Virtual Reality Tests Reality of Executive Functions

OK, parents, you’ve decided to take the plunge and have your kid tested for ADHD. How does this happen in the doctor’s office? You’re nervous, your child is nervous, you’re all alone in the room with the doctor, and your child is perfectly still and silent. Where are the signs of ADHD? In a medical setting, how you and your child describe his or her behavior count for most of the diagnosis. The doctor will probably not witness these behaviors him- or herself, but will most likely ask some pointed questions and conclude that your child struggles with attention in a variety of settings, and may prescribe medications.

 However, there are tests, called “psycho-educational” assessments (shortened to “psycho-ed,” a rather unflattering moniker), which probe a bit deeper for some of the real-world or everyday problems associated with ADHD, particularly executive functioning deficits. They also look at some psychological issues, such as anxiety, depression, rule-breaking, etc.

Still, these psycho-ed assessments are also anecdotal, ”paper-and-pencil” tests. An examiner (usually a psychologist) asks you, your child, and/or your child’s teacher, a series of questions, and you answer them with “Always,”  “Frequently,” “Sometimes,” “Rarely,” or “Never”. These tests probe more deeply into whether the student falls within the norms of these behaviors for their age and gender, or whether there are indications of a deficit, disability, or some other dis-word.

The authors of a study[1] were verifying whether a virtual reality (VR) “computer game” could predict whether or not a person has deficits in executive functions (EF). A problem with traditional paper-and-pencil assessments of attention is that they are administered in a quiet office, with few distractions, in a one-on-one setting. The examiner does not get to visit the child’s classroom, witness his or her behaviors when trying to control him-/herself in a quiet classroom, becoming easily distracted by someone or something in his/her environment, or forgetting to write down a homework assignment and having no idea what to do once he or she gets come.

I’ll quote directly from the published paper:

 In this study, performance on a VR-Stroop-like task of inhibition correlated with more traditional forms (paper–pencil and parent questionnaires) of EF assessment, but VR performance more accurately reflected everyday behavioral EF.

A “Stroop” task is a brain puzzle where you are shown a name of a color, for example, blue, but it is printed in a different color. When you see this: blue, and you are asked what color is written, you might say “red” because the color you see is red. This is supposed to test how often you can juggle conflicting information in your brain and come up with a correct answer, even when there is interference.

…the “Virtual Classroom” was originally developed as a controlled environment with varying levels of distraction in which attentional processes can be assessed in children (Rizzo et al., 2000b)… The environment also incorporates systematic and controlled presentations of typical classroom distracters, such as classroom noises and movement of virtual classmates or cars in the street.

This idea struck me as quite brilliant. They are simulating a real environment, with distractions, while administering the test. It’s adding an extra level of distraction, which is usually present in everyday situations, so the child’s performance should be equal to or worse than a typical child’s.

…by its ability to explain outcome on well-recognized scales of behavioral EF and externalizing behavior, while a similar paper–pencil EF test (D-KEFS CWIT) failed to predict the same outcomes. These results support the idea that VR does not only look like the real world, it also includes demands that require real world functional abilities.

btw: D-KEFS, the Delis–Kaplan Executive Function System,  is an assessment that has five sub-tests that measure some facet of executive functioning: ability to reason, ability to prioritize, being flexible, juggling conflicting information in working memory, etc. The CWIT is the Color Word Interference Test, which is a version of the Stroop color name/word test.

The researchers concluded that “VR appears to be a strong predictor of everyday life executive functioning and behavior.” While they could not conclude the VR game could predict similar results on all of the paper-and-pencil tests they compared it to, it did at least produce results that confirm that executive function deficits are present in the child.

Finally, another reason to use this kind of technology when looking for indicators of “real” ADHD (and not just anxiety, or some other behavioral disturbance) and EF deficits is that kids like to do it:

VR technology seems to enhance participant enjoyment leading to increased motivation (Rizzo et al., 2004). The use of VR appears to reduce motivation problems and ceiling effects reported in paper–pencil cognitive tests (Rizzo et al., 2004; Schultheis et al., 2002).

So let’s get those goggles going in our doctors’ offices, and help people realize how real – and not virtual – this attention problem is!