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6 Sep 2019

Areces D et al. Brain Sci 2019; 9: E274.

Executive functioning is reportedly impaired in individuals with ADHD and can be associated with the behavioural symptoms of the disorder (Barkley and Murphy, 2010). Incorporation of virtual reality (VR) into the development of reliable, ecologically valid measures of ADHD symptoms has shown promise (Rodríguez et al. 2017), as participants are immersed in a realistic, rather than artificial, environment whilst the objectivity of the test is maintained. The aim of this study was to determine whether a validated VR test, Nesplora Aquarium, was able to predict current and retrospective self-reports of ADHD symptoms in adolescents and adults.

A non-clinical sample of adolescents and adults (aged 16‒54 years) participated in the study. The Spanish version of the Adult ADHD Self-Report Scale (ASRS) was used to measure current ADHD symptoms. Retrospective symptoms of ADHD were measured using the ADHD subscale from the Wender Utah Rating Scale (WURS), using the Spanish adaptation. Use of the VR test provided the following variables: correct responses, omissions, commissions, response time, variability, switching and perseveration errors. The first regression model, Model 1, included the effect of age, gender and the variables of the Nesplora Aquarium. Model 2 added the number of omissions, commissions and response time in task 1 to the previous model. Model 3 added the omissions, commissions and response time in task 2 to the previous model.

In total, 156 participants (mean age 21.23 years [standard deviation (SD) 8.04]; 55.1% male) in Spain completed the task. Participants reported a medium–high socioeconomic level; 13.4% had completed up to secondary education and 86.6% had university qualifications. Overall, 53.3% of participants were defined as mid-to-late adolescents (aged 16‒20 years; mean age 16.74 years [SD 1.097]) and 46.8% were classified as adults (aged 21‒54 years; mean age 27.55 years [SD 9.108]). No participants reported an ADHD diagnosis or other psychiatric or neurological disorder.

Model 1 was shown to predict the majority of variance explained (R2) in current ADHD symptoms (R2 = 0.940, p < 0.001). For all of the variables included in Model 1, only the number of correct answers (R2 = 0.983 [3.919], p < 0.001) and omission errors (R2 = 0.159 [3.253], p < 0.001) were statistically significant variables in the prediction of current ADHD symptoms. Similarly, for retrospective symptoms of ADHD, Model 1, with four significant predictors (gender, R2 = 0.100 [2.603], p < 0.05; corrected answers, R2 = 0.859 [2.504], p < 0.05; omissions, R2 = 0.204 [3.066], p < 0.001; and perseveration errors, R2 = 0.229 [2.117], p < 0.05), explained 88.8% of the variance (R2 = 0.888, p < 0.001) in childhood ADHD symptoms. Introduction of the other variables in Models 2 (∆R2 = 0.002) and 3 (∆R2 = 0.001) did not show further significant increases in the variance explained compared with Model 1 for either current or predictive symptoms of ADHD (p > 0.05 vs Model 1).

This study had some limitations, including the fact that the sample size was small, which may limit the generalisability of these findings, and that a clinical sample of ADHD was not used. Inclusion of participants with ADHD would allow comparison of the present variables with the non-clinical sample used. There was also a wide age range used in the sample, and a limited number of participants in each age group; as such, since the symptoms of ADHD can vary over time, these results may not be generalisable. The authors indicated that additional measures of ADHD symptoms could be used in future studies, such as the Diagnostic and Statistical Manual of Mental Disorders – 5th Edition protocol. Finally, on the rating scales used, only six items were used to measure current ADHD symptoms, whereas retrospective ADHD symptoms were measured using 25 items.

The authors concluded that Nesplora Aquarium, a VR-continuous performance test, provided significant predictors of current and retrospective ADHD symptoms in adolescents and adults, showing independence, respondent subjectivity and ecological validity. These results suggest that inattention problems may remain after adolescence, while impulsivity (as measured by perseveration errors) and gender differences in ADHD may diminish through adulthood.

Read more about using VR to predict current and retrospective symptoms of ADHD in adolescence and adulthood here


*Nesplora Aquarium is a VR-continuous performance test designed to measure executive functioning in adolescents and adults. By wearing 3D glasses with sensors and headphones, participants are ‘immersed’ in a virtual aquarium. Following the go/no-go paradigm, participants complete three tasks. The first is task training 1/learning task 1, which consists of an AX (go-task) or 1-back paradigm; the participant must press a button when they see a clownfish, hear the word ‘clownfish’, or if the previous fish or word has been a surgeon[fish]. The second is task 1 (dual execution-Xno training/task), which is a Dual X_no or Dual No_go task, where the participant must press a button whenever a fish appears or a word is heard, except when they see a clownfish or hear the word ‘surgeon[fish]’. The third is task 2 (Dual execution-Inversion of the target stimuli in Dual execution-Xno task) which is also a Dual X_no or Dual No_go task, where the participant must press a button whenever a fish appears or a word is heard except when seeing the surgeon[fish] or hearing the word ‘clownfish’. Through the inversion of the target stimuli, it is possible to evaluate the control of interference by both switching capacity (cost of task change) and perseveration errors. The whole test can be completed in 20 minutes, with each task composed of 140 evaluation items and 20 training items
Measured variables included:
– Correct responses: the sum of the participant’s correct responses, considered a measure of working memory
– Omission errors: the sum of the participant’s errors (failing to press the button when they were supposed to), considered an indicator of attentional arousal in situations of high cognitive load for working memory
– Commission errors: the sum of the participant’s errors (pressing the button when they were not supposed to), considered an indicator of impulsivity
– Reaction time: average time the participant took to press the button when the target stimuli were presented, considered an indicator of processing speed
– Variability: the difference between the fastest and slowest reaction time, considered a measure of changes in sustained attention or fatigability
– Switching: the difference between the participant’s correct response in the last part of the task and the beginning of the next task, considered an indicator of the capacity to shift attention
– Perseveration of errors: the errors registered in the dual execution tasks, considered a marker of cognitive flexibility
Group 1: 16‒20 years; Group 2: 21‒25 years; Group 3: 26‒30 years; Group 4: 31‒35 years; Group 5: 36‒40 years; Group 6: 41‒45 years; Group 7: 46‒50 years; Group 8: 51‒55 years

Areces D, García T, Cueli M, et al. Is a virtual reality test able to predict current and retrospective ADHD symptoms in adulthood and adolescence? Brain Sci 2019; 9: E274.

Barkley RA, Murphy KR. Impairment in occupational functioning and adult ADHD: the predictive utility of executive function (EF) ratings versus EF tests. Arch Clin Neuropsychol 2010; 25: 157-173.

Rodríguez C, García T, Areces D. New and future challenges concerning the use of virtual reality tools for assessing ADHD. Curr Dev Disord 2017; 4: 8-10.

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