognitive research and clinical applications, as it offers valuable insights into an individual's cognitive wellbeing and performance. Conventional neuropsychological assessments represent the established method for assessing different aspects of memory. Recent technological advancements, specifically in the field of virtual reality (VR), have introduced novel methods for evaluating memory. Objective This systematic review aims to examine the current state of memory assessment using VR technologies, assessing the degree of convergence and divergence between VR-based memory assessments and conventional neuropsychological tests. Method A systematic review of the literature was conducted searching PubMed, PsycINFO, Web of Science databases, leading to the incorporation of 24 studies. Studies were grouped according to the examined memory domain (episodic, prospective, spatial domain). Convergence and divergence validity were examined for each, and information on software and hardware features was collected. Results This review demonstrates a notable alignment between VR-based memory assessments and conventional neuropsychological tests. Moreover, VR tasks have shown to exhibit associations with executive functions and overall cognitive performance. The inclusion of various ecological contexts, such as residential environments, commercial establishments, and simulated scenarios, serves to augment the ecological validity of memory evaluations conducted in VR. Discussion The findings indicate that VR assessments demonstrate a functional perspective by effectively capturing the dynamic relationship between memory, executive functions, and overall cognitive performance. Nevertheless, it is imperative to acknowledge and tackle certain constraints that may hinder the widespread adoption and utilization of VR tasks. These limitations encompass factors such as restricted accessibility to VR tasks and the presence of heterogeneity in VR hardware and software. The dynamic and ever-changing nature of VR technology presents a range of potential avenues for future investigation and utilization in the domain of memory evaluation.
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Affiliation(s)
| | - Eleonora Diletta Sarcinella
- Department of Psychology, Research Center in Communication Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | | | - Sara Arlati
- Institute of Intelligent Industrial Technologies and Systems for Advanced Manufacturing–STIIMA National Research Council of Italy–CNR, Milan, Italy
| | | | - Marco Cavallo
- Faculty of Psychology, eCampus University, Novedrate, Italy
| | | | - Elisa Pedroli
- Faculty of Psychology, eCampus University, Novedrate, Italy
- Department of Geriatrics and Cardiovascular Medicine, IRCCS Istituto Auxologico Italiano, Milan, Italy
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Johnsen KH, Kvitland LR, Sollie H, Reiestad M, Jonsbu E, Hagen K, Weidle B. Is the Conners' continuous performance test helpful for assessing attention deficit hyperactivity disorder in a clinical setting? Nord J Psychiatry 2024; 78:120-127. [PMID: 37971369 DOI: 10.1080/08039488.2023.2279640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Despite lacking validation for Norwegian populations, the Conners Continuous Performance Test II (CCPT-II) is applied to almost one-third of children receiving an ADHD diagnosis. However, evidence of the CCPT-II's ability to differentiate between children with and without ADHD is contradictory. Thus, this study examines how CCPT-II results correlate with ADHD symptoms reported by mothers and teachers in a sample representing ordinary child and adolescent mental health services and explores the extent to which the CCPT-II influences the diagnostic result. METHODS Correlations between CCPT-II results and ADHD Rating Scale scores and a clinical diagnosis of ADHD were analysed in children aged 6-15 years (N = 69) referred to a child and adolescent psychiatric outpatient clinic. RESULTS Total ADHD symptom scores rated by mothers correlated with hit reaction time (HRT) block change (.260), HRT inter-stimulus interval (ISI) change (.264) and CCPT-II overall index (.263), while hyperactivity subscale scores correlated with omissions (.285), HRT (.414) and variability (.400). In teachers' ratings, total ADHD and both subscale scores correlated with commissions (.280-.382), while hyperactivity scores correlated with variability (.265). A higher number of commissions was the only significant difference in CCPT-II performance between children diagnosed with and children without ADHD. CONCLUSIONS Correlations between CCPT-II results and ADHD symptoms were all small to moderate. As such, CCPT-II results should be interpreted with caution, because they correspond to a limited degree with other sources of information.
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Affiliation(s)
| | - Levi Rostad Kvitland
- Regional Centre for Child and Youth Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olav's University Hospital, Trondheim, Norway
| | - Henrik Sollie
- Department of Mental Health, Kristiansund Hospital, Trondheim, Norway
| | - Magnus Reiestad
- Møre and Romsdal Hospital Trust, Department of Neurology, Molde Hospital, Norway
| | - Egil Jonsbu
- Department Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Mental Health, Møre og Romsdal Hospital Trust, Molde Hospital, Norway
| | - Kristen Hagen
- Department Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Mental Health, Møre og Romsdal Hospital Trust, Molde Hospital, Norway
- Bergen Centre for Brain Plasticity, Haukeland University Hospital, Bergen, Norway
| | - Bernhard Weidle
- Regional Centre for Child and Youth Mental Health, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Child and Adolescent Psychiatry, St. Olav's University Hospital, Trondheim, Norway
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Hasenbein L, Stark P, Trautwein U, Gao H, Kasneci E, Göllner R. Investigating social comparison behaviour in an immersive virtual reality classroom based on eye-movement data. Sci Rep 2023; 13:14672. [PMID: 37673939 PMCID: PMC10483041 DOI: 10.1038/s41598-023-41704-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/30/2023] [Indexed: 09/08/2023] Open
Abstract
Higher-achieving peers have repeatedly been found to negatively impact students' evaluations of their own academic abilities (i.e., Big-Fish-Little-Pond Effect). Building on social comparison theory, this pattern is assumed to result from students comparing themselves to their classmates; however, based on existing research designs, it remains unclear how exactly students make use of social comparison information in the classroom. To determine the extent to which students (N = 353 sixth graders) actively attend and respond to social comparison information in the form of peers' achievement-related behaviour, we used eye-tracking data from an immersive virtual reality (IVR) classroom. IVR classrooms offer unprecedented opportunities for psychological classroom research as they allow to integrate authentic classroom scenarios with maximum experimental control. In the present study, we experimentally varied virtual classmates' achievement-related behaviour (i.e., their hand-raising in response to the teacher's questions) during instruction, and students' eye and gaze data showed that they actively processed this social comparison information. Students who attended more to social comparison information (as indicated by more frequent and longer gaze durations at peer learners) had less favourable self-evaluations. We discuss implications for the future use of IVR environments to study behaviours in the classroom and beyond.
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Affiliation(s)
- Lisa Hasenbein
- Hector Research Institute of Education Sciences and Psychology, University of Tübingen, Europastraße 6, 72072, Tübingen, Germany.
| | - Philipp Stark
- Hector Research Institute of Education Sciences and Psychology, University of Tübingen, Europastraße 6, 72072, Tübingen, Germany
| | - Ulrich Trautwein
- Hector Research Institute of Education Sciences and Psychology, University of Tübingen, Europastraße 6, 72072, Tübingen, Germany
| | - Hong Gao
- Human-Centered Technologies for Learning, Technical University of Munich, Arcisstraße 21, 80333, Munich, Germany
| | - Enkelejda Kasneci
- Human-Centered Technologies for Learning, Technical University of Munich, Arcisstraße 21, 80333, Munich, Germany
| | - Richard Göllner
- Hector Research Institute of Education Sciences and Psychology, University of Tübingen, Europastraße 6, 72072, Tübingen, Germany.
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Barnett MD, Coldiron AM. Development of the Virtual Kitchen Protocol for Prospective Memory: a virtual reality-based measure of everyday prospective memory abilities. J Clin Exp Neuropsychol 2023; 45:618-635. [PMID: 38063062 DOI: 10.1080/13803395.2023.2287779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 11/19/2023] [Indexed: 12/30/2023]
Abstract
INTRODUCTION Prospective memory is the ability to remember to accomplish a task at a specified point in the future. While this cognitive ability has a large impact on daily functioning, it is rarely assessed during neuropsychological evaluations. Furthermore, existing clinical prospective memory measures are few in number and have significant limitations, including applicability to everyday functioning and appropriate norming for older adulthood. There are also many gaps in the literature on prospective memory, such as how environmental factors affect performance across the lifespan. METHOD In the current study, we develop and establish a new virtual reality-based measure of prospective memory, the Virtual Kitchen Protocol for Prospective Memory. Young adults (ages 18-29; n = 56), healthy older adults (ages 60-90; n = 94), and clinical older adults (ages 62-90; n = 30) were compared on their performances on both the developed virtual reality prospective memory test and a parallel paper-and-pencil prospective memory test to investigate the impact of test environment across participant group. RESULTS The Virtual Kitchen Protocol for Prospective Memory was found to adequately differentiate between young adult, healthy older adult, and clinical older adult populations - suggesting baseline ability for prospective memory assessment in clinical settings with older adults and potential for future improvement of neuropsychological evaluations. Additionally, the developed virtual prospective memory task appeared to mimic environmental factors in everyday life but did not replicate the benefit previously measured in healthy older adults' prospective memory ability in naturalistic settings. CONCLUSIONS Overall, the current study built upon extant knowledge of prospective memory in both normal and abnormal aging, suggesting future directions in replicating familiar home environments. Findings provided additional evidence toward future validation of virtual reality assessment tools in clinical neuropsychological evaluations of cognitive abilities, such as prospective memory, with both healthy and clinical older adult populations.
