Acceptance of virtual reality to promote attention orientation in children: a qualitative study among children with ADHD and neurotypical development

Abstract

Background

Immersive Virtual Reality (VR) could be a practical tool for supporting ADHD children in learning to manage their symptoms better. However, VR applications are often addressed to the adolescent/adult population only and few studies have applied VR in children with ADHD.

Objective

To evaluate the usability and acceptance of a custom-designed VR environment in children with ADHD and with neurotypical development.

Methods

Nine children aged between 7-11 with ADHD and ten age-matched children with typical development were enrolled and tried the VR environment once. Questionnaires were administered to evaluate technology acceptance and children’s satisfaction. Objective data recorded by the VR application and observations from the therapists while supervising children’s interactions within the virtual scenario were also taken into account.

Results

No significant differences emerged among the two groups for any of the investigated variables. Satisfaction with the experience was high in both groups. Children specified that they found the VR application very fun, well-organized, and suitable for use. There was a tendency toward a greater appreciation for the usefulness of the VR application among ADHD children compared with their neurotypical peers.

Conclusions

Results suggest that, beyond individual characteristics and ADHD presence, children generally exhibited a positive attitude toward VR technology; the potential for retaining high levels of involvement, which can positively influence motivation and treatment compliance, was highlighted, thus making the proposed VR environment suitable for future clinical use.

Introduction

Over the past few decades, digital technology has evolved significantly, transforming multimedia tools, initially static and based on screens, into more dynamic and engaging environments, such as virtual reality (VR) [1]. VR creates immersive three-dimensional (3D) environments where users can fully engage in multidimensional, interactive, and realistic experiences [2].

With its unique ability to evoke and/or exercise behavioural, motor, and emotional responses that mirror real-life experiences, VR has found successful application in neuromotor and cognitive rehabilitation [3,4]. Its engaging nature configures it as a motivating, safe, and controlled learning environment [5–7]. Several studies have also explored its use and efficacy in treating and diagnosing children with Attention/deficit-hyperactivity disorder (ADHD) [6,8–13].

ADHD is a neurodevelopmental disorder characterized by an attention/hyperactivity deficit of neurobiological origin. It is defined by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with the child’s normal psychological development and hinders the performance of common daily activities in different life contexts, such as school, play, and family [14].

In this context, digital technologies and VR are particularly useful in tasks requiring alertness, attention, inhibitory control, and impulsivity management, as well as general behaviour and learning abilities [15–20]. VR’s role in rehabilitation treatment has shown significant effects, creating a learning environment with intrinsically motivating and safe playful characteristics, providing stable and controlled stimuli over time, and adapting to the patient’s specific needs. This feature encourages cognitive skills development and improves the behavioural aspects of children with ADHD [11,21–24]. The use of VR in ADHD therapy introduces an innovative approach, complementing traditional methods with technological tools that provide immersive and controlled experiences.

Given the heterogeneous clinical profiles associated with ADHD, VR-based interventions must be personalized, addressing specific attentional, impulsive, and emotional regulation deficits in a targeted manner [25].

Nonetheless, along with the therapeutic effects and positive emotional engagement, it is known that adverse effects can occur when interacting with VR. The best-known of these is cybersickness, a condition causing malaise accompanied by symptoms such as nausea, headache, dizziness or disorientation [26]. For these reasons, the literature emphasizes the importance of research that verifies that the characteristics of VR technologies meet their users’ specific needs. This is especially significant in children and children with ADHD, in particular. The recommendations about the use of VR in children below the age of 13 are indeed still mixed. For instance, some Head-Mounted Display (HMD) companies have specified that their products should not be used by children below the age of 12 (e.g., Sony) or 13 (e.g., Meta), while others suggest adult supervision (e.g., HTC). In addition, HMDs are generally developed considering the adult population, so the risk of symptoms, depending on the wrong ergonomic design, may be present [27]. In the case of children with ADHD, their susceptibility and unpredictability make them an even more vulnerable population due to the interplay of cognitive deficits, emotional dysregulation, peer relationship problems, comorbid psychopathology, and increased exposure to risk [28,29]. Furthermore, children with ADHD may be particularly susceptible to cybersickness due to their existing challenges with balance and motor cognitive control; they can often exhibit sensory over responsivity, which is linked to anxiety and sensory processing issues and, for this reason, children with ADHD may be more susceptible to sensory overload, which could potentially exacerbate symptoms like nausea or eyestrain when using HMDs [25]. Moreover, ADHD is associated with lower balance scores and impaired habituation to peripheral stimuli; the deficits in motor and cognitive control which could exacerbate the disorienting effects of VR environments, potentially leading to increased motion sickness or discomfort [30]. Therefore, the motor control issues associated with ADHD could lead to difficulties in maintaining the steady head position required for optimal use of HMDs [31].

