The Virtual Classroom: A Virtual Reality Environment for the Assessment and Rehabilitation of Attention Deficits

The effect of feedback in attention training on Attention Bias to Threat in individuals with Sluggish Cognitive Tempo

BACKGROUND AND OBJECTIVES

This study was conducted to identify the characteristics of attentional bias of individuals with Sluggish Cognitive Tempo (SCT) and how Attention Bias to Threat (ABT) changes when feedback was provided in attention training.

METHODS

First, a dot probe task was conducted to confirm the ABT of the SCT feedback group (N = 27) and SCT no feedback group (N = 25), and healthy control group (N = 30) before intervention. Thereafter, a VR-based attention training was conducted three times with feedback or no feedback. Finally, a dot probe task was executed again.

RESULTS

The SCT groups showed a higher ABT than the healthy control group. A result of the attention training, the reaction time of disengage was significantly reduced when provided feedback. In addition, it was confirmed that the ABT of the SCT group that received feedback, was significantly reduced.

LIMITATIONS

First, the only stimulus used to examine the ABT was the angry face, and the reaction time to other threatening facial expressions was not confirmed. Second, attention training was conducted three times, but further studies are needed on the effect of the duration of training on the magnitude of effect.

CONCLUSIONS

This study identified ABT associated with internalizing symptoms of SCT and suggests that attention training with immediate and continuous feedback is needed to reduce ABT.

Impact of Emotions on Test of Variables of Attention(TOVA) Performance in a Pediatric Clinical Population: A Retrospective Study

BACKGROUND

Continuous Performance Tests, like the Test of Variables of Attention (TOVA), are commonly used to assess attention processes in clinical settings. Although a few previous studies have explored the effects of emotions on the outcome of such tests, the results are scarce and contradictory at times.

OBJECTIVE

Through this retrospective study, we  aimed to explore the correlation between performance on the TOVA and parent-reported emotional symptoms in youth.

METHODS

We used preexisting datasets of Mood and Feelings Questionnaire, Screen for Child Anxiety Related Disorders, and Vanderbilt Attention-Deficit/Hyperactivity Disorder Diagnostic Rating Scale as well as preexisting results from the TOVA test from 216 patients aged between 8 and 18 years. Pearson's correlation coefficients, as well as linear regression models, were computed to examine the association between depressive and anxiety symptoms and the four indices of TOVA (response time variability, response time, commission errors, and omission errors). Additionally, we used generalized estimating equations to determine whether the reported emotional symptoms affect the TOVA outcome differently as the test progresses.

RESULTS

Our results showed no significant effect of the reported emotional symptoms on the TOVA results even when controlling for sex or reported inattention and hyperactivity.

CONCLUSION

TOVA results do not seem to be affected by emotional symptoms in youth. This being said, future studies should also explore other factors that can affect the performance on the TOVA, like motor disability, sleepiness, or neurodevelopmental disorders affecting cognitive abilities.

Investigating social comparison behaviour in an immersive virtual reality classroom based on eye-movement data

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.

Presence and simulator sickness predict the usability of a virtual reality attention task

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.

Encoding of everyday objects in older adults: Episodic memory assessment in virtual reality

Introduction

Age-related decline in episodic memory performance in otherwise healthy older adults is indisputably evident. Yet, it has been shown that under certain conditions episodic memory performance in healthy older adults’ barely deviates from those seen in young adults. Here we report on the quality of object encoding in an ecologically valid, virtual-reality based memory assessment in a sample of healthy older and younger adults with comparable memory performance.

Methods

We analyzed encoding by establishing both a serial and semantic clustering index and an object memory association network.

Results

As expected, semantic clustering was superior in older adults without need for additional allocation of executive resources whereas young adults tended more to rely on serial strategies. The association networks suggested a plethora of obvious but also less obvious memory organization principles, some of which indicated converging approaches between the groups as suggested by a subgraph analysis and some of which indicated diverging approaches as suggested by the respective network interconnectivity. A higher interconnectivity was observed in the older adults’ association networks.

Discussion

We interpreted this as a consequence of superior semantic memory organization (extent to which effective semantic strategies diverged within the group). In conclusion, these results might indicate a diminished need for compensatory cognitive effort in healthy older adults when encoding and recalling everyday objects under ecologically valid conditions. Due to an enhanced and multimodal encoding model, superior crystallized abilities might be sufficient to counteract an age-related decline in various other and specific cognitive domains. This approach might potentially elucidate age-related changes in memory performance in both healthy and pathological aging.

Evaluating the Effectiveness of Visuospatial Memory Stimulation Using Virtual Reality in Head and Neck Cancer Patients-Pilot Study

The prevalence of Cancer-related Cognitive Impairment (CRCI) in cancer patients necessitates the search for methods to help stimulate cognitive function. An innovative and repeatedly used method in oncology departments is virtual reality (VR). To date, no one has used VR for head and neck cancer patients in an attempt to stimulate their working memory. The goal of our research is to intervene with off-the-shelf VR applications in HNC patients to lower the risk of CRCI. Twenty-two patients with head and neck cancer were enrolled in this pilot study to characterize their visuospatial memory capacity, a form of working memory. During the oncological treatment, the patient had 30 min sessions, three times a week, using publicly available applications of VR. No significant changes were observed in the pre- and post-study. The individual patient results present a favorable trend of changes in their working memory after the intervention: despite oncological treatment, visual-spatial memory did not deteriorate in 88% of patients, including 28% of patients with higher scores than before the intervention. In this pilot study, VR was safely used in patients with head and neck cancer with no negative side effects. The use of VR may prevent CRCI in most HNC patients and, in some, VR may improve their cognitive functioning. A more rigorous study with larger numbers and controls is advised.