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Affiliation(s)
- Michael D Barnett
- Department of Psychology and Counseling, University of Texas at Tyler, Tyler, TX, USA
| | - Allyson M Coldiron
- Department of Psychology and Counseling, University of Texas at Tyler, Tyler, TX, USA
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Kourtesis P, Kouklari EC, Roussos P, Mantas V, Papanikolaou K, Skaloumbakas C, Pehlivanidis A. Virtual Reality Training of Social Skills in Adults with Autism Spectrum Disorder: An Examination of Acceptability, Usability, User Experience, Social Skills, and Executive Functions. Behav Sci (Basel) 2023; 13:bs13040336. [PMID: 37102850 PMCID: PMC10136366 DOI: 10.3390/bs13040336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/14/2023] [Accepted: 04/15/2023] [Indexed: 04/28/2023] Open
Abstract
Poor social skills in autism spectrum disorder (ASD) are associated with reduced independence in daily life. Current interventions for improving the social skills of individuals with ASD fail to represent the complexity of real-life social settings and situations. Virtual reality (VR) may facilitate social skills training in social environments and situations similar to those in real life; however, more research is needed to elucidate aspects such as the acceptability, usability, and user experience of VR systems in ASD. Twenty-five participants with ASD attended a neuropsychological evaluation and three sessions of VR social skills training, which incorporated five social scenarios with three difficulty levels. Participants reported high acceptability, system usability, and user experience. Significant correlations were observed between performance in social scenarios, self-reports, and executive functions. Working memory and planning ability were significant predictors of the functionality level in ASD and the VR system's perceived usability, respectively. Yet, performance in social scenarios was the best predictor of usability, acceptability, and functionality level. Planning ability substantially predicted performance in social scenarios, suggesting an implication in social skills. Immersive VR social skills training in individuals with ASD appears to be an appropriate service, but an errorless approach that is adaptive to the individual's needs should be preferred.
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Affiliation(s)
- Panagiotis Kourtesis
- Department of Psychology, National and Kapodistrian University of Athens, 157 84 Athens, Greece
- Department of Psychology, University of Edinburgh, Edinburgh EH8 9AD, UK
| | - Evangelia-Chrysanthi Kouklari
- Department of Child Psychiatry, Aghia Sophia Children's Hospital, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece
- 1st Department of Psychiatry, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Petros Roussos
- Department of Psychology, National and Kapodistrian University of Athens, 157 84 Athens, Greece
| | - Vasileios Mantas
- 1st Department of Psychiatry, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
| | - Katerina Papanikolaou
- Department of Child Psychiatry, Aghia Sophia Children's Hospital, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece
| | - Christos Skaloumbakas
- Department of Child Psychiatry, P. & A. Kyriakou Children's Hospital, 115 28 Athens, Greece
- Habilis, R&D Team, 141 22 Athens, Greece
| | - Artemios Pehlivanidis
- 1st Department of Psychiatry, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, 115 28 Athens, Greece
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Voinescu A, Petrini K, Stanton Fraser D. Presence and simulator sickness predict the usability of a virtual reality attention task. VIRTUAL REALITY 2023; 27:1-17. [PMID: 37360806 PMCID: PMC10038382 DOI: 10.1007/s10055-023-00782-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 02/26/2023] [Indexed: 06/28/2023]
Abstract
Attention is the ability to actively process specific information within one's environment over longer periods of time while disregarding other details. Attention is an important process that contributes to overall cognitive performance from performing every day basic tasks to complex work activities. The use of virtual reality (VR) allows study of the attention processes in realistic environments using ecological tasks. To date, research has focused on the efficacy of VR attention tasks in detecting attention impairment, while the impact of the combination of variables such as mental workload, presence and simulator sickness on both self-reported usability and objective attention task performance in immersive VR has not been examined. The current study tested 87 participants on an attention task in a virtual aquarium using a cross-sectional design. The VR task followed the continuous performance test paradigm where participants had to respond to correct targets and ignore non-targets over 18 min. Performance was measured using three outcomes: omission (failing to respond to correct targets), commission errors (incorrect responses to targets) and reaction time to correct targets. Measures of self-reported usability, mental workload, presence and simulator sickness were collected. The results showed that only presence and simulator sickness had a significant impact on usability. For performance outcomes, simulator sickness was significantly and weakly associated with omission errors, but not with reaction time and commission errors. Mental workload and presence did not significantly predict performance. Our results suggest that usability is more likely to be negatively impacted by simulator sickness and lack of presence than performance and that usability and attention performance are linked. They highlight the importance of considering factors such as presence and simulator sickness in attention tasks as these variables can impact usability. Supplementary Information The online version contains supplementary material available at 10.1007/s10055-023-00782-3.
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Affiliation(s)
- Alexandra Voinescu
- Department of Psychology, University of Bath, Claverton Down, Bath, BA2 7AY UK
- International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health, Babeș-Bolyai University, Cluj-Napoca, Romania
| | - Karin Petrini
- Department of Psychology, University of Bath, Claverton Down, Bath, BA2 7AY UK
- Centre for the Analysis of Motion, Entertainment Research and Applications, University of Bath, Bath, UK
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Wei Z, Zhong C, Gao Y. Art therapy practices in museum education: A mini review. Front Psychol 2023; 13:1075427. [PMID: 36743648 PMCID: PMC9895939 DOI: 10.3389/fpsyg.2022.1075427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/30/2022] [Indexed: 01/21/2023] Open
Abstract
This article reviews the potential functions and approaches of museum education in alleviating psychological anxiety, particularly the psychological anxiety experienced by adolescents during the COVID-19 pandemic. We outline the main forms of museum education, highlighting how it supports the potential functions of art therapy for psychological anxiety. Thereafter, we review the representative research on museum art therapy practice for different populations to invite discussion, dialogue, and awareness of future directions for museum education and suggest gaps in the research that require further study.
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Affiliation(s)
- Zhizi Wei
- College of Teachers Education, Zhejiang Normal University, Jinhua, Zhejiang, China
| | - Chaofang Zhong
- College of Teachers Education, Zhejiang Normal University, Jinhua, Zhejiang, China,*Correspondence: Chaofang Zhong, ✉
| | - Yunteng Gao
- Shandong First Medical University, Jinan, Shandong, China
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Huang XT, Wang J, Wang Z, Wang L, Cheng C. Experimental study on the influence of virtual tourism spatial situation on the tourists' temperature comfort in the context of metaverse. Front Psychol 2023; 13:1062876. [PMID: 36687952 PMCID: PMC9846819 DOI: 10.3389/fpsyg.2022.1062876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/30/2022] [Indexed: 01/06/2023] Open
Abstract
The Metaverse is a new application of the internet and social form which integrates a myriad of new technologies. It can not only create a parallel space that is closely connected to the real world while highly independent, but also bring the immersive experience of virtual scenarios without delay. The virtual tourism space situations that integrate realistic visual, audio, and temperature sensations can restore the real tourism environment to the greatest extent, and improve tourists' perception and satisfaction with the experience. The purpose of this experimental lab study is to examine the effects of the virtual tourism audio-visual conditions and environmental temperature on tourists' thermal sensation and temperature comfort. VR equipment and microclimate simulation technology was applied in a 3 × 2 × 2 experimental design (n = 180), simulating the virtual tourism scenarios. Electrocardiogram devices were also employed to assess participants' physiological indicators. Study results suggest that: (1) Virtual tourism spatial situations (environmental temperature and audio-visual conditions) significantly affect participants' thermal sensation and part of the physiological indicators; (2) Virtual tourism spatial situations (environmental temperature and audio-visual conditions) significantly affect participants' temperature comfort; and (3) Physiological responses (indicators) mediate the effect from tourism spatial situations to temperature comfort. The study mainly contributes to the literature about virtual tourism experience and spatial situations under the concept of the Metaverse, as well as provides theoretical and managerial implications for the development of "immersive" virtual tourism scenarios.
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Affiliation(s)
- Xiao-Ting Huang
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China
| | - Jiahui Wang
- Isenberg School of Management, University of Massachusetts, Amherst, MA, United States
| | - Zhihui Wang
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China
| | - Linqiang Wang
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China,*Correspondence: Linqiang Wang, ✉
| | - Chenfei Cheng
- Department of Culture and Tourism Management, School of Management, Shandong University, Jinan, Shandong, China
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Cho YJ, Yum JY, Kim K, Shin B, Eom H, Hong YJ, Heo J, Kim JJ, Lee HS, Kim E. Evaluating attention deficit hyperactivity disorder symptoms in children and adolescents through tracked head movements in a virtual reality classroom: The effect of social cues with different sensory modalities. Front Hum Neurosci 2022; 16:943478. [PMID: 35992945 PMCID: PMC9386071 DOI: 10.3389/fnhum.2022.943478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/15/2022] [Indexed: 11/22/2022] Open
Abstract
Background Attention deficit hyperactivity disorder (ADHD) is clinically diagnosed; however, quantitative analysis to statistically analyze the symptom severity of children with ADHD via the measurement of head movement is still in progress. Studies focusing on the cues that may influence the attention of children with ADHD in classroom settings, where children spend a considerable amount of time, are relatively scarce. Virtual reality allows real-life simulation of classroom environments and thus provides an opportunity to test a range of theories in a naturalistic and controlled manner. The objective of this study was to investigate the correlation between participants’ head movements and their reports of inattention and hyperactivity, and to investigate how their head movements are affected by different social cues of different sensory modalities. Methods Thirty-seven children and adolescents with (n = 20) and without (n = 17) ADHD were recruited for this study. All participants were assessed for diagnoses, clinical symptoms, and self-reported symptoms. A virtual reality-continuous performance test (VR-CPT) was conducted under four conditions: (1) control, (2) no-cue, (3) visual cue, and (4) visual/audio cue. A quantitativecomparison of the participants’ head movements was conducted in three dimensions (pitch [head nods], yaw [head turns], and roll [lateral head inclinations]) using a head-mounted display (HMD) in a VR classroom environment. Task-irrelevant head movements were analyzed separately, considering the dimension of movement needed to perform the VR-CPT. Results The magnitude of head movement, especially task-irrelevant head movement, significantly correlated with the current standard of clinical assessment in the ADHD group. Regarding the four conditions, head movement showed changes according to the complexity of social cues in both the ADHD and healthy control (HC) groups. Conclusion Children and adolescents with ADHD showed decreasing task-irrelevant movements in the presence of social stimuli toward the intended orientation. As a proof-of-concept study, this study preliminarily identifies the potential of VR as a tool to understand and investigate the classroom behavior of children with ADHD in a controlled, systematic manner.
