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Initial study finds promise and limitations in using virtual reality (VR) to treat ADHD

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Giv­en the lim­i­ta­tions of exist­ing evi­dence-based ADHD treat­ments, i.e., stim­u­lant med­ica­tion and behav­ior ther­a­py — research on nov­el inter­ven­tion approach­es con­tin­ues to be impor­tant.

Cog­ni­tive train­ing is one such approach that has been sug­gest­ed as a poten­tial adjunct or even replace­ment for med­ica­tion treat­ment. While cog­ni­tive train­ing takes dif­fer­ent forms, e.g., com­put­er­ized atten­tion train­ing, work­ing mem­o­ry train­ing, the basic idea is that by repeat­ed­ly prac­tic­ing cog­ni­tive tasks relat­ed to atten­tion, one’s abil­i­ty to focus and attend will improve. In oth­er words, atten­tion will improve with prac­tice, just as many oth­er skills do. In my view, the evi­dence sup­port­ing this hypoth­e­sis is lim­it­ed in that although gains are gen­er­al­ly found on tasks sim­i­lar to those used in train­ing, gen­er­al­iza­tion of gains to real-world tasks where sus­tain­ing atten­tion is impor­tant, e.g., while read­ing, doing home­work, etc., have been more dif­fi­cult to doc­u­ment.

In recent years, vir­tu­al real­i­ty (VR) has been intro­duced as a treat­ment for sev­er­al psy­chi­atric dis­or­ders, par­tic­u­lar­ly anx­i­ety dis­or­ders; pos­i­tive find­ings have been report­ed. In VR treat­ment for anx­i­ety dis­or­ders, the client is ‘exposed’ to sources of anx­i­ety in the vir­tu­al envi­ron­ment, allow­ing for grad­ual expo­sure in a con­trolled set­ting. For exam­ple, in the treat­ment of PTSD, VR allows a per­son to expe­ri­ence the trau­ma sce­nario again in a safe, con­trolled way through the use of inter­ac­tive com­put­er-gen­er­at­ed envi­ron­ments that can be mod­i­fied to resem­ble the trau­ma­tiz­ing event. Using VR for ADHD has nev­er been test­ed, how­ev­er. A recent study thus rep­re­sents an ini­tial effort to exam­ine this approach.

The New Study

In this study, Vir­tu­al Reme­di­a­tion Ver­sus Methylphenidate to Improve Dis­tractibil­i­ty in Chil­dren With ADHD: A Con­trolled Ran­dom­ized Clin­i­cal Tri­al Study, 51 7- to 11-year old chil­dren diag­nosed with ADHD were ran­dom­ly assigned to a vir­tu­al real­i­ty inter­ven­tion, med­ica­tion treat­ment, or sup­port­ive psy­chother­a­py. Before and after treat­ment, which last­ed 6 weeks, ADHD symp­toms were assessed via a par­ent rat­ing scale, a com­put­er­ized atten­tion test, and a vir­tu­al class­room assess­ment task.

In the lat­ter, par­tic­i­pants wore VR head­sets that placed them ‘inside’ a vir­tu­al class­room. A vir­tu­al ‘teacher’ instruct­ed them to view a series of let­ters on a black­board and to click the mouse when a par­tic­u­lar com­bi­na­tion of let­ters appeared on the board. To make the task more dif­fi­cult, mul­ti­ple dis­trac­tors, e.g., pen­cils drop­ping, paper air­plane fly­ing across the class, etc., were pre­sent­ed dur­ing the task. Cor­rect respons­es were defined by click­ing the mouse after the des­ig­nat­ed let­ters appeared; click­ing to any oth­er com­bi­na­tion of let­ters were con­sid­ered errors.

Treat­ment last­ed 6 weeks. Chil­dren in the med­ica­tion group were treat­ed with a long act­ing form of methylphenidate with dose titrat­ed every 2 weeks based on a par­ent inter­view. The psy­chother­a­py con­di­tion was pri­mar­i­ly focused on pro­vid­ing emo­tion­al sup­port and address­ing the impact of ADHD on children’s every­day lives; it was includ­ed pri­mar­i­ly to con­trol for ther­a­pist atten­tion.

In the Vir­tu­al Real­i­ty con­di­tion, chil­dren wore VR head­sets that sim­u­lat­ed a reg­u­lar class­room. Dur­ing 12 30-minute train­ing ses­sions, chil­dren per­formed a let­ter detec­tion task (details not pro­vid­ed) while inhibit­ing atten­tion to var­i­ous class­room dis­trac­tions. As train­ing pro­gressed, the dis­trac­tors increased to make the task more dif­fi­cult. You may note that the train­ing task sounds very sim­i­lar to the assess­ment task described above; from the descrip­tion pro­vid­ed in the paper, it is not evi­dent how they dif­fered.