Immersive virtual reality for improving cognitive deficits in children with ADHD: a systematic review and meta-analysis

Virtual reality (VR) shows great potential in treating and managing various mental health conditions. This includes using VR for training or rehabilitation purposes. For example, VR is being used to improve cognitive functioning (e.g. attention) among children with attention/deficit-hyperactivity disorder (ADHD). The aim of the current review and meta-analysis is to evaluate the effectiveness of immersive VR-based interventions for improving cognitive deficits in children with ADHD, to investigate potential moderators of the effect size and assess treatment adherence and safety. The meta-analysis included seven randomised controlled trials (RCTs) of children with ADHD comparing immersive VR-based interventions with controls (e.g. waiting list, medication, psychotherapy, cognitive training, neurofeedback and hemoencephalographic biofeedback) on measures of cognition. Results indicated large effect sizes in favour of VR-based interventions on outcomes of global cognitive functioning, attention, and memory. Neither intervention length nor participant age moderated the effect size of global cognitive functioning. Control group type (active vs passive control group), ADHD diagnostic status (formal vs. informal) and novelty of VR technology were not significant moderators of the effect size of global cognitive functioning. Treatment adherence was similar across groups and there were no adverse effects. Results should be cautiously interpreted given the poor quality of included studies and small sample.

Examining the Auditory Selective Attention Switch in a Child-Suited Virtual Reality Classroom Environment

The ability to focus ones attention in different acoustical environments has been thoroughly investigated in the past. However, recent technological advancements have made it possible to perform laboratory experiments in a more realistic manner. In order to investigate close-to-real-life scenarios, a classroom was modeled in virtual reality (VR) and an established paradigm to investigate the auditory selective attention (ASA) switch was translated from an audio-only version into an audiovisual VR setting. The new paradigm was validated with adult participants in a listening experiment, and the results were compared to the previous version. Apart from expected effects such as switching costs and auditory congruency effects, which reflect the robustness of the overall paradigm, a difference in error rates between the audio-only and the VR group was found, suggesting enhanced attention in the new VR setting, which is consistent with recent studies. Overall, the results suggest that the presented VR paradigm can be used and further developed to investigate the voluntary auditory selective attention switch in a close-to-real-life classroom scenario.

The effect of feedback in virtual attention training on orienting attention in individuals with sluggish cognitive tempo

OBJECTIVE

This study was conducted to assess the effectiveness of feedback in a virtual attention training program to improve the attentional characteristics of sluggish cognitive tempo (SCT).

METHOD

The SCT group (N = 60) and control group (N = 30) were identified, and the attention network test-revised (ANT-R) was performed to measure attention characteristics. Based on this result, a virtual reality (VR) feedback attention training program was developed to improve the efficiency of engagement and disengagement of attention in SCT. Sixty participants with SCT were recruited and grouped into two conditions: VR feedback (n = 30) and no-feedback (n = 30) conditions.

RESULTS

The results show that the VR attention training program with feedback significantly improves the attention-orienting network.

CONCLUSION

This suggests that it is necessary to provide immediate feedback for effective attention training for SCT and continuous intervention may be possible when feedback is provided together.

Efficacy of Continuous Performance Testing in Adult ADHD in a Clinical Sample Using QbTest

OBJECTIVE

Continuous performance tests are widely used to aid diagnostic decision making and measure symptom reduction in adult ADHD clinical populations. The diagnostic accuracy of the Quantified Behavior Test plus (QbTest+), developed to identify ADHD populations as an objective measure of ADHD symptoms, was explored.

METHODS

The utility of the QbTest+ was investigated in a clinical cohort of 69 adult patients referred to a specialist ADHD clinic in the UK.

RESULTS

Scores from the QbTest+ failed to differentiate between patients diagnosed with ADHD and those who did not receive a diagnosis after full clinical assessment.

CONCLUSIONS

Based on our findings, we recommend clinicians are cautious when interpreting results of the QbTest+ in clinical populations. This study highlights the need for investigation into the lack of validation of commonly used objective measures in ADHD populations.

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

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.

Available Virtual Reality-Based Tools for Executive Functions: A Systematic Review

Introduction

Executive dysfunctions constitute a significant public health problem: their high impact on everyday life makes it a priority to identify early strategies for evaluating and rehabilitating these disorders in a real-life context. The ecological limitation of traditional neuropsychological tests and several difficulties in administering tests or training in real-life scenarios have paved the way to use Virtual Reality-based tools to evaluate and rehabilitate Executive Functions (EFs) in real-life.

Objective

This work aims to conduct a systematic review to provide a detailed description of the VR-based tools currently developed for the evaluation and rehabilitation of EFs.

Methods

We systematically searched for original manuscripts regarding VR tools and EFs by looking for titles and abstracts in the PubMed, Scopus, PsycInfo, and Web of Science databases up to November 2021 that contained the following keywords “Virtual Reality” AND “Executive function^*.”

Results and Conclusion

We analyzed 301 articles, of which 100 were included. Our work shows that available VR-based tools appear promising solutions for an ecological assessment and treatment of EFs in healthy subjects and several clinical populations.

Virtual Reality Technology in Cognitive Rehabilitation Application: A Bibliometric Analysis (Preprint)

Background

In recent years, with the development of computer science and medical science, virtual reality (VR) technology has become a promising tool for improving cognitive function. Research on VR-based cognitive training has garnered increasing attention.

Objective

This study aimed to investigate the application status, research hot spots, and emerging trends of VR in cognitive rehabilitation over the past 20 years.

Methods

Articles on VR-based cognitive rehabilitation from 2001 to 2021 were retrieved from the Web of Science Core Collection. CiteSpace software was used for the visual analysis of authors and countries or regions, and Scimago Graphica software was used for the geographic visualization of published countries or regions. Keywords were clustered using the gCLUTO software.

Results

A total of 1259 papers were included. In recent years, research on the application of VR in cognitive rehabilitation has been widely conducted, and the annual publication of relevant literature has shown a positive trend. The main research areas include neuroscience and neurology, psychology, computer science, and rehabilitation. The United States ranked first with 328 papers, and Italy ranked second with 140 papers. Giuseppe Riva, an Italian academic, was the most prolific author with 29 publications. The most frequently cited reference was “Using Reality to Characterize Episodic Memory Profiles in Amnestic Mild Cognitive Impairment and Alzheimer’s Disease: Influence of Active and Passive Encoding.” The most common keywords used by researchers include “virtual reality,” “cognition,” “rehabilitation,” “performance,” and “older adult.” The largest source of research funding is from the public sector in the United States.