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Affiliation(s)
- Yoon Jae Cho
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Yon Yum
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Kwanguk Kim
- Department of Computer Science, Hanyang University, Seoul, South Korea
| | - Bokyoung Shin
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyojung Eom
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Yeon-ju Hong
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jiwoong Heo
- Department of Computer Science, Hanyang University, Seoul, South Korea
| | - Jae-jin Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Department of Research Affairs, Yonsei University College of Medicine, Seoul, South Korea
| | - Eunjoo Kim
- Department of Psychiatry, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Department of Psychiatry, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, South Korea
- *Correspondence: Eunjoo Kim,
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Hasenbein L, Stark P, Trautwein U, Queiroz ACM, Bailenson J, Hahn JU, Göllner R. Learning with simulated virtual classmates: Effects of social-related configurations on students’ visual attention and learning experiences in an immersive virtual reality classroom. COMPUTERS IN HUMAN BEHAVIOR 2022. [DOI: 10.1016/j.chb.2022.107282] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Dincelli E, Yayla A. Immersive virtual reality in the age of the Metaverse: A hybrid-narrative review based on the technology affordance perspective. JOURNAL OF STRATEGIC INFORMATION SYSTEMS 2022. [DOI: 10.1016/j.jsis.2022.101717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Björling EA, Sonney J, Rodriguez S, Carr N, Zade H, Moon SH. Exploring the Effect of a Nature-based Virtual Reality Environment on Stress in Adolescents. FRONTIERS IN VIRTUAL REALITY 2022; 3:831026. [PMID: 38846011 PMCID: PMC11156422 DOI: 10.3389/frvir.2022.831026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2024]
Abstract
Adolescent mental health is a growing public health issue, with 30% of teens reporting increased stress and 20% of adolescents suffering from depression. Given the scarcity and lack of scalability of mental health services available, the use of self-administered, evidence-based technologies to support adolescent mental health is both timely and imperative. We conducted a mixed-methods pilot study with 31 adolescents ages 14-19 (m = 17.97) to explore the self-administration of a nature-based virtual reality tool. Participant use of the VR environment ranged from 1 to 10 sessions (m = 6.6) at home over a 2-week period while reporting their daily stress and mood levels. All participants completed all of the study protocols, indicating our protocol was feasible and the VR environment engaging. Post-study interviews indicated that most participants found the VR tool to be relaxing and helpful with stress. The themes of Calm Down, Relaxation, and Escape emerged to articulate the participants' experiences using the VR environment. Additionally, participants provided rich data regarding their preferences and activity in the VR environment as well as its effect on their emotional states. Although the sample size was insufficient to determine the impact on depression, we found a significant reduction in momentary stress as a result of using the VR tool. These preliminary data inform our own virtual reality environment design, but also provide evidence of the potential for self-administered virtual reality as a promising tool to support adolescent mental health.
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Affiliation(s)
- Elin A. Björling
- Human Centered Design and Engineering, University of Washington, Seattle, WA, United States
| | - Jennifer Sonney
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA, United States
| | - Sofia Rodriguez
- Human Centered Design and Engineering, University of Washington, Seattle, WA, United States
| | - Nora Carr
- Human Centered Design and Engineering, University of Washington, Seattle, WA, United States
| | - Himanshu Zade
- Human Centered Design and Engineering, University of Washington, Seattle, WA, United States
| | - Soo Hyun Moon
- Human Centered Design and Engineering, University of Washington, Seattle, WA, United States
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14
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Rodrigo-Yanguas M, González-Tardón C, Bella-Fernández M, Blasco-Fontecilla H. Serious Video Games: Angels or Demons in Patients With Attention-Deficit Hyperactivity Disorder? A Quasi-Systematic Review. Front Psychiatry 2022; 13:798480. [PMID: 35573357 PMCID: PMC9091561 DOI: 10.3389/fpsyt.2022.798480] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/11/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To carry out a quasi-systematic review of the use of serious video games for health as a cognitive rehabilitative tool in patients diagnosed with attention-deficit hyperactivity disorder. METHOD A quasi-systematic review of serious video games used as an evaluative and rehabilitative tool in patients with ADHD was conducted. It included behavioral patterns in the use of video games and addiction problems in this population. For its elaboration the PRISMA GUIDES were followed. The search was carried out in three PubMed databases, MEDLINE, and PsycInfo using the keywords: [game OR serious game OR computer game) AND (psychotherapy OR rehabilitation OR intervention OR mental disorders) AND (adhd)], [(adhd) AND (Video game addiction)]. All articles written in English, Spanish, or Portuguese from January 1970 to June 2021 were included: those in which reference was made to the use of video games and/or new technologies as a therapeutic and evaluative tool in children and adults diagnosed with ADHD, as well as those that referred to behavioral and clinical patterns in the use of video games. RESULTS We found 605 articles of which 128 were reviewed (44 observational studies, 26 quasi-experimental studies, 26 experimental studies, 8 systematic reviews, 9 narrative texts, 6 case reports, 7 pilot studies, 8 systematic reviews, and 2 meta-analyses). Serious video games can be used to ameliorate ADHD symptoms while improving adherence to treatment. Some serious video games show high accuracy properties assessing ADHD features. CONCLUSION Serious video games for health are increasingly being used as a cognitive rehabilitation tool in patients with attention-deficit hyperactivity disorder (ADHD). SYSTEMATIC REVIEW REGISTRATION [www.crd.york.ac.uk/prospero], identifier [CRD42021247784].
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Affiliation(s)
- María Rodrigo-Yanguas
- Servicio de Psiquiatría, Puerta de Hierro Health Research Institute-Segovia de Arana (IDIPHISA)-Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.,Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | | | - Marcos Bella-Fernández
- Servicio de Psiquiatría, Puerta de Hierro Health Research Institute-Segovia de Arana (IDIPHISA)-Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.,Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Department of Psychology, Universidad Pontificia de Comillas, Madrid, Spain
| | - Hilario Blasco-Fontecilla
- Servicio de Psiquiatría, Puerta de Hierro Health Research Institute-Segovia de Arana (IDIPHISA)-Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.,Faculty of Medicine, Universidad Autónoma de Madrid, Madrid, Spain.,Consulting Asistencial Sociosanitario SL, Madrid, Spain.,Centro de Investigación Biomédica en Red de Salud Mental, Madrid, Spain
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15
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Kim E, Han J, Choi H, Prié Y, Vigier T, Bulteau S, Kwon GH. Examining the Academic Trends in Neuropsychological Tests for Executive Functions Using Virtual Reality: Systematic Literature Review. JMIR Serious Games 2021; 9:e30249. [PMID: 34822341 PMCID: PMC8663439 DOI: 10.2196/30249] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 08/31/2021] [Accepted: 09/19/2021] [Indexed: 01/19/2023] Open
Abstract
Background In neuropsychology, fully immersive virtual reality (VR) has been spotlighted as a promising tool. It is considered that VR not only overcomes the existing limitation of neuropsychological tests but is also appropriate for treating executive functions (EFs) within activities of daily living (ADL) due to its high ecological validity. While fully immersive VR offers new possibilities of neuropsychological tests, there are few studies that overview the intellectual landscape and academic trends in the research related to mainly targeted EFs with fully immersive VR. Objective The objective of this study is to get an overview of the research trends that use VR in neuropsychological tests and to analyze the research trends using fully immersive VR neuropsychological tests with experimental articles. Methods This review was carried out according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles were searched in three web databases using keywords related to VR, EFs, and cognitive abilities. The study was conducted in two steps, keyword analysis and in-depth systematic review. In the web database search from 2000 to 2019, 1167 articles were initially collected, of which 234 articles in the eligibility phase were used to conduct keyword analysis and a total of 47 articles were included for systematic review. Results In keyword analysis, the number of articles focused on dementia including the keywords “MCI,” “SCD,” and “dementia” were highlighted over the period, rather than other symptoms. In addition, we identified that the use of behavioral and physiological data in virtual environments (VEs) has dramatically increased in recent studies. In the systematic review, we focused on the purpose of study, assessment, treatment, and validation of usability and structure. We found that treatment studies and uncategorized studies including presence and cybersickness issues have emerged in the recent period. In addition, the target symptoms and range of participants were diversified. Conclusions There has been a continuously increasing interest in dealing with neuropsychology by using fully immersive VR. Target cognitive abilities have been diversified, as well as target symptoms. Moreover, the concept of embodied cognition was transplanted in this research area.
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Affiliation(s)
- Euisung Kim
- Graduate School of Technology and Innovation Management, Hanyang University, Seoul, Republic of Korea
| | - Jieun Han
- Graduate School of Technology and Innovation Management, Hanyang University, Seoul, Republic of Korea
| | - Hojin Choi
- Department of Neurology, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Yannick Prié
- Laboratory of Digital Science of Nantes (LS2N), CNRS UMR6004, Nantes Université, Nantes, France
| | - Toinon Vigier
- Laboratory of Digital Science of Nantes (LS2N), CNRS UMR6004, Nantes Université, Nantes, France
| | - Samuel Bulteau
- CHU Nantes, Psychiatry Department, Nantes, France.,INSERM U1246, SPHERE, University of Nantes, University of Tours, Nantes, France
| | - Gyu Hyun Kwon
- Graduate School of Technology and Innovation Management, Hanyang University, Seoul, Republic of Korea
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16
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Son HM, Lee DG, Joung YS, Lee JW, Seok EJ, Chung TM, Oh S. A novel approach to diagnose ADHD using virtual reality. INTERNATIONAL JOURNAL OF WEB INFORMATION SYSTEMS 2021. [DOI: 10.1108/ijwis-03-2021-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The current golden standard for attention deficit hyperactivity disorder (ADHD) diagnosis is clinical diagnosis based on psychiatric interviews and psychological examinations. This is suboptimal, as clinicians are unable to view potential patients in multiple natural settings – a necessary condition for objective diagnosis. The purpose of this paper is to improve the objective diagnosis of ADHD by analyzing a quantified representation of the actions of potential patients in multiple natural environments.
