Function-led assessment of children’s goal-directed behavior and ADHD symptoms in virtual reality

Objective, reliable, and ecologically valid measurement of goal-directed behavior and related cognitive processes, such as executive functions and prospective memory, has proven to be challenging. Difficulties in these cognitive domains can have severe consequences for everyday life, but current neuropsychological tests may not be optimal tools for the comprehensive assessment of such problems. It has been suggested that naturalistic tasks that simulate everyday life activities could provide the researcher and clinician with complementary means to better evaluate these important domains while allowing the assessment of other aspects of behavior, such as the symptoms of various clinical disorders like attention deficit/hyperactivity disorder (ADHD). The main aim of this Dissertation was to develop and apply a new virtual reality (VR) task, named Executive Performance in Everyday LIving (EPELI), as a more ecologically valid alternative for the assessment of goal-directed behavior in children. More specific aims included examining EPELI’s ecological validity, discriminating capacity for ADHD, reliability, usability, and potential cybersickness symptoms. Also, eye movement behavior was quantified to study visual attention in ADHD. In addition to the immersive head- mounted display version, a non-immersive version for flat screen displays was developed and tested. A total of 85 children with ADHD and 146 typically developing children aged 9 to 13 years took part in the four studies comprising this Dissertation. The results revealed that EPELI shows ecological validity by being associated with parent- rated everyday problems of attention and executive function. Furthermore, task performance in EPELI successfully discriminates between children with and without ADHD. Eye movement behavior can be used to further improve this discriminating capacity and to quantify visual attention in greater detail. EPELI has good usability, is considered enjoyable by children, and does not cause cybersickness symptoms. Moreover, most of its measures show adequate reliability. The non-immersive flat screen display version can be used remotely with commonly available hardware, but children consider it less immersive than the head-mounted display version. All in all, EPELI was shown to be a valuable complement to the assessment of goal- directed behavior in children. To our knowledge, it is the first immersive VR task for school-aged children that can be used to quantify goal-directed behavior and ADHD symptoms in open-ended everyday scenarios. EPELI provides rich yet well-controlled objective data that reflect these behaviors and symptoms. In clinical settings, such data could be used to complement survey instruments and interviews, which are subjective. Being able to replicate some aspects of real-life problems in simulated settings could also facilitate communication with the child, caregivers, and other stakeholders such as teachers. These findings encourage to extend the research on VR with function-led tasks like EPELI to other clinical neuropsychiatric conditions and further simulated contexts.