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

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 nondecision 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. Why do children with attention deficit hyperactivity disorder (ADHD) fail to pay attention? How can we link clinical symptoms of ADHD, reported by parents or children, to objective, quantifiable cognitive deficits? Here, we aim to identify the mechanisms that link ADHD symptoms with deficits in performance during a widely used probe of attention-the continuous performance task (CPT). A large literature delineates how objective deficits in this demanding task are associated with the symptoms of ADHD 1-4 and that these deficits are partly rectified by psychostimulant medication 5-7. One possible mechanism to link ADHD symptoms with deficits in attention-demanding tasks is rapid shifts in a child's field of view (FOV) resulting from eye or head movements. Concentrated attention on a target usually corresponds with the object falling at or near the center of the FOV 8-10. Thus, shifting of the FOV away from targets could readily disrupt performance on attention-laden tasks. There is some empirical evidence supporting this concept. First, studies that track eye movements demonstrate that children with ADHD fail to maintain visual focus on a target, making excessive, off-target eye movements, or saccades 11-14. However, maintaining gaze on a target without any other demands lacks the complexity of most tasks that require focused attention, and this paradigm does not probe selective attention. A second research strand monitors head movement in an effort to track shifts in a child's FOV 15,16. For example, one study found that compared to typically developing children, those with ADHD show excessive and distinct patterns of head movement while performing attention-demanding tasks 17. However, the possibility of links between ...

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

“…Similar to Mangalmurti et al (2020) and Lev et al (2020) we found that eye-tracking during attention-demanding tasks, whether in a VR environment or traditional CPT demonstrate that ADHD is associated with slow disengagement from confidence intervals after removal of between-subject variability. Statistical significance denoted by "*" for p ≤ 0.05 and "**" for p < 0.001.…”

“…This proof of principle project also did not contrast ADHD performance to a healthy comparison group, without ADHD. The VR classroom has repeatedly shown significantly worse performance in behavior our previous studies (e.g., Parsons et al, 2007;Adams et al, 2009) and others (e.g., Mangalmurti et al, 2020), suggesting that that these effects would likely discriminate between groups. We consider this project to be the first in the series of projects and recommend future studies conduct testing between ADHD and typically developing children to assess differences in eye-tracking performance within the VR classroom.…”

“…While not employing eye-tracking measures, a recent paper by Mangalmurti et al (2020) assessed how field-of-view (FOV) related to symptoms of ADHD within a virtual classroom during a CPT. The researchers measured changes in the FOV by recording head rotations to distractors in a VR classroom in children with ADHD to better understand what was driving attentional deficits.…”

Quantifying ADHD symptoms in open-ended everyday life contexts with a new virtual reality task

“…While this may well be the case, we provide new evidence that hyperactivity in ADHD participants can also be objectively measured in lifelike situations where the participants are moving freely. Thus far, the focus has mostly been on head movements (see, e.g., Parsons et al, 2019;Mangalmurti et al, 2020). We selected controller motion as the hyperactivity measure, since it is more closely related to performing actions in the game, whereas head movements can also reflect visual search.…”

Digital Transformations of Classrooms in Virtual Reality

“…As also reported by [55], eye movements should be examined along with head movements to understand attention and interaction more in-depth, since eyes can move differently. In addition, [44] studied the relationship between performance, sense of presence, and cybersickness, whereas [38] examined attention, more particularly ADHD with continuous performance task in a virtual classroom. However, both works are more in the clinical domain, which are relatively different from an everyday classroom setup.…”