Design/methodology/approach
The authors use both virtual reality (VR) and artificial intelligence (AI) to create an objective ADHD diagnostic test. Diagnostic and statistical manual of mental disorders, 5th Edition (DSM-5) and ADHD Rating Scale are used to create a rule-based system of quantifiable VR-observable actions. As a potential patient completes tasks within multiple VR scenes, certain actions trigger an increase in the severity measure of the corresponding ADHD symptom. The resulting severity measures are input to an AI model, which classifies the potential patient as having ADHD in the form inattention, hyperactivity-impulsivity, combined or neither.
Findings
The result of this study shows that VR-observed actions can be extracted as quantified data, and classification of this quantified data achieves near-perfect sensitivity and specificity with a 98.3% accuracy rate on a convolutional neural network model.
Originality/value
To the best of the authors’ knowledge, this is the first study to incorporate VR and AI into an objective DSM-5-based ADHD diagnostic test. By including stimulation to the visual, auditory and equilibrium senses and tracking movement and recording voice, we present a method to further the research of objective ADHD diagnosis.
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17
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Kaimara P, Oikonomou A, Deliyannis I. Could virtual reality applications pose real risks to children and adolescents? A systematic review of ethical issues and concerns. VIRTUAL REALITY 2021; 26:697-735. [PMID: 34366688 PMCID: PMC8328811 DOI: 10.1007/s10055-021-00563-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 07/20/2021] [Indexed: 06/13/2023]
Abstract
Virtual reality technologies (VRTs) are high-tech human-computer interfaces used to develop digital content and can be applied to multiple different areas, often offering innovative solutions to existing problems. A wide range of digital games is being also developed with VRTs and together with their components, the games' structural elements are appealing to children and engaging them more in virtual worlds. Our research interest is directed towards children's development and the effects of VRTs within gaming environments. Contemporary psychology studies perceive human development as a holistic and lifelong process with important interrelationships between physical, mental, social and emotional aspects. For the objectives and scope of this work, we examine children development across three domains: physical, cognitive and psychosocial. In this context, the authors review the literature on the impact of VRTs on children, in terms of software and hardware. Since research requires an wide-ranging approach, we study the evidence reported on the brain and neural structure, knowledge, behaviour, pedagogy, academic performance, and wellness. Our main concern is to outline the emerging ethical issues and worries of parents, educators, ophthalmologists, neurologists, psychologists, paediatricians and all relevant scientists, as well as the industry's views and actions. The systematic review was performed on the databases Scopus, IEEE Xplore, PubMed, and Google Scholar from 2010 to 2020 and 85 studies were selected. The review concluded that findings remain contradictory especially for the psychosocial domain. Official recommendations from organizations and well-documented researches by academics on child well-being are reassuring if health and safety specifications and particularly the time limit are met. Research is still ongoing, constantly updated and consist of a priority for the scientific community given that technology evolves.
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Affiliation(s)
- Polyxeni Kaimara
- Department of Audio and Visual Arts, Ionian University, Tsirigoti Sq. 7, 49100 Corfu, Greece
| | - Andreas Oikonomou
- School of Pedagogical and Technological Education (ASPETE), Alexandrou Papanastasiou 13, Thessaloniki, Greece
| | - Ioannis Deliyannis
- Department of Audio and Visual Arts, Ionian University, Tsirigoti Sq. 7, 49100 Corfu, Greece
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18
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A Lean UX Process Model for Virtual Reality Environments Considering ADHD in Pupils at Elementary School in COVID-19 Contingency. SENSORS 2021; 21:s21113787. [PMID: 34070754 PMCID: PMC8199328 DOI: 10.3390/s21113787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022]
Abstract
Today, the world is experiencing the COVID-19 health contingency, which prevents people from being exposed to one another and restricts physical contact. Under this context, the use of technology has become an essential tool to face the challenges of daily life, and virtual reality can be an alternative in the development of solutions that effectively support the acquisition of learning skills and knowledge transmission through the execution of tasks designed by multi-disciplinary groups. In addition, it can encourage the user to continue with the acquisition of learning skills in a friendly and fun way in a health and education context. This work proposes the use of virtual reality environments as an alternative to support the learning process in children with special educational needs such as Attention Deficit Hyperactivity Disorder (ADHD) and other associated disorders that occur in basic education. These proposed reality environments are designed under the Lean UX process model and their contents are designed according to expert therapeutic guidelines. As a result of this proposal, a case study is presented in which the user experience is evaluated through the use of an interactive environment to support the special educational needs of elementary school children attending an educational institution in Mexico.
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19
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Development of a Virtual Ecological Environment for Learning the Taipei Tree Frog. SUSTAINABILITY 2021. [DOI: 10.3390/su13115911] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The learning objectives of environmental education emphasize investigation in real life to enhance students’ skills and experiences in solving practical problems. This study used the virtual reality (VR) technology to develop a virtual ecological environment for learning about the Taipei tree frog, supported by situated learning and game-based learning design to enhance students’ learning interest and motivation. Users can wear the head-mounted display (HMD) to explore the virtual environment for learning the Taipei tree frog’s ecological behavior, such as foraging and mating as well as its habitats and predators. A teaching experiment was conducted to investigate students’ learning effectiveness and the senses of presence and anxiety after using the virtual ecological environment. The experimental group (wearing the HMD) contained 40 students, the control group (using the desktop VR) contained 40 students, and both groups were used as samples to learn about the Taipei tree frog. The results indicated that using HMD VR and desktop VR could both enhance learning achievements, but the learning effectiveness of the former was significantly higher than that of the latter. The levels of anxiety for both groups were about the same, but the level of presence for the experimental group was higher than that of the control group because the HMD VR provided a more immersive experience than the desktop VR. The virtual ecological environment can save the time and effort of travelling to the natural habitat for observing the Taipei tree frog, and the design of role-playing game (RPG) can enhance learners’ interest and motivation. Therefore, it is a useful tool for promoting environmental education.
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20
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Gilboa Y, Fogel-Grinvald H, Chevignard M. Virtual Classroom Assessment for Children and Adolescents With Attention Deficits: A Systematic Review and Meta-Analysis of Measurement Properties. J Atten Disord 2021; 25:300-311. [PMID: 30371134 DOI: 10.1177/1087054718808590] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective: The virtual classroom (VC) is a head-mounted display immersive system for the assessment of attention. A meta-analysis was performed to examine the use of the VC to assess attention in children and adolescents. Method: We conducted a systematic literature search to select articles up to December 2017. Results: Thirteen studies using the VC to assess attention were included. Studies reporting comparisons between patients with various clinical conditions and healthy controls were included in the meta-analysis. The meta-analysis results revealed significant differences between groups for the percentage of identified targets (nine studies; total combined N = 431), for commission errors, and reaction time (eight studies; total combined N = 399) in favor of the nonclinical group. Conclusion: Preliminary evidence establishes the validity of the VC and suggests that this task has the potential to serve as a useful and enjoyable ecological assessment tool for the diagnosis of attention deficits in children and adolescents. (J. of Att. Dis. XXXX; XX(X) XX-XX).
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Affiliation(s)
- Yafit Gilboa
- School of Occupational Therapy, The Hebrew University of Jerusalem, Israel
| | | | - Mathilde Chevignard
- Rehabilitation Department for Children and Adolescents with Acquired Neurological Injury, and Outreach Team for children and adolescents with acquired brain injury, Saint-Maurice Hospitals, France.,Laboratoire d'Imagerie Biomédicale, LIB, 75006 Sorbonne Université, Paris, France.,GRC n°18, Handicap Cognitif et Réadaptation (HanCRe), Sorbonne Université, Paris, France
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21
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Diaz-Orueta U, Blanco-Campal A, Lamar M, Libon DJ, Burke T. Marrying Past and Present Neuropsychology: Is the Future of the Process-Based Approach Technology-Based? Front Psychol 2020; 11:361. [PMID: 32210882 PMCID: PMC7069278 DOI: 10.3389/fpsyg.2020.00361] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 02/17/2020] [Indexed: 01/05/2023] Open
Abstract
A cognitive assessment strategy that is not limited to examining a set of summary test scores may be more helpful for early detection of emergent illness such as Alzheimer's disease (AD) and may permit a better understanding of cognitive functions and dysfunctions in those with AD and other dementia disorders. A revisit of the work already undertaken by Kaplan and colleagues using the Boston Process-Approach provides a solid basis for identifying new opportunities to capture data on neurocognitive processes, test-taking strategies and response styles. Thus, this critical review will combine traditional process-based assessment strategies with support provided or offered by newer technologies that have the potential to add value to data collection and interpretation. There is now considerable interest in neuropsychological test administration using computer/digital technology, both in research and in clinical settings. To add value, any computerized version of an existing cognitive test should respect the administration procedure for which normative data were obtained, should be time-saving in terms of scoring and interpretation, and should, we argue, facilitate gathering information about the processes and strategies followed in test completion. This article will offer an overview of the steps needed when implementing computerization of neuropsychological tests using a Process-Based Approach (PBA) to these technology-based adaptations and will discuss further developments in this area by linking it to future technological developments that may be possible in the area of neuropsychological assessment. Additionally, an overview of neuropsychological tests that may benefit from computerization will be presented, together with suggestions on the specific processes, strategies and features that may be captured with the aid of such computerization. Finally, hypotheses on how virtual reality could be an asset for the future of the PBA to neuropsychological assessment will also be discussed.