Conclusions

The bibliometric analysis provided an overview of the application of VR in cognitive rehabilitation. VR-based cognitive rehabilitation can be integrated into multiple disciplines. We conclude that, in the context of the COVID-19 pandemic, the development of VR-based telerehabilitation is crucial, and there are still many problems that need to be addressed, such as the lack of consensus on treatment methods and the existence of safety hazards.

Measuring Attentional Distraction in Children With ADHD Using Virtual Reality Technology With Eye-Tracking

Objective

Distractions inordinately impair attention in children with Attention-Deficit Hyperactivity Disorder (ADHD) but examining this behavior under real-life conditions poses a challenge for researchers and clinicians. Virtual reality (VR) technologies may mitigate the limitations of traditional laboratory methods by providing a more ecologically relevant experience. The use of eye-tracking measures to assess attentional functioning in a VR context in ADHD is novel. In this proof of principle project, we evaluate the temporal dynamics of distraction via eye-tracking measures in a VR classroom setting with 20 children diagnosed with ADHD between 8 and 12 years of age.

Method

We recorded continuous eye movements while participants performed math, Stroop, and continuous performance test (CPT) tasks with a series of "real-world" classroom distractors presented. We analyzed the impact of the distractors on rates of on-task performance and on-task, eye-gaze (i.e., looking at a classroom whiteboard) versus off-task eye-gaze (i.e., looking away from the whiteboard).

Results

We found that while children did not always look at distractors themselves for long periods of time, the presence of a distractor disrupted on-task gaze at task-relevant whiteboard stimuli and lowered rates of task performance. This suggests that children with attention deficits may have a hard time returning to tasks once those tasks are interrupted, even if the distractor itself does not hold attention. Eye-tracking measures within the VR context can reveal rich information about attentional disruption.

Conclusions

Leveraging virtual reality technology in combination with eye-tracking measures is well-suited to advance the understanding of mechanisms underlying attentional impairment in naturalistic settings. Assessment within these immersive and well-controlled simulated environments provides new options for increasing our understanding of distractibility and its potential impact on the development of interventions for children with ADHD.

Effect of Distractors on Sustained Attention and Hyperactivity in Youth With Attention Deficit Hyperactivity Disorder Using a Mobile Virtual Reality School Program

OBJECTIVE

This study examined whether distractors in virtual reality (VR) environment affected the attention and hyperactivity in children and adolescents with ADHD.

METHOD

A total of 40 students (21 ADHD, 19 controls) aged between 9 and 17 years participated in this study. A rapid visual information processing task utilizing VR (VR-RVP) was performed under two conditions (no-distractor and distractor condition). Task performance and head movement during each condition were compared, and additional analyses were conducted after grouping participants into two developmental stages.

RESULTS

Children with ADHD performed comparably to the controls under the distractor condition, but had poorer performance under the no-distractor condition. They displayed more head movement under the distractor condition than in the no-distractor condition.

CONCLUSION

VR is possibly a useful tool for investigating the effect of distractors on individuals with ADHD, and children with ADHD are more vulnerable to a low-level stimulation situation than normal children in VR.

An immersive virtual reality-based application for treating ADHD: A remote evaluation of acceptance and usability

Introduction

Virtual reality (VR) is a digital technology currently considered to implement rehabilitation programs for children with ADHD, a disorder characterised by inattention, overactivity and impulsiveness. This study presents the results of the acceptance and usability of a VR application developed for children with ADHD aiming to provide an environment capable of supporting the development of the different attentional components. Due to COVID-19 restrictions, this study had the secondary aim of assessing whether a remote evaluation was feasible and meaningful.

Methods

A sample of 20 clinical experts (neuro and psychomotor therapists of the developmental age) was involved in assessing the proposed environment. Two different tools have been applied: the Technology Acceptance Model (TAM-3) questionnaire and a semi-structured interview were self-administered. Six sessions were planned in total, and each one lasted 30 min.

Results

With respect to the acceptance of the system, the mean of the answers given is for most of the constructs greater than 4, showing agreement among experts. Cronbach alpha and correlations of subscales seem to confirm the reliability of measures. According to results from the interviews, the developed application has shown versatility in being able to be applied to the heterogeneity of the disorder and it was also possible to obtain valuable insights on possible additional features and functionalities. Regarding the secondary aim, the collected outcomes were positive: all the participants were satisfied with what they could perceive about the application.

Conclusions

The results of this work pave the way for a future validation study with children due to the active participation of clinicians and their unanimous positive judgement confirming that the application was considered user-friendly and well accepted.

Responsivity of the Striatal Dopamine System to Methylphenidate-A Within-Subject I-123-β-CIT-SPECT Study in Male Children and Adolescents With Attention-Deficit/Hyperactivity Disorder

BACKGROUND

Methylphenidate (MPH) is the first-line pharmacological treatment of attention-deficit/hyperactivity disorder (ADHD). MPH binds to the dopamine (DA) transporter (DAT), which has high density in the striatum. Assessments of the striatal dopamine transporter by single positron emission computed tomography (SPECT) in childhood and adolescent patients are rare but can provide insight on how the effects of MPH affect DAT availability. The aim of our within-subject study was to investigate the effect of MPH on DAT availability and how responsivity to MPH in DAT availability is linked to clinical symptoms and cognitive functioning.

METHODS

Thirteen adolescent male patients (9-16 years) with a diagnosis of ADHD according to the DSM-IV and long-term stimulant medication (for at least 6 months) with MPH were assessed twice within 7 days using SPECT after application of I-123-β-CIT to examine DAT binding potential (DAT BP). SPECT measures took place in an on- and off-MPH status balanced for order across participants. A virtual reality continuous performance test was performed at each time point. Further clinical symptoms were assessed for baseline off-MPH.

