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

Abstract

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.

Keywords: ADHD; head movement; multiple sensory modalities; social cues; virtual reality.

FIGURE 1

Virtual reality (VR) classroom environment. VR classroom condition presented to the participants. (A) No-cue condition, in which the teacher avatar was presented in the center of the visual field without presenting any social cues. (B) The visual cue (hand gesture) provided by the teacher avatar in the visual cue condition and the visual/audio cue condition. The images are presented in chronological order; the teacher avatar gestures toward one screen, then the stimulus appears on the pointed screen.

FIGURE 2

Correlation analyses in the ADHD group between head movement measurements and the ADHD-RS total score. (A) Correlation with average pitch, (B) correlation with average yaw, (C) correlation with average roll, (D) correlation with average task-irrelevant movement. ADHD-RS total scores of the ADHD group had statistically significant correlations with yaw movement (i.e., task-relevant head movement) and task-irrelevant head movement averaged across all four conditions. Linear fit lines are provided for results with p < 0.05.

FIGURE 3

Comparison of task-irrelevant head movement between conditions by group. The main effects of the condition and group-by-condition interactions were statistically significant, while the main effects of group were not. According to the post-hoc analyses performed with FDR correction, the healthy control (HC) group showed statistically significant differences between all conditions; however, the ADHD group did not show a significant difference of task-irrelevant head movement between the visual and visual/audio cue conditions.