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Affiliation(s)
- Unai Diaz-Orueta
- Department of Psychology, Maynooth University, Maynooth, Ireland
| | - Alberto Blanco-Campal
- Department of Psychiatry for the Older Person, Memory Clinic Services, Health Service Executive, Navan and Ardee, Ireland
| | - Melissa Lamar
- Rush Alzheimer’s Disease Center, Rush University Medical Center, Chicago, IL, United States
| | - David J. Libon
- New Jersey Institute for Successful Aging, School of Osteopathic Medicine, Rowan University, Stratford, NJ, United States
| | - Teresa Burke
- School of Psychology, Faculty of Science and Health, Dublin City University, Dublin, Ireland
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22
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Mangalmurti A, Kistler WD, Quarrie B, Sharp W, Persky S, Shaw P. Using virtual reality to define the mechanisms linking symptoms with cognitive deficits in attention deficit hyperactivity disorder. Sci Rep 2020; 10:529. [PMID: 31953449 PMCID: PMC6969149 DOI: 10.1038/s41598-019-56936-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/09/2019] [Indexed: 11/09/2022] Open
Abstract
The mechanisms underpinning attentional deficits are only partially understood. Here we ask if shifts in a child's field of view (FOV) act as a mediator between symptoms of attention deficit hyperactivity disorder (ADHD) and associated cognitive anomalies, particularly in attentional processes. Real time measurement of shifts in FOV were obtained on 85 children (mean age 9.4 (SD 1.9) years; 45 with DSM 5-defined ADHD) as they completed the continuous performance task in a "virtual classroom". We extracted measures reflecting focused and selective attention across the task, along with diffusion modelling of latent cognitive processes of information uptake, response conservativeness and non-decision time. Mediation analyses showed that shifts in FOV partially mediated the relationship between hyperactive impulsive symptoms and both poor focused attention and information uptake. Performance accuracy decreased and shifts in FOV increased during the task, but these changes over time did not differ by symptom severity. Employing virtual reality and mediation analysis, we implicate shifts in FOV as a mechanism linking symptoms of ADHD and deficits in focused attention and in the gathering of information to make decisions. The identification of mediating mechanisms might provide new targets for intervention.
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Affiliation(s)
- Aman Mangalmurti
- Neurobehavioral Clinical Research Section, Social and Behavioral Research Branch, NHGRI/NIH, Bethesda, United States
| | - William D Kistler
- Immersive Virtual Environment Testing Unit, Social and Behavioral Research Branch, NHGRI/NIH, Bethesda, United States
| | - Barrington Quarrie
- Neurobehavioral Clinical Research Section, Social and Behavioral Research Branch, NHGRI/NIH, Bethesda, United States
| | - Wendy Sharp
- Neurobehavioral Clinical Research Section, Social and Behavioral Research Branch, NHGRI/NIH, Bethesda, United States
| | - Susan Persky
- Immersive Virtual Environment Testing Unit, Social and Behavioral Research Branch, NHGRI/NIH, Bethesda, United States
| | - Philip Shaw
- Neurobehavioral Clinical Research Section, Social and Behavioral Research Branch, NHGRI/NIH, Bethesda, United States.
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23
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Mozgai S, Hartholt A, Rizzo A“S. Systematic Representative Design and Clinical Virtual Reality. PSYCHOLOGICAL INQUIRY 2020. [DOI: 10.1080/1047840x.2019.1693873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Sharon Mozgai
- University of Southern California Institute for Creative Technologies, Los Angeles, California
| | - Arno Hartholt
- University of Southern California Institute for Creative Technologies, Los Angeles, California
| | - Albert “Skip” Rizzo
- University of Southern California Institute for Creative Technologies, Los Angeles, California
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24
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Jang S, Choi J, Oh J, Yeom J, Hong N, Lee N, Kwon JH, Hong J, Kim JJ, Kim E. Use of Virtual Reality Working Memory Task and Functional Near-Infrared Spectroscopy to Assess Brain Hemodynamic Responses to Methylphenidate in ADHD Children. Front Psychiatry 2020; 11:564618. [PMID: 33551860 PMCID: PMC7859615 DOI: 10.3389/fpsyt.2020.564618] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 12/23/2020] [Indexed: 11/13/2022] Open
Abstract
Virtual reality (VR) neuropsychological tests have emerged as a method to explore drug effects in real-life contexts in attention deficit hyperactivity disorder (ADHD) children. Functional near-infrared spectroscopy (fNIRS) is a useful tool to measure brain activity during VR tasks in ADHD children with motor restlessness. The present study aimed to explore the acute effects of methylphenidate (MPH) on behavioral performance and brain activity during a VR-based working memory task simulating real-life classroom settings in ADHD children. In total, 23 children with ADHD performed a VR n-back task before and 2 h after MPH administration concurrent with measurements of oxygenated hemoglobin signal changes with fNIRS. Altogether, 12 healthy control (HC) subjects participated in the same task but did not receive MPH treatment. Reaction time (RT) was shortened after MPH treatment in the 1-back condition, but changes in brain activation were not observed. In the 2-back condition, activation of the left dorsolateral prefrontal cortex (DLPFC) and bilateral medial prefrontal cortex (mPFC) was decreased alongside behavioral changes such as shorter RT, lower RT variability, and higher accuracy after MPH administration. Bilateral mPFC activation in the 2-back condition inversely correlated with task accuracy in the pre-MPH condition; this inverse correlation was not observed after MPH administration. In ADHD children, deactivation of the default mode network mediated by mPFC reduced during high working memory load, which was restored through MPH treatment. Our results suggest that the combination of VR classroom tasks and fNIRS examination makes it easy to assess drug effects on brain activity in ADHD children in settings simulating real-life.
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Affiliation(s)
- Sooah Jang
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Jooyoung Oh
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yonsei University Gangman Severance Hospital, Seoul, South Korea
| | - Jungyeon Yeom
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Narae Hong
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Narae Lee
- College of Medicine, Hallym University, Chuncheon, South Korea
| | - Joon Hee Kwon
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jieun Hong
- Department of Psychiatry, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Jae-Jin Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yonsei University Gangman Severance Hospital, Seoul, South Korea
| | - Eunjoo Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea.,Department of Psychiatry, Yonsei University Gangman Severance Hospital, Seoul, South Korea
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25
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Manshaee G, Tabrizi M, Ghamarani A, Rasti J. Comparison of the effectiveness of virtual reality with medication on the memory of attention deficit hyperactivity disorder students. INTERNATIONAL ARCHIVES OF HEALTH SCIENCES 2020. [DOI: 10.4103/iahs.iahs_66_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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26
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Romero-Ayuso D, Castillero-Perea Á, González P, Navarro E, Molina-Massó JP, Funes MJ, Ariza-Vega P, Toledano-González A, Triviño-Juárez JM. Assessment of cognitive instrumental activities of daily living: a systematic review. Disabil Rehabil 2019; 43:1342-1358. [PMID: 31549907 DOI: 10.1080/09638288.2019.1665720] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE Cognitive instrumental activities of daily living are particularly related to executive functions, such as scheduling appointments, monthly payments, managing the household economy, shopping or taking the bus. The aim of this systematic review was to determine the available tests for the assessment of executive functions with ecological validity to predict individuals' functioning. MATERIALS AND METHODS An electronic search was conducted in MEDLINE, Cochrane Central, PsyCInfo and IEEE Xplore until May 2019, in addition to a manual search. The PRISMA criteria and the Covidence platform were used to select articles and extract data. RESULTS After applying the search selection criteria, 76 studies were identified. They referred to 110 tools to assess instrumental activities of daily living. Those that have received most attention are related to menu preparation and shopping. Performance-based measures are the most widely used traditional methods. Most tests were aimed at the adult population with acquired brain damage, cognitive impairment or dementia. There was a predominance of tests based on the Multiple Errands Test paradigm. CONCLUSIONS In recent years, it has increased the number of tools that assess the instrumental activities of daily living based on technologies such as personal or environmental sensors and serious games.IMPLICATIONS FOR REHABILITATIONAssessment of Instrumental Activities of Daily Living through performance-based measures is especially useful for the early detection of dysfunctions or preclinical disability.Difficulties in performing instrumental activities of daily living are closely associated with deficits in executive functions and prospective memory.Activities of Daily Living can be understood as multitasks.The use of virtual reality-based tests was shown to be sensitive to the detection of cognitive deficits in Activities of Daily Living.An advantage of using virtual reality in assessments is that it can help to predict the level of personal autonomy in patients who are in an institutional environment and could be a first approximation to the real environment.