RESULTS

On-MPH status was associated with a highly significant change (-29.9%) of striatal DAT BP as compared to off-MPH (t = -4.12, p = 0.002). A more pronounced change in striatal DAT BP was associated with higher off-MPH attentional and externalizing symptom ratings (Pearson r = 0.68, p = 0.01). Striatal DAT BP off-MPH, but not on-MPH, was associated with higher symptom ratings (Pearson r = 0.56, p = 0.04).

CONCLUSION

Our findings corroborate previous reports from mainly adult samples that MPH changes striatal DAT BP availability and suggest higher off-MPH DAT BP, likely reflecting low baseline DA levels, as a marker of symptom severity.

Examining the Academic Trends in Neuropsychological Tests for Executive Functions Using Virtual Reality: Systematic Literature Review

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.

Neurodevelopmental disorders: An innovative perspective via the response to intervention model

Neurodevelopmental disorders are a group of conditions classified together by the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders which include intellectual disability, communication disorders, autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorder (SLD), and motor disorders. SLD is present in many students, who exhibit significant difficulties in the acquisition of reading, written expression, and mathematics, mostly due to problems with executive functions (EF). The present study is a review of the current situation of neurodevelopmental disorders and SLD focusing on the benefits of the response to intervention model (RtI), which allows the combination of evaluation and intervention processes. It also addresses the key role of EF. The importance of adapting RtI to new possibilities such as the use of virtual reality is discussed and a theoretical framework for carrying that out is provided.

An Immersive and Interactive Platform for Cognitive Assessment and Rehabilitation (bWell): Design and Iterative Development Process

BACKGROUND

Immersive technologies like virtual reality can enable clinical care that meaningfully aligns with real-world deficits in cognitive functioning. However, options in immersive 3D environments are limited, partly because of the unique challenges presented by the development of a clinical care platform. These challenges include selecting clinically relevant features, enabling tasks that capture the full breadth of deficits, ensuring longevity in a rapidly changing technology landscape, and performing the extensive technical and clinical validation required for digital interventions. Complicating development, is the need to integrate recommendations from domain experts at all stages.

OBJECTIVE

The Cognitive Health Technologies team at the National Research Council Canada aims to overcome these challenges with an iterative process for the development of bWell, a cognitive care platform providing multisensory cognitive tasks for adoption by treatment providers.

METHODS

The team harnessed the affordances of immersive technologies while taking an interdisciplinary research and developmental approach, obtaining active input from domain experts with iterative deliveries of the platform. The process made use of technology readiness levels, agile software development, and human-centered design to advance four main activities: identification of basic requirements and key differentiators, prototype design and foundational research to implement components, testing and validation in lab settings, and recruitment of external clinical partners.

RESULTS

bWell was implemented according to the findings from the design process. The main features of bWell include multimodal (fully, semi, or nonimmersive) and multiplatform (extended reality, mobile, and PC) implementation, configurable exercises that pair standardized assessment with adaptive and gamified variants for therapy, a therapist-facing user interface for task administration and dosing, and automated activity data logging. bWell has been designed to serve as a broadly applicable toolkit, targeting general aspects of cognition that are commonly impacted across many disorders, rather than focusing on 1 disorder or a specific cognitive domain. It comprises 8 exercises targeting different domains: states of attention (Egg), visual working memory (Theater), relaxation (Tent), inhibition and cognitive control (Mole), multitasking (Lab), self-regulation (Butterfly), sustained attention (Stroll), and visual search (Cloud). The prototype was tested and validated with healthy adults in a laboratory environment. In addition, a cognitive care network (5 sites across Canada and 1 in Japan) was established, enabling access to domain expertise and providing iterative input throughout the development process.

CONCLUSIONS

Implementing an interdisciplinary and iterative approach considering technology maturity brought important considerations for the development of bWell. Altogether, this harnesses the affordances of immersive technology and design for a broad range of applications, and for use in both cognitive assessment and rehabilitation. The technology has attained a maturity level of prototype implementation with preliminary validation carried out in laboratory settings, with next steps to perform the validation required for its eventual adoption as a clinical tool.

Effects of Classroom Design on the Memory of University Students: From a Gender Perspective

Classroom design has important effects on the cognitive functions of students. However, this relationship has rarely been analysed in terms of gender. The aim of the present study, therefore, is to analyse the influence of different design variables (classroom geometry, wall colour, and artificial lighting) on university students’ memories from a gender perspective. To do so, 100 university students performed a memory task while visualising different design configurations using a virtual reality setup. Key results show that certain parameters, such as 5.23 m classroom width, 10,500 Kelvin lighting colour temperature, or the blue hue on the walls influence men and women in a similar way, while a purple hue or walls with low colour saturation can generate significantly different behaviour, especially in cognitive processes such as short-term memory. In this study, the use of virtual reality proved to be a useful tool to explore the design effects of virtual learning environments, increasingly present due to training trends and catalysed by the 2020 pandemic. This is a turning point and an international novelty as it will enable the design of classrooms (both physical and virtual) that maximise the cognitive functions of learners, regardless of gender.

User-Agent Bond in Generalizable Environments: Long-Term Risk-Reduction via Nudged Virtual Choices

Avatars or agents are digitized self-representations of a player in mediated environments. While using agents to navigate through mediated environments, players form bonds with their self-agents or characters, a process referred to as identification. Identification can involve automatic, but temporary, self-concept "shifts in implicit self-perceptions" (Klimmt et al., 2010, p. 323) of the media user by adopting or emphasizing the action choices on behalf of the social expectation of the avatar in the mediated environment. In the current study, we test the possibility that users' identification with video game avatars-a bond built between avatars and players- would account for subsequent behavior changes. We did so by using 3-month longitudinal data involving a narratively-based serious game: Socially Optimized Learning in Virtual Environments (SOLVE), a 3D-interactive game designed to reduce risky sexual behaviors among young men who have sex with men (n = 444). Results show that video game identification predicts both the reduction of risky sexual behaviors over time, and reduction in the number of non-primary partners with whom risky sex occurs. And when players identify with the game character, they tend to make healthier choices, which significantly mediates the link between video game identification and reduction of risky behaviors.