Results 

On the vir­tu­al class­room assess­ment, youth who com­plet­ed cog­ni­tive train­ing in the VR envi­ron­ment showed improved per­for­mance that exceed­ed stu­dents in the psy­chother­a­py con­di­tion and that matched that found for stu­dents receiv­ing med­ica­tion. Fur­ther­more, they actu­al­ly made sig­nif­i­cant­ly few­er errors than stu­dents in the med­ica­tion group (it was not clear, how­ev­er, whether stu­dents were on med­ica­tion at the sec­ond assess­ment).

When it came to par­ent rat­ings of ADHD symp­toms, how­ev­er, there was no evi­dence that the VR train­ing had any pos­i­tive impact. In con­trast, as has been demon­strat­ed in numer­ous stud­ies, youth treat­ed with med­ica­tion had sig­nif­i­cant and sub­stan­tial reduc­tions in both inat­ten­tive and hyper­ac­tive symp­toms.

Summary and Implications

This study is an inter­est­ing ini­tial effort to exam­ine VR in the treat­ment of ADHD. How­ev­er, although the VR inter­ven­tion showed pos­i­tive effects on the VR assess­ment task, this is not sur­pris­ing giv­en how sim­i­lar the assess­ment was to the actu­al inter­ven­tion. Because of this sim­i­lar­i­ty, it is not clear that the VR com­po­nent was essen­tial as prac­tic­ing a sim­i­lar com­put­er-based task out­side of the VR envi­ron­ment could have yield­ed sim­i­lar results. In that regard, a stronger con­trol would have been a com­put­er-based atten­tion train­ing task that did not include VR. Anoth­er lim­i­ta­tion, as not­ed above, is that the VR inter­ven­tion had no dis­cernible impact on par­ents’ behav­ior rat­ings.

While the results of this study are lim­it­ed, they high­light some impor­tant prin­ci­ples in eval­u­at­ing nov­el ADHD treat­ments. For exam­ple, when train­ing stud­ies report treat­ment effects, it is not uncom­mon to find that ben­e­fits were obtained on some par­tic­u­lar mea­sure. In the study above, the pos­i­tive impact on per­for­mance in the VR assess­ment could be high­light­ed.

It is impor­tant, how­ev­er, to ask whether the out­come affect­ed is a mean­ing­ful one. Most pro­fes­sion­als and par­ents would be more inter­est­ed in how a treat­ment impacts core ADHD symp­toms than on how it may affect per­for­mance on a spe­cif­ic lab-based test. Thus, in my opin­ion, the fail­ure to observe reduc­tions in par­ents’ reports of ADHD symp­toms sub­stan­tial­ly under­mines the val­ue of the inter­ven­tion test­ed here.

Anoth­er issue to con­sid­er is how close­ly the mea­sures used to eval­u­ate an intervention’s impact match the inter­ven­tion itself. In this study, the VR assess­ment mea­sure was high­ly sim­i­lar to what occurred in the VR train­ing; this alone could explain why chil­dren got bet­ter on the task. Ide­al­ly, the inter­ven­tion effects should gen­er­al­ize to ‘real world’ tasks and/or set­tings that are dif­fer from the train­ing itself.

For exam­ple, while it is nice to show that a com­put­er-based atten­tion train­ing inter­ven­tion leads to bet­ter scores on a com­put­er­ized atten­tion mea­sure, it is more impor­tant to doc­u­ment that atten­tion also improves in set­tings that real­ly mat­ter, e.g., while the child is doing home­work or in the class­room.

In con­clu­sion, while I com­mend the authors for this ini­tial effort to exam­ine the use of VR in ADHD treat­ment, there is much work remain­ing to estab­lish whether this a viable approach. Tak­ing a cue from the VR treat­ments devel­oped for anx­i­ety dis­or­ders, where VR is used to expose clients to ‘envi­ron­ments’ that elic­it anx­i­ety, it may be fruit­ful to use a vir­tu­al class­room envi­ron­ment to train atten­tion dur­ing more mean­ing­ful aca­d­e­m­ic tasks. For exam­ple, it may be pos­si­ble to com­bine neu­ro­feed­back with a vir­tu­al class­room to pro­vide feed­back to chil­dren on their atten­tion lev­el as the ‘teacher’ presents an actu­al les­son.

This seems as though it could be an inter­est­ing approach to try.

– Dr. David Rabin­er is a child clin­i­cal psy­chol­o­gist and Direc­tor of Under­grad­u­ate Stud­ies in the Depart­ment of Psy­chol­o­gy and Neu­ro­science at Duke Uni­ver­si­ty. He pub­lish­es the Atten­tion Research Update, an online newslet­ter that helps par­ents, pro­fes­sion­als, and edu­ca­tors keep up with the lat­est research on ADHD.

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