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Affiliation(s)
- Dulce Romero-Ayuso
- Division of Occupational Therapy, Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain
| | | | - Pascual González
- LoUISE Research Group, Computing Systems Department, University of Castilla-La Mancha, Albacete, Spain
| | - Elena Navarro
- LoUISE Research Group, Computing Systems Department, University of Castilla-La Mancha, Albacete, Spain
| | - José Pascual Molina-Massó
- LoUISE Research Group, Computing Systems Department, University of Castilla-La Mancha, Albacete, Spain
| | - M Jesús Funes
- Mind, Brain and Behaviour Research Center (CIMCYC) and Department of Experimental Psychology, University of Granada, Granada, Spain
| | - Patrocinio Ariza-Vega
- Division of Occupational Therapy, Department of Physical Therapy, Faculty of Health Sciences, University of Granada, Granada, Spain.,Rehabilitation and Traumatology Service, Virgen de Las Nieves University Hospital of Granada, Granada, Spain
| | - Abel Toledano-González
- Department of Psychology, Faculty of Occupational Therapy, Speech Therapy and Nursing, University of Castilla-La Mancha, Ciudad Real, Spain
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Ferreira-Brito F, Fialho M, Virgolino A, Neves I, Miranda AC, Sousa-Santos N, Caneiras C, Carriço L, Verdelho A, Santos O. Game-based interventions for neuropsychological assessment, training and rehabilitation: Which game-elements to use? A systematic review. J Biomed Inform 2019; 98:103287. [PMID: 31518700 DOI: 10.1016/j.jbi.2019.103287] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 08/19/2019] [Accepted: 09/07/2019] [Indexed: 01/16/2023]
Abstract
Game-based interventions (GBI) have been used to promote health-related outcomes, including cognitive functions. Criteria for game-elements (GE) selection are insufficiently characterized in terms of their adequacy to patients' clinical conditions or targeted cognitive outcomes. This study aimed to identify GE applied in GBI for cognitive assessment, training or rehabilitation. A systematic review of literature was conducted. Papers involving video games were included if: (1) presenting empirical and original data; (2) using video games for cognitive intervention; and (3) considering attention, working memory or inhibitory control as outcomes of interest. Ninety-one papers were included. A significant difference between the number of GE reported in the assessed papers and those composing video games was found (p < .001). The two most frequently used GE were: score system (79.2% of the interventions using video games; for assessment, 43.8%; for training, 93.5%; and for rehabilitation, 83.3%) and narrative context (79.2% of interventions; for assessment, 93.8%; for training, 73.9% and for rehabilitation, 66.7%). Usability assessment was significantly associated with six of the seven GE analyzed (p-values between p ≤ 0.001 and p. = 027). The use of GE that act as extrinsic motivation promotors (e.g., numeric feedback system) may jeopardize patients' long-term adherence to interventions, mainly if associated with progressive difficulty-increase of gaming experience. Lack of precise description of GE and absence of a theoretical framework supporting GE selection are important limitations of the available clinical literature.
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Affiliation(s)
- Filipa Ferreira-Brito
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal.
| | - Mónica Fialho
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal.
| | - Ana Virgolino
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal.
| | - Inês Neves
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal.
| | - Ana Cristina Miranda
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal; USF AlbaSaude, ACeS de Sintra, Administração Regional de Saúde de Lisboa e Vale do Tejo, Bairro da Tabaqueira 30, 2635-101 Rio de Mouro, Portugal.
| | - Nuno Sousa-Santos
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal; Escola Superior de Saúde de Leiria, Instituto Politécnico de Leiria, Campus 2 - Morro do Lena, Alto do Vieiro - Apartado 4137, 2411-901 Leiria, Portugal.
| | - Cátia Caneiras
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal; Healthcare Department, Nippon Gases Portugal, Rua Real Fábrica de Atanados, n°. 1, 2600-242 Vila Franca de Xira, Portugal.
| | - Luís Carriço
- LASIGE, Faculdade de Ciências, Universidade de Lisboa, Portugal; Departamento de Informática, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisboa, Portugal.
| | - Ana Verdelho
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal; Instituto de Medicina Molecular (iMM), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, 1649-028 Lisboa, Portugal; Departamento de Neurociências, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, 1649-028 Lisboa, Portugal.
| | - Osvaldo Santos
- Instituto de Saúde Ambiental (ISAMB), Faculdade de Medicina, Universidade de Lisboa, Av. Prof. Egas Moniz, Ed. Egas Moniz, Piso 0, Ala C, 1649-028 Lisboa, Portugal.
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Coleman B, Marion S, Rizzo A, Turnbull J, Nolty A. Virtual Reality Assessment of Classroom - Related Attention: An Ecologically Relevant Approach to Evaluating the Effectiveness of Working Memory Training. Front Psychol 2019; 10:1851. [PMID: 31481911 PMCID: PMC6711453 DOI: 10.3389/fpsyg.2019.01851] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/29/2019] [Indexed: 12/12/2022] Open
Abstract
Computerized cognitive interventions to improve working memory also purport to improve ADHD-related inattention and off task behavior. Such interventions have been shown to improve working memory, executive functioning, and fluid reasoning on standardized neuropsychological measures. However, debate continues as to whether such programs lead to improvement on ecologically relevant outcomes, such as classroom behavior. This study sought to propose a novel, ecologically relevant approach to evaluate the effectiveness of working memory training on real-world attention performance. Participants included 15 children, aged 6-15, identified as having attention problems were assessed via the virtual classroom continuous performance task (VCCPT) before and after completing 5 weeks of Cogmed working memory training. The VCCPT is a validated measure of sustained and selective attention set within a virtual reality (VR) environment. Several key areas of attention performance were observed to improve, including omission errors, reaction time, reaction time variability, and hit variability. Results suggest that working memory training led to substantial improvements in sustained attention in a real-life scenario of classroom learning. Moreover, the use of psychometrically validated VR measurement provides incremental validity beyond that of teacher or parent report of behavior. Observing such improvements on ecologically relevant measures of attention adds to the discussion around how to evaluate the effectiveness of working memory training as it pertains to real-life improvements and serves to inform consumer awareness of such products and their claims.
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Affiliation(s)
- Benjamin Coleman
- College of Extended Learning, Point Loma Nazarene University, San Diego, CA, United States
| | - Sarah Marion
- Northwest Nazarene University, Nampa, ID, United States
| | - Albert Rizzo
- Institute of Creative Technologies, University of Southern California, Los Angeles, CA, United States
| | - Janiece Turnbull
- Fuller Graduate School of Psychology, Pasadena, CA, United States
| | - Anne Nolty
- Fuller Graduate School of Psychology, Pasadena, CA, United States
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Pizzi G, Scarpi D, Pichierri M, Vannucci V. Virtual reality, real reactions?: Comparing consumers' perceptions and shopping orientation across physical and virtual-reality retail stores. COMPUTERS IN HUMAN BEHAVIOR 2019. [DOI: 10.1016/j.chb.2019.02.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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A Comparison of Virtual Reality Classroom Continuous Performance Tests to Traditional Continuous Performance Tests in Delineating ADHD: a Meta-Analysis. Neuropsychol Rev 2019; 29:338-356. [PMID: 31161465 DOI: 10.1007/s11065-019-09407-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
Abstract
Computerized continuous performance tests (CPTs) are commonly used to characterize attention in attention deficit-hyperactivity disorder (ADHD). Virtual classroom CPTs, designed to enhance ecological validity, are increasingly being utilized. Lacking is a quantitative meta-analysis of clinical comparisons of attention performance in children with ADHD using virtual classroom CPTs. The objective of the present systematic PRISMA review was to address this empirical void and compare three-dimensional (3D) virtual classroom CPTs to traditional two-dimensional (2D) CPTs. The peer-reviewed literature on comparisons of virtual classroom performance between children with ADHD and typically developing children was explored in six databases (e.g., Medline). Published studies using a virtual classroom to compare attentional performance between children with ADHD and typically developing children were included. Given the high heterogeneity with modality comparisons (i.e., computerized CPTs vs. virtual classroom CPTs for ADHD), both main comparisons included only population comparisons (i.e., control vs. ADHD) using each CPT modality. Meta-analytic findings were generally consistent with previous meta-analyses of computerized CPTs regarding the commonly used omission, commission, and hit reaction time variables. Results suggest that the virtual classroom CPTs reliably differentiate attention performance in persons with ADHD. Ecological validity implications are discussed pertaining to subtle meta-analytic outcome differences compared to computerized 2D CPTs. Further, due to an inability to conduct moderator analyses, it remains unclear if modality differences are due to other factors. Suggestions for future research using the virtual classroom CPTs are provided.
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Valladares-Rodriguez S, Fernández-Iglesias MJ, Anido-Rifón L, Facal D, Rivas-Costa C, Pérez-Rodríguez R. Touchscreen games to detect cognitive impairment in senior adults. A user-interaction pilot study. Int J Med Inform 2019; 127:52-62. [PMID: 31128832 DOI: 10.1016/j.ijmedinf.2019.04.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 09/12/2018] [Accepted: 04/15/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Alzheimer's disease is a degenerative brain disease and the most common cause of dementia. Today, 47 million people live with dementia worldwide. This number is projected to increase to more than 131 million by 2050, as populations age. Therefore, the World Health Organization considers serious cognitive deterioration a public health priority. OBJECTIVES Advanced cognitive evaluation mechanisms are needed to help make an early diagnosis. These new mechanisms should overcome the limitations of current neuropsychological tests, including delayed detection; being perceived as intrusive; being non-ecological; being dependent on confounding factors; or their administration being expensive, among others. A promising novel approach consists of the introduction of serious games based on virtual reality and machine learning able to assess cognitive traits relevant to the diagnosis of mild cognitive impairment and Alzheimer's disease. METHODS As a result of a preliminary pilot experiment, promising evidence was obtained about the predictive power of this solution. However, for these new serious games to be effective, evidence has to be gathered on the player experience by senior adults, avoiding the limitations of traditional tests at the same time. This study addresses these aspects with the participation of 74 senior users and 15 test administrators. RESULTS Main findings confirm the usability and playability of Panoramix, a game battery designed according to the principles discussed above, its technological acceptability and its accessibility. For example, in relation to acceptability, the game battery was scored 4.39 in a 5-point scale, while its average usability score was 4.45 regardless of socio-cultural level or previous experience with digital technologies. In addition, health professionals confirm both, usability and playability, levels with an average score of 6.5 in a 7-point scale. Participants' willingness of using this kind of systems for cognitive evaluation was also confirmed. CONCLUSION Promising results obtained pave the way for additional work to confirm the diagnostic validity according to clinical standards of these new cognitive assessment tools.