Benefits in Alzheimer's Disease of Sensory and Multisensory Stimulation

Alzheimer's disease (AD) is a serious neurodegenerative disease, which seriously affects the behavior, cognition, and memory of patients. Studies have shown that sensory stimulation can effectively improve the cognition and memory of AD patients, and its role in brain plasticity and neural regulation is initially revealed. This paper aims to review the effect of various sensory stimulation and multisensory stimulation for AD, and to explain the possible mechanism, so as to provide some new ideas for further research in this field. We searched the Web of Science and PubMed databases (from 2000 to October 27, 2020) for literature on the treatment of AD with sensory and multisensory stimulation, including music therapy, aromatherapy, rhythmic (e.g., visual or acoustic) stimulation, light therapy, multisensory stimulation, and virtual reality assisted therapy, then conducted a systematic analysis. Results show these sensory and multisensory stimulations can effectively ameliorate the pathology of AD, arouse memory, and improve cognition and behaviors. What's more, it can cause brain nerve oscillation, enhance brain plasticity, and regulate regional cerebral blood flow. Sensory and multisensory stimulation are very promising therapeutic methods, and they play an important role in the improvement and treatment of AD, but their potential mechanism and stimulation parameters need to be explored and improved.

The Influence of State and Trait Anxiety on the Achievement of a Virtual Reality Continuous Performance Test in Children and Adolescents with ADHD Symptoms

The three types of presentations of ADHD often co-occur with other disorders, anxiety being one of the most prevalent. For this reason and because there are few studies that have examined the influence of anxiety on attentional activities, this study aims to determine how internalizing difficulties (anxiety levels) can influence performance in a virtual reality continuous performance test. The study used a non-probabilistic clinical sample comprising 68 boys (66%) and 35 girls (34%) aged between 6 and 16 (M = 12.24; SD = 2.45) who had been referred to clinical services for the evaluation of ADHD symptoms. Once informed consent was given, the children were administered the STAI-C scale and a virtual reality continuous performance test by expert researchers. Hierarchical regression models showed that only state anxiety demonstrated significant explanatory power over attentional variables. These findings confirm how important it is for children to feel relaxed when they undergo psychological evaluation tests, as otherwise the individual’s intervention design would be based on biased data. Similarly, the findings also suggested an effect of IQ in the interpretation of continuous performance scores.

Application of digital practice to improve head movement, visual perception and activities of daily living for subacute stroke patients with unilateral spatial neglect: Preliminary results of a single-blinded, randomized controlled trial

BACKGROUND

Virtual reality (VR) based digital practice is an attractive way to provide a patient engagement, motivation and adaptable environment for stroke rehabilitation. However, clinical evidence of efficacy with VR-based digital practice is very limited. In this study, we investigated the effects of VR-based digital practice program on unilateral spatial neglect (USN) rehabilitation in patients with subacute stroke.

METHODS

Twenty-four subacute stroke patients with USN were enrolled and randomly assigned to digital practice group (n = 12) and control group (n = 12). Patients in digital practice group received training programs with VR-based applications with leap motion environment. Control group received conventional USN specific training programs. All patients were underwent 4 week practice program (3 sessions/week, a half-hour/session). We analyzed training effects before and after training by assessing the line bisection test, Catherine Bergego Scale, modified Barthel index, Motor-Free Visual Perception Test Vertical Version (MVPT-V), and horizontal head movements (rotation degree and velocity during the VR-based applications), and compared the results between the two groups.

RESULTS

Compared to control group, digital practice group showed significantly greater improvements in the line bisection test (P = .020), and visual perceptual tasks (MVPT-V, responded more on left visual task, P = .024; correctly respond more on both left and right visual tasks, P = .024 and P = .014, respectively; and faster response time, P = .014). Additionally, horizontal head movement of rotation degree and velocity during the VR based practice in the digital practice group were significantly increased more than control group (P = .007 and P = .001, respectively).

CONCLUSIONS

VR-based digital practice program might be an affordable approach for visual perception and head movement recovery for subacute stroke patients with USN.

Virtual Classroom Assessment for Children and Adolescents With Attention Deficits: A Systematic Review and Meta-Analysis of Measurement Properties

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).

The relationship between reflex eye realignment and the percept of single vision in young children

Effective binocular vision is dependent on both motor and perceptual function. Young children undergo development of both components while interacting with their dynamic three-dimensional environment. When this development fails, eye misalignment and double vision may result. We compared the range of image disparities over which young children display reflex motor realignment of their eyes with the range over which they report a single versus double percept. In response to step changes in the disparity of a 2.2° wide stimulus, 5-year-olds generated an adult-like reflex vergence velocity tuning function peaking at 2° of disparity, with a mean latency of 210 ms. On average, they reported double vision for stimulus disparities of 3° and larger, compared to 1° in adult reports. Three-year-olds also generated reflex vergence tuning functions peaking at approximately 2° of disparity, but their percepts could not be assessed. These data suggest that, by age 5, reflex eye realignment responses and percepts driven by these brief stimuli are tightly coordinated in space and time to permit robust binocular function around the point of fixation. Importantly, the plastic neural processes maintaining this tight coordination during growth control the stability of visual information driving learning during childhood.

Objective Assessment of Attention-Deficit Hyperactivity Disorder (ADHD) Using an Infinite Runner-Based Computer Game: A Pilot Study

In the last few years, several computerized tasks have been developed to increase the objectivity of the diagnosis of attention-deficit hyperactivity disorder (ADHD). This article proposes the "running raccoon" video game to assess the severity of inattention in patients diagnosed with ADHD. Unlike existing tests, the proposed tool is a genuine video game in which the patient must make a raccoon avatar jump to avoid falling into different gaps. The distance to the gap is recorded for each jump. To evaluate the proposed game, an experiment was conducted in which 32 children diagnosed with ADHD participated. For each participant, the median and interquartile range of these distances were calculated, along with the number of omissions. Experimental results showed a significant correlation between the participants' inattention (measured by the Attention-Deficit/Hyperactivity Disorder Symptoms and Normal Behavior rating scale (SWAN) inattention subscale) with each of these three measures. In addition to its accuracy, other benefits are its short duration and the possibility of being run on both standard computers and mobile devices. These characteristics facilitate its acceptance in clinical environments or even its telematic use. The obtained results, together with the characteristics of the video game, make it an excellent tool to support clinicians in the diagnosis of ADHD.