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Affiliation(s)
| | | | - Luis Anido-Rifón
- Department of Telematics Engineering, University of Vigo, Vigo, Spain
| | - David Facal
- Department of Developmental Psychology, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
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Weech S, Kenny S, Barnett-Cowan M. Presence and Cybersickness in Virtual Reality Are Negatively Related: A Review. Front Psychol 2019; 10:158. [PMID: 30778320 PMCID: PMC6369189 DOI: 10.3389/fpsyg.2019.00158] [Citation(s) in RCA: 190] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/16/2019] [Indexed: 12/21/2022] Open
Abstract
In order to take advantage of the potential offered by the medium of virtual reality (VR), it will be essential to develop an understanding of how to maximize the desirable experience of "presence" in a virtual space ("being there"), and how to minimize the undesirable feeling of "cybersickness" (a constellation of discomfort symptoms experienced in VR). Although there have been frequent reports of a possible link between the observer's sense of presence and the experience of bodily discomfort in VR, the amount of literature that discusses the nature of the relationship is limited. Recent research has underlined the possibility that these variables have shared causes, and that both factors may be manipulated with a single approach. This review paper summarizes the concepts of presence and cybersickness and highlights the strengths and gaps in our understanding about their relationship. We review studies that have measured the association between presence and cybersickness, and conclude that the balance of evidence favors a negative relationship between the two factors which is driven principally by sensory integration processes. We also discuss how system immersiveness might play a role in modulating both presence and cybersickness. However, we identify a serious absence of high-powered studies that aim to reveal the nature of this relationship. Based on this evidence we propose recommendations for future studies investigating presence, cybersickness, and other related factors.
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Affiliation(s)
- Séamas Weech
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
- The Games Institute, University of Waterloo, Waterloo, ON, Canada
| | - Sophie Kenny
- The Games Institute, University of Waterloo, Waterloo, ON, Canada
| | - Michael Barnett-Cowan
- Department of Kinesiology, University of Waterloo, Waterloo, ON, Canada
- The Games Institute, University of Waterloo, Waterloo, ON, Canada
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Valladares-Rodriguez S, Fernández-Iglesias MJ, Anido-Rifón L, Facal D, Pérez-Rodríguez R. Episodix: a serious game to detect cognitive impairment in senior adults. A psychometric study. PeerJ 2018; 6:e5478. [PMID: 30202646 PMCID: PMC6129148 DOI: 10.7717/peerj.5478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/30/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction Assessment of episodic memory is traditionally used to evaluate potential cognitive impairments in senior adults. The present article discusses the capabilities of Episodix, a game to assess the aforementioned cognitive area, as a valid tool to discriminate among mild cognitive impairment (MCI), Alzheimer’s disease (AD) and healthy individuals (HC); that is, it studies the game’s psychometric validity study to assess cognitive impairment. Materials and Methods After a preliminary study, a new pilot study, statistically significant for the Galician population, was carried out from a cross-sectional sample of senior adults as target users. A total of 64 individuals (28 HC, 16 MCI, 20 AD) completed the experiment from an initial sample of 74. Participants were administered a collection of classical pen-and-paper tests and interacted with the games developed. A total of six machine learning classification techniques were applied and four relevant performance metrics were computed to assess the classification power of the tool according to participants’ cognitive status. Results According to the classification performance metrics computed, the best classification result is obtained using the Extra Trees Classifier (F1 = 0.97 and Cohen’s kappa coefficient = 0.97). Precision and recall values are also high, above 0.9 for all cognitive groups. Moreover, according to the standard interpretation of Cohen’s kappa index, classification is almost perfect (i.e., 0.81–1.00) for the complete dataset for all algorithms. Limitations Weaknesses (e.g., accessibility, sample size or speed of stimuli) detected during the preliminary study were addressed and solved. Nevertheless, additional research is needed to improve the resolution of the game for the identification of specific cognitive impairments, as well as to achieve a complete validation of the psychometric properties of the digital game. Conclusion Promising results obtained about psychometric validity of Episodix, represent a relevant step ahead towards the introduction of serious games and machine learning in regular clinical practice for detecting MCI or AD. However, more research is needed to explore the introduction of item response theory in this game and to obtain the required normative data for clinical validity.
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Affiliation(s)
| | | | - Luis Anido-Rifón
- Department of Telematics Engineering, Universidad de Vigo, Vigo, Spain
| | - David Facal
- Department of Developmental Psychology, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
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Areces D, Dockrell J, García T, González-Castro P, Rodríguez C. Analysis of cognitive and attentional profiles in children with and without ADHD using an innovative virtual reality tool. PLoS One 2018; 13:e0201039. [PMID: 30110334 PMCID: PMC6093610 DOI: 10.1371/journal.pone.0201039] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 07/06/2018] [Indexed: 02/07/2023] Open
Abstract
In previous studies, children with Attention-Deficit Hyperactivity Disorder (ADHD) have been found to have more difficulties with processing speed, working memory, and attentional tasks. The present study aimed to compare the cognitive variables (working memory and processing speed) and the attentional profiles of a sample of students with and without ADHD, using scales from the WISC-IV, and the virtual reality-based attentional test known as 'Aula Nesplora'; and determine the extent to which the aforementioned variables may predict student group membership. A total of 88 students took part in this study (66 males and 22 females), aged from 6 to 16 years (M = 10.20; SD = 2.79). The sample was divided into two groups: an ADHD group (n = 50) and a Control group (n = 38). Students in the ADHD group obtained lower scores in working memory and in processing speed, as well as demonstrating poorer performance in Aula Nesplora than did their peers. Working memory, and the number of omissions, were both shown to be reliable predictors of group membership. This study revealed the importance of obtaining data from attentional variables differentiated by modality when considering cognitive variables, in order to better characterize the difficulties experienced by individuals diagnosed with ADHD.
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Affiliation(s)
- Débora Areces
- Department of Psychology, University of Oviedo, Oviedo, Spain
| | - Julie Dockrell
- Department of Psychology, University College London, London, United Kingdom
| | - Trinidad García
- Department of Psychology, University of Oviedo, Oviedo, Spain
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Ouellet É, Boller B, Corriveau-Lecavalier N, Cloutier S, Belleville S. The Virtual Shop: A new immersive virtual reality environment and scenario for the assessment of everyday memory. J Neurosci Methods 2018; 303:126-135. [PMID: 29581009 DOI: 10.1016/j.jneumeth.2018.03.010] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/21/2018] [Accepted: 03/21/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Assessing and predicting memory performance in everyday life is a common assignment for neuropsychologists. However, most traditional neuropsychological tasks are not conceived to capture everyday memory performance. NEW METHOD The Virtual Shop is a fully immersive task developed to assess memory in a more ecological way than traditional neuropsychological assessments. Two studies were undertaken to assess the feasibility of the Virtual Shop and to appraise its ecological and construct validity. In study 1, 20 younger and 19 older adults completed the Virtual Shop task to evaluate its level of difficulty and the way the participants interacted with the VR material. The construct validity was examined with the contrasted-group method, by comparing the performance of younger and older adults. In study 2, 35 individuals with subjective cognitive decline completed the Virtual Shop task. Performance was correlated with an existing questionnaire evaluating everyday memory in order to appraise its ecological validity. To add further support to its construct validity, performance was correlated with traditional episodic memory and executive tasks. RESULTS All participants successfully completed the Virtual Shop. The task had an appropriate level of difficulty that helped differentiate younger and older adults, supporting the feasibility and construct validity of the task. COMPARISON WITH EXISTING METHOD(S) The performance on the Virtual Shop was significantly and moderately correlated with the performance on the questionnaire and on the traditional memory and executive tasks. CONCLUSIONS Results support the feasibility and both the ecological and construct validity of the Virtual Shop.
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Affiliation(s)
- Émilie Ouellet
- Research Center, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal, Québec, Canada, H3W 1W5; Department of Psychology, Université de Montréal, 90 avenue Vincent d'Indy, Montréal, Québec, Canada, H2V 2S9.
| | - Benjamin Boller
- Research Center, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal, Québec, Canada, H3W 1W5; Department of Psychology, Université du Québec à Trois-Rivières, 2008A Michel-Sarrazin, 3351 boulevard des Forges, Trois-Rivières, Québec, Canada, G8Z 4M3.
| | - Nick Corriveau-Lecavalier
- Research Center, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal, Québec, Canada, H3W 1W5; Department of Psychology, Université de Montréal, 90 avenue Vincent d'Indy, Montréal, Québec, Canada, H2V 2S9.
| | - Simon Cloutier
- Research Center, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal, Québec, Canada, H3W 1W5; Department of Psychology, Université de Montréal, 90 avenue Vincent d'Indy, Montréal, Québec, Canada, H2V 2S9.
| | - Sylvie Belleville
- Research Center, Institut universitaire de gériatrie de Montréal, 4565 chemin Queen-Mary, Montréal, Québec, Canada, H3W 1W5; Department of Psychology, Université de Montréal, 90 avenue Vincent d'Indy, Montréal, Québec, Canada, H2V 2S9.
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Bashiri A, Ghazisaeedi M, Shahmoradi L. The opportunities of virtual reality in the rehabilitation of children with attention deficit hyperactivity disorder: a literature review. KOREAN JOURNAL OF PEDIATRICS 2017; 60:337-343. [PMID: 29234356 PMCID: PMC5725338 DOI: 10.3345/kjp.2017.60.11.337] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/22/2017] [Accepted: 04/11/2017] [Indexed: 11/30/2022]
Abstract
Attention deficit hyperactivity disorder (ADHD) is one of the most common psychiatric disorders in childhood. This disorder, in addition to its main symptoms, creates significant difficulties in education, social performance, and personal relationships. Given the importance of rehabilitation for these patients to combat the above issues, the use of virtual reality (VR) technology is helpful. The aim of this study was to highlight the opportunities for VR in the rehabilitation of children with ADHD. This narrative review was conducted by searching for articles in scientific databases and e-Journals, using keywords including VR, children, and ADHD. Various studies have shown that VR capabilities in the rehabilitation of children with ADHD include providing flexibility in accordance with the patients' requirements; removing distractions and creating an effective and safe environment away from real-life dangers; saving time and money; increasing patients' incentives based on their interests; providing suitable tools to perform different behavioral tests and increase ecological validity; facilitating better understanding of individuals' cognitive deficits and improving them; helping therapists with accurate diagnosis, assessment, and rehabilitation; and improving working memory, executive function, and cognitive processes such as attention in these children. Rehabilitation of children with ADHD is based on behavior and physical patterns and is thus suitable for VR interventions. This technology, by simulating and providing a virtual environment for diagnosis, training, monitoring, assessment and treatment, is effective in providing optimal rehabilitation of children with ADHD.
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Affiliation(s)
- Azadeh Bashiri
- Health Information Management Department, School of Allied-Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Marjan Ghazisaeedi
- Health Information Management Department, School of Allied-Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Shahmoradi
- Health Information Management Department, School of Allied-Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
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Duffield TC, Parsons TD, Landry A, Karam S, Otero T, Mastel S, Hall TA. Virtual environments as an assessment modality with pediatric ASD populations: a brief report. Child Neuropsychol 2017; 24:1129-1136. [PMID: 28903621 DOI: 10.1080/09297049.2017.1375473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Virtual environments (VEs) have demonstrated promise as a neuropsychological assessment modality and may be well suited for the evaluation of children suspected of having an autism spectrum disorder (ASD). Some recent studies indicate their potential for enhancing reliability, ecologically validity, and sensitivity over traditional neuropsychological evaluation measures. Although research using VEs with ASD is increasing to the degree that several reviews of the literature have been conducted, the reviews to date lack rigor and are not necessarily specific to cognitive or neuropsychological assessment as many focus on intervention. The aim of this project was to comprehensively examine the current literature status of neuropsychological assessment in pediatric ASD using VEs by conducting a systematic review. Specifically, psychometric comparisons of VEs to traditional neuropsychological assessment measures that examined reliability, validity, and/or diagnostic accuracy for pediatric individuals, age 18 and below, with ASD were sought. The search using key words yielded 899 manuscripts, 894 of which were discarded for not meeting inclusion criteria. The remaining five met exclusion criteria. Therefore, the systematic review was modified to a brief report. These findings (or lack thereof) indicate a significant gap in the literature in that psychometric comparisons of these tools for the neuropsychological assessment of pediatric individuals with ASD are lacking. An important future direction of research will be extending the demonstrated incremental validity of VE neuropsychological assessment with other neurodevelopmental (e.g., attention-deficit/hyperactivity disorder) and adult populations to pediatric ASD populations.
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Affiliation(s)
- Tyler C Duffield
- a Department of Family Medicine , Sports Medicine Program, Oregon Health & Science University , Portland , OR , USA
| | - Thomas D Parsons
- b Department of Psychology , University of North Texas , Denton , TX , USA
| | - Allisen Landry
- c Department of Pediatrics , Oregon Health & Science University , Portland , OR , USA
| | - Shaza Karam
- c Department of Pediatrics , Oregon Health & Science University , Portland , OR , USA
| | - Tiffany Otero
- c Department of Pediatrics , Oregon Health & Science University , Portland , OR , USA
| | - Sarah Mastel
- c Department of Pediatrics , Oregon Health & Science University , Portland , OR , USA
| | - Trevor A Hall
- c Department of Pediatrics , Oregon Health & Science University , Portland , OR , USA
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Kim HE, Hong YJ, Kim MK, Jung YH, Kyeong S, Kim JJ. Effectiveness of self-training using the mobile-based virtual reality program in patients with social anxiety disorder. COMPUTERS IN HUMAN BEHAVIOR 2017. [DOI: 10.1016/j.chb.2017.04.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Fu XY, Xie XT, Zhao Y. [Neurocognitive function of children with acute lymphoblastic leukemia and long-term disease-free survival and related influencing factors]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:899-903. [PMID: 28774365 PMCID: PMC7390049 DOI: 10.7499/j.issn.1008-8830.2017.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 04/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To investigate the neurocognitive function of children with acute lymphoblastic leukemia (ALL) and long-term disease-free survival and related influencing factors. METHODS A total of 40 ALL children with long-term disease-free survival were enrolled as study group, and 40 healthy children were enrolled as control group. The Chinese Wechsler Intelligence Scale for Children (C-WISC), continuous performance test (CPT), and Stroop test software were used for the evaluation of all children. Neurocognitive function was compared between groups and influencing factors were analyzed. RESULTS Compared with the control group, the study group had significantly lower full intelligence quotient, verbal intelligence quotient, and performance intelligence quotient in C-WICS (P<0.05) and significantly higher numbers of mistakes and misses in CPT (P<0.05). There were no significant differences in the numbers of correct answers, mistakes, and misses of word-color consistency between the study group and the control group (P>0.05), while the study group had significantly higher numbers of mistakes and misses of word-color contradiction and irrelevance (P<0.05). The total dose of high-dose methotrexate and ALL risk classification were associated with the reduction in intelligence quotient, and children's younger age at diagnosis of ALL was associated with the higher numbers of misses and mistakes. Girls tended to have a significantly lower performance intelligence quotient than boys (P<0.05). CONCLUSIONS ALL children with long-term disease-free survival have neurocognitive impairment, which may be associated with the dose of chemotherapeutic drugs, age at diagnosis, and sex.
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Affiliation(s)
- Xiao-Yan Fu
- Department of Pediatrics, Tongji Hospital of Tongji University, Shanghai 200065, China.
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Valladares-Rodríguez S, Pérez-Rodríguez R, Anido-Rifón L, Fernández-Iglesias M. Trends on the application of serious games to neuropsychological evaluation: A scoping review. J Biomed Inform 2016; 64:296-319. [PMID: 27815228 DOI: 10.1016/j.jbi.2016.10.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 10/12/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The dramatic technological advances witnessed in recent years have resulted in a great opportunity for changing the way neuropsychological evaluations may be performed in clinical practice. Particularly, serious games have been posed as the cornerstone of this still incipient paradigm-shift, as they have characteristics that make them especially advantageous in trying to overcome limitations associated with traditional pen-and-paper based neuropsychological tests: they can be easily administered and they can feature complex environments for the evaluation of neuropsychological constructs that are difficult to evaluate through traditional tests. The objective of this study was to conduct a scoping literature review in order to map rapidly the key concepts underpinning this research area during the last 25years on the use of serious games for neuropsychological evaluation. METHODS MEDLINE, PsycINFO, Scopus and IEEE Xplore databases were systematically searched. The main eligibility criteria were to select studies published in a peer-reviewed journal; written in English; published in the last 25years; focused on the human population, and classified in the neuropsychological field. Moreover, to avoid risk of bias, studies were selected by consensus of experts, focusing primarily in psychometric properties. Therefore, selected studies were analyzed in accordance with a set of dimensions of analysis commonly used for evaluating neuropsychological tests. RESULTS After applying the selected search strategy, 57 studies -including 54 serious games- met our selection criteria. The selected studies deal with visuospatial capabilities, memory, attention, executive functions, and complex neuropsychological constructs such as Mild Cognitive Impairment (MCI). Results show that the implementation of serious games for neuropsychological evaluation is tackled in several different ways in the selected studies, and that studies have so far been mainly exploratory, just aiming at testing the feasibility of the proposed approaches. DISCUSSION It may be argued that the limited number of databases used might compromise this study. However, we think that the finally included sample is representative, in spite of how difficult is to achieve an optimum and maximum scope. Indeed, this review identifies other research issues related to the development of serious games beyond their reliability and validity. The main conclusion of this review is that there is a great interest in the research community in the use of serious games for neuropsychological evaluation. This scoping review is pertinent, in accordance with the increasing number of studies published in the last three years, they demonstrate its potential as a serious alternative to classic neuropsychological tests. Nevertheless, more research is needed in order to implement serious games that are reliable, valid, and ready to be used in the everyday clinical practice.
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Neguț A, Jurma AM, David D. Virtual-reality-based attention assessment of ADHD: ClinicaVR: Classroom-CPT versus a traditional continuous performance test. Child Neuropsychol 2016; 23:692-712. [PMID: 27258210 DOI: 10.1080/09297049.2016.1186617] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Virtual-reality-based assessment may be a good alternative to classical or computerized neuropsychological assessment due to increased ecological validity. ClinicaVR: Classroom-CPT (VC) is a neuropsychological test embedded in virtual reality that is designed to assess attention deficits in children with attention deficit hyperactivity disorder (ADHD) or other conditions associated with impaired attention. The present study aimed to (1) investigate the diagnostic validity of VC in comparison to a traditional continuous performance test (CPT), (2) explore the task difficulty of VC, (3) address the effect of distractors on the performance of ADHD participants and typically-developing (TD) controls, and (4) compare the two measures on cognitive absorption. A total of 33 children diagnosed with ADHD and 42 TD children, aged between 7 and 13 years, participated in the study and were tested with a traditional CPT or with VC, along with several cognitive measures and an adapted version of the Cognitive Absorption Scale. A mixed multivariate analysis of covariance (MANCOVA) revealed that the children with ADHD performed worse on correct responses had more commissions and omissions errors than the TD children, as well as slower target reaction times . The results showed significant differences between performance in the virtual environment and the traditional computerized one, with longer reaction times in virtual reality. The data analysis highlighted the negative influence of auditory distractors on attention performance in the case of the children with ADHD, but not for the TD children. Finally, the two measures did not differ on the cognitive absorption perceived by the children.
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Affiliation(s)
- Alexandra Neguț
- a Evidence-based Assessment and Psychological Interventions Doctoral School, The International Institute for the Advanced Studies of Psychotherapy and Applied Mental Health , Babeș-Bolyai University , Cluj-Napoca , Romania
| | - Anda Maria Jurma
- b Neuroscience Department , Victor Babeș University of Medicine and Pharmacy , Timișoara , Romania
| | - Daniel David
- c Department of Clinical Psychology and Psychotherapy , Babeș-Bolyai University , Cluj-Napoca , Romania.,d Icahn School of Medicine at Mount Sinai , New York , NY , USA
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