Rehabilitative Effects of Virtual Reality Technology for Mild Cognitive Impairment: A Systematic Review With Meta-Analysis

Objective: To evaluate the impact of virtual reality (VR) technology on the cognitive functions (overall cognitive ability, executive function, short-term memory, and long-term memory) of people with mild cognitive impairment (MCI).

Methods: All major databases, including Web of Science, PubMed, Scopus, Proquest, WanFang, and CNKI, were searched to identify all relevant studies published in English or Chinese since October 28th, 2019. Two researchers independently conducted document retrieval, study selection, data extraction, and methodological quality evaluation.

Result: 15 randomized controlled trials were analyzed (N = 612 people with MCI), with the methodological quality evaluation score ranging from 5 to 7 points. A random effects model was selected to combine effect sizes. The result of the meta-analysis indicates that VR significantly enhanced MCI patients' overall cognitive ability (SMD = 0.869, 95% confidence interval [CI] = 0.330–1.407, P = 0.002, I² = 86.822, n = 537) and executive function (SMD = 1.083, 95%, 95%CI = 00.134–2.031, P = 0.025, I² = 93.748, n = 220). The meta-analysis indicated that after VR training, effects on short-term memory (SMD = 0.488, 95%CI = −0.108–1.084, P = 0.109, I² = 62.354, n = 131) and long-term memory (SMD = 0.335, 95%CI = −1.194–0.863, P = 0.0.214, I² = 58.868, n = 152) were not statistically significant.

Conclusions: The present meta-analysis verifies the potential rehabilitative effects of VR technology for mild cognitive impairment.

A Virtual-Reality System Integrated With Neuro-Behavior Sensing for Attention-Deficit/Hyperactivity Disorder Intelligent Assessment

Attention-deficit/Hyperactivity disorder(ADHD) is a common neurodevelopmental disorder among children. Traditional assessment methods generally rely on behavioral rating scales (BRS) performed by clinicians, and sometimes parents or teachers. However, BRS assessment is time consuming, and the subjective ratings may lead to bias for the evaluation. Therefore, the major purpose of this study was to develop a Virtual Reality (VR) classroom associated with an intelligent assessment model to assist clinicians for the diagnosis of ADHD. In this study, an immersive VR classroom embedded with sustained and selective attention tasks was developed in which visual, audio, and visual-audio hybrid distractions, were triggered while attention tasks were conducted. A clinical experiment with 37 ADHD and 31 healthy subjects was performed. Data from BRS was compared with VR task performance and analyzed by rank-sum tests and Pearson Correlation. Results showed that 23 features out of total 28 were related to distinguish the ADHD and non-ADHD children. Several features of task performance and neuro-behavioral measurements were also correlated with features of the BRSs. Additionally, the machine learning models incorporating task performance and neuro-behavior were used to classify ADHD and non-ADHD children. The mean accuracy for the repeated cross-validation reached to 83.2%, which demonstrated a great potential for our system to provide more help for clinicians on assessment of ADHD.

How brain imaging provides predictive biomarkers for therapeutic success in the context of virtual reality cognitive training

As Virtual reality (VR) is increasingly used in neurological disorders such as stroke, traumatic brain injury, or attention deficit disorder, the question of how it impacts the brain's neuronal activity and function becomes essential. VR can be combined with neuroimaging to offer invaluable insight into how the targeted brain areas respond to stimulation during neurorehabilitation training. That, in turn, could eventually serve as a predictive marker for therapeutic success. Functional magnetic resonance imaging (fMRI) identified neuronal activity related to blood flow to reveal with a high spatial resolution how activation patterns change, and restructuring occurs after VR training. Portable and quiet, electroencephalography (EEG) conveniently allows the clinician to track spontaneous electrical brain activity in high temporal resolution. Then, functional near-infrared spectroscopy (fNIRS) combines the spatial precision level of fMRIs with the portability and high temporal resolution of EEG to constitute an ideal measuring tool in virtual environments (VEs). This narrative review explores the role of VR and concurrent neuroimaging in cognitive rehabilitation.

Accuracy and precision of stimulus timing and reaction times with Unreal Engine and SteamVR

The increasing interest in Virtual Reality (VR) as a tool for neuroscientific research contrasts with the current lack of established toolboxes and standards. In several recent studies, game engines like Unity or Unreal Engine were used. It remains to be tested whether these software packages provide sufficiently precise and accurate stimulus timing and time measurements that allow inferring ongoing mental and neural processes. We here investigated the precision and accuracy of the timing mechanisms of Unreal Engine 4 and SteamVR in combination with the HTC Vive VR system. In a first experiment, objective external measures revealed that stimulus durations were highly accurate. In contrast, in a second experiment, the assessment of the precision of built-in timing procedures revealed highly variable reaction time measurements and inaccurate determination of stimulus onsets. Hence, we developed a new software-based method that allows precise and accurate reaction time measurements with Unreal Engine and SteamVR. Instead of using the standard timing procedures implemented within Unreal Engine, time acquisition was outsourced to a background application. Timing benchmarks revealed that the newly developed method allows reaction time measurements with a precision and accuracy in the millisecond range. Overall, the present results indicate that the HTC Vive together with Unreal Engine and SteamVR can achieve high levels of precision and accuracy both concerning stimulus duration and critical time measurements. The latter can be achieved using a newly developed routine that allows not only accurate reaction time measures but also provides precise timing parameters that can be used in combination with time-sensitive functional measures such as electroencephalography (EEG) or transcranial magnetic stimulation (TMS).

The Adoption of New Treatment Modalities by Health Professionals and the Relative Weight of Empirical Evidence in Favor of Virtual Reality Exposure Versus Mindfulness in the Treatment of Anxiety Disorders

Anxiety disorders are among the most prevalent mental disorders, and cognitive-behavioral therapy (CBT) with exposure exercises is considered as the gold-standard psychological intervention. New psychotherapeutic modalities have emerged in the last decade and, among them, mindfulness has been rapidly adopted by therapists. The adoption rate is slower for the use of virtual reality (VR) to conduct exposure. The goal of the present position paper is to contrast, for the treatment of anxiety disorders, the weight of empirical evidences supporting the use of exposure in VR with the use of mindfulness-based therapy (MBT). Based on the most recent meta-analyses, we found that CBT with exposure conducted in VR was more thoroughly researched and supported than MBT, receiving validation from roughly twice as many studies with high control (i.e., randomized, active controls with clinical samples). However, this conclusion is nuanced by reviewing gaps in the literature for both therapies. Potential factors influencing clinicians' choice of treatment and suggestions for future research directions are proposed.

Using virtual reality to define the mechanisms linking symptoms with cognitive deficits in attention deficit hyperactivity disorder

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.

The Influence of Methylphenidate on Hyperactivity and Attention Deficits in Children With ADHD: A Virtual Classroom Test

Objective: This study compares the performance in a continuous performance test within a virtual reality classroom (CPT-VRC) between medicated children with ADHD, unmedicated children with ADHD, and healthy children. Method:N = 94 children with ADHD (n = 26 of them received methylphenidate and n = 68 were unmedicated) and n = 34 healthy children performed the CPT-VRC. Omission errors, reaction time/variability, commission errors, and body movements were assessed. Furthermore, ADHD questionnaires were administered and compared with the CPT-VRC measures. Results: The unmedicated ADHD group exhibited more omission errors and showed slower reaction times than the healthy group. Reaction time variability was higher in the unmedicated ADHD group compared with both the healthy and the medicated ADHD group. Omission errors and reaction time variability were associated with inattentiveness ratings of experimenters. Head movements were correlated with hyperactivity ratings of parents and experimenters. Conclusion: Virtual reality is a promising technology to assess ADHD symptoms in an ecologically valid environment.

A Virtual Versus an Augmented Reality Cooking Task Based-Tools: A Behavioral and Physiological Study on the Assessment of Executive Functions

Virtual reality (VR) and augmented reality (AR) are two novel graphics immersive techniques (GIT) that, in the last decade, have been attracting the attention of many researchers, especially in psychological research. VR can provide 3D real-life synthetic environments in which controllers allow human interaction. AR overlays synthetic elements to the real world and the human gaze to target allow hand gesture to act with synthetic elements. Both techniques are providing more ecologically environments than traditional methods, and most of the previous researches, on one side, have more focused on the use of VR for treatment and assessment showing positive effectiveness results. On the other, AR has been proving for the treatment of specific disorders but there are no studies that investigated the feasibility and effectiveness of AR in the neuropsychological assessment. Starting from these premises, the present study aimed to compare the performance and sense of presence using both techniques during an ecological task, such as cooking. The study included 50 cognitively healthy subjects. The cooking task consisted of four levels that increased in difficulty. As the level increased, additional activities appeared. The order of presentation of each exposure condition (AR and VR) was counterbalanced for each participant. The VR-cooking task has been performed through "HTC/VIVE" and AR through "Microsoft HoloLens." Furthermore, the study recorded and compared the psychophysiological changes [heart rate and skin conductance response (SCR)] during the cooking task in both conditions. To measure the sense of presence occurring during the two exposure conditions, subjects completed the Slater-Usoh-Steed Questionnaire (SUSQ) and the ITC-Sense of Presence Inventory (ITC-SOPI) immediately after each condition. The behavioral results showed that times are always lower in VR than in AR, increasing constantly in accordance with the difficulty of the tasks. Regarding physiological responses, the findings showed that AR condition produced more individual excitement and activation than VR. Finally, VR was able to produce higher levels of sense of presence than AR condition. The overall results support that VR currently represents the GIT with greater usability and feasibility compared to AR, probably due to the differences in the human-computer interaction between the two techniques.

Virtual Reality Assessment of Classroom - Related Attention: An Ecologically Relevant Approach to Evaluating the Effectiveness of Working Memory Training

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.

Comprehensive review on virtual reality for the treatment of violence: implications for youth with schizophrenia

Youth violence is a complex and multifactorial issue that has severe health and social consequences. While treatment options exist to treat/reduce violence in at-risk populations such as schizophrenia, there remains limitations in the efficacy of current interventions. Virtual reality (VR) appears to be a unique possibility to expose offenders and to train coping skills in virtual situations that are capable of eliciting aggression-relevant behavior without threatening others. The focus of this paper is to provide a comprehensive review of studies using VR to manage violence across several at-risk populations, with a particular emphasis on youth with schizophrenia. Despite the encouraging success of VR applications for the treatment of different mental health problems, no studies have explored the usability of VR to specifically treat violence in patients with schizophrenia. A limited number of studies have focused on violence risk factors in other mental health problems (i.e., emotion regulation in individual suffering from post-traumatic disorders) that may be targeted in treatments to reduce the risk of violence. The preliminary studies using VR as a therapeutic element have shown reductions in anger, improvements in conflict-resolution skills as well as in empathy levels, and decreases in aggression. Possible applications of these interventions in youth with schizophrenia will be discussed.

Joint Attention Virtual Classroom: A Preliminary Study

OBJECTIVE

Previous studies have suggested that a virtual classroom is immersive and ecologically valid neuropsychological assessment, but those studies have limited components for social attentions. Therefore, the objective in the current study is the development of a joint attention virtual reality (JA-VR) classroom to incorporate social attentions between a participant and a virtual avatar teacher.

METHODS

Fifty-eight participants were recruited for current study (25 for pilot and 33 for main studies; 32.8% female, n=19; age: M=24.5, SD=4.0). We suggested a JA-VR classroom, and compared it with previous methods including a VR classroom without JA components. We conducted attention experiments with AX-version of continuous performance tasks.

RESULTS

Our results suggest that the new JA-VR classroom had convergent validity with previous methods, and that the JA-VR classroom promoted attentional processing among participants better than both old VR and non-VR measures.

CONCLUSION

We add an important social attention concept to the virtual classroom, and believe that this work is an methodological foundation for the study of social attention in school life. We hope it ultimately help people with mental handicaps in social attention.

Are We Ready for Real-world Neuroscience?

Real-world environments are typically dynamic, complex, and multisensory in nature and require the support of top-down attention and memory mechanisms for us to be able to drive a car, make a shopping list, or pour a cup of coffee. Fundamental principles of perception and functional brain organization have been established by research utilizing well-controlled but simplified paradigms with basic stimuli. The last 30 years ushered a revolution in computational power, brain mapping, and signal processing techniques. Drawing on those theoretical and methodological advances, over the years, research has departed more and more from traditional, rigorous, and well-understood paradigms to directly investigate cognitive functions and their underlying brain mechanisms in real-world environments. These investigations typically address the role of one or, more recently, multiple attributes of real-world environments. Fundamental assumptions about perception, attention, or brain functional organization have been challenged-by studies adapting the traditional paradigms to emulate, for example, the multisensory nature or varying relevance of stimulation or dynamically changing task demands. Here, we present the state of the field within the emerging heterogeneous domain of real-world neuroscience. To be precise, the aim of this Special Focus is to bring together a variety of the emerging "real-world neuroscientific" approaches. These approaches differ in their principal aims, assumptions, or even definitions of "real-world neuroscience" research. Here, we showcase the commonalities and distinctive features of the different "real-world neuroscience" approaches. To do so, four early-career researchers and the speakers of the Cognitive Neuroscience Society 2017 Meeting symposium under the same title answer questions pertaining to the added value of such approaches in bringing us closer to accurate models of functional brain organization and cognitive functions.

Comparison between two continuous performance tests for identifying ADHD: Traditional vs. virtual reality

Background/Objective: Continuous Performance Tests (CPTs) have demonstrated validity when differentiating children with ADHD from healthy controls. However, these CPTs have limitations such as low ecological validity. New CPTs based on the use of Virtual Reality (VR) have appeared as supposedly improved methods for assessing ADHD. This study aims to compare the discriminant value of attentional variables produced by a VR CPT (Aula Nesplora) with that of variables from a traditional CPT (Test of Variables of Attention; TOVA) for identifying ADHD. Method: A total of 338 children aged between 6 and 16 years old (M = 10.84, SD = 3.01) participated in the study: 31.95% correspond to the inattentive presentation, 15.38% to the impulsive-hyperactive presentation, 22.78% to the combined presentation, and the remaining 29.88% correspond to children without ADHD. Results: Results indicated that Aula Nesplora predicts ADHD presentations better than TOVA. It also differentiates better between ADHD and non-ADHD students. Conclusions: These findings show the potential advantages of using virtual reality in ADHD assessment, as it facilitates the diagnosis of ADHD and the differentiation of its presentations in a realistic environment.

Efficacy of a Continuous Performance Test Based on Virtual Reality in the Diagnosis of ADHD and Its Clinical Presentations

OBJECTIVE

To analyze the diagnostic effectiveness of the AULA Nesplora test to discriminate the different ADHD presentations: impulsive/hyperactive (I/H), inattentive, and combined.

METHOD

A total of 117 students (76.9% male and 23.1% female) between 5 and 16 years of age ( M = 11.18 years, SD = 3.10 years) participated, and were divided into three groups with ADHD according to their presentation, and a control group.

RESULTS

Each of the test conditions allowed the discrimination between the I/H and combined presentations with respect to the control group, and between the I/H and inattentive presentations. However, differences among ADHD presentations were only evident when the results were separately analyzed for the visual and auditory modalities.

CONCLUSION

This study showed that the indicators offered by the AULA Nesplora test (omissions, commissions, response times, and motor activity) make it possible to establish a differential diagnosis of ADHD presentations when analyzed under different contextual conditions.

Virtual prognostication: When virtual alcohol choices predict change in alcohol consumption over 6-months

Narrative games, in which users interact with virtual agents, are increasingly being used in health interventions to change targeted behaviors. In virtual social interactions, based on similar real-life contextual cues, past behavior can predict virtual choices. Here, based on theories in learning and interactivity, we examined the whether following a virtual intervention, choices in social interactions may be particularly diagnostic of future behavior changes. To test this, we needed to: (1) leverage a contextualized risk (e.g., involving alcohol consumption) scenario (e.g., having one more drink with my partner) given a target audience (e.g., sexually risky young men who have sex with men (YMSM)), (2) include within this context an evidence-based virtual intervention (e.g., promoting alcohol reduction), (3) instantiate and record a virtual choice (water or alcohol) in a virtual dating game scenario intervention with IA for that target audience, and (4) assess pre and 6-months post-intervention YMSM's alcohol use. Using a Socially Optimized Learning Environment (SOLVE) intervention game with IA and alcohol use measures, we found that virtual water choice (versus virtual alcohol choice) significantly predicted real-life alcohol consumption change. Furthermore, personality factors (e.g., Behavioral Approach System) predicted virtual choices and alcohol consumption change. Implications of these findings are discussed.

A Virtual-Reality Approach for the Assessment and Rehabilitation of Multitasking Deficits

Virtual reality technology can be used for ecologically valid assessment and rehabilitation of cognitive deficits. This article expands the scope of applications to ecologically valid multitasking. A commercially available driving simulator was upgraded by adding an ever-changing sequence of concurrent, everyday-like tasks. Furthermore, the simulator software was modified and interfaced with a non-motorized treadmill to yield a pedestrian street crossing simulator. In the latter simulator, participants walk on through a virtual city, stop at busy streets to wait for a gap in traffic, and then cross. Again, a sequence of everyday-like tasks is added. A feasibility study yielded adequate “presence” in both virtual scenarios, and plausible data about performance decrements under multi-task compared to single-task conditions. The present approach could be suitable for the assessment and training of multitasking skills in older adults and neurological patients.