On the other hand, recent preliminary studies have shown that these technologies are safe in terms of symptom arousal [32–34].

Given these considerations, a significant gap remains in the literature regarding the evaluation of digital applications, mainly when applied to vulnerable populations [35]. The recent technology progress and its growing potential call for an increased focus on the acceptance and usability throughout all the phases of the development of VR applications [16], as these will be crucial in determining the effectiveness and safety of these tools for their target users.

This study aims to evaluate the usability and acceptance of a custom-designed immersive virtual environment in two age-matched groups of children with ADHD and neurotypical development. The application, explicitly tailored for rehabilitation or assessment purposes, foresees different search tasks with an increasing level of difficulty to perform in a living room [36]. The study involved age-matched samples of children diagnosed with ADHD and children with typical development who were asked to try the VR experience once and to rate it according to different scales. We hypothesized that children would fully accept virtual environments and that their conscious use would not induce negative effects and cyber-sickness. Demonstrating usability and acceptance represents a critical first step toward the clinical deployment of novel digital interventions. Beyond delivering clinical effects, such tools must first be user-friendly, intuitive, and engaging to support adherence and actual use throughout time.

Related work

The best-known application in the treatment of ADHD through virtual reality is the Virtual Classroom (VC) [37], which has proven to be valid support both for the evaluation of neuropsychological and behavioural functions in the presence of ADHD and a promising rehabilitation tool for attention processes, thanks to the possibility of measuring parameters such as errors of commission and omission, mean response time, motor activity and quality of attention. The studies performed using the VC confirmed its ability to quantify measures and, therefore, carry out more precise behavioural monitoring than in traditional tests. Studies show that children with ADHD, compared to participants with normotypic development, have a higher number of errors of omission and commission, excess motor activity, a slower response time, and a lower score in processing speed and working memory [6,38–40].

More recent studies [10] have focused on the potential of creating virtual environments as an alternative to VC, such as free play environments (e.g. the schoolyard, the park, etc.), in which the main focus is represented by the basic activities of daily life, including the possibility of exercising social skills. These skills represent an essential problem in the early stages of interactions and a risk factor for subsequent psychopathological disorders [10,33,41–44]. The environment created can be customized according to the patient’s characteristics and programmed to make the task more enjoyable, providing feedback and guidance during the activity, thus preventing children from losing interest. This approach not only fosters the child’s interest in learning but also has direct positive effects on attention skills and the reduction of impulsivity [45]. As a rehabilitation tool, this environment is potentially helpful to increase compliance and motivation in the child because it is pleasant and easy to use [13] while improving adherence to treatment and motivation in patients [46].

Several studies have confirmed the beneficial effects of ecological virtual environments on cognitive functioning [21,24], the perception of time, which is often inaccurate in children with ADHD [47], and social behaviour [12,24,33,48]. Specific features of virtual environments that influence children’s attentional performance, such as the presence of a virtual teacher and the addition of social elements, have also been identified [22,23,49].

On the basis of what was reported in the literature, the virtual environment used in this study was developed to promote attention orientation, inhibit impulsivity, increase sustained attention span, strengthen memory, and increase children’s motivation and involvement in carrying out the required task [36]. The main difference between the proposed VR environment and the ones present in literature consisted of the higher levels of interaction; indeed, children could walk freely in the 3D world and manipulate all virtual objects. This may contribute to reinforcing the learned skills according to one of the principles of the embodied cognition perspective, in which it is emphasized that mental operations and skills are structurally shaped by physical actions [50].

A second innovative aspect with respect to other studies exploiting HMD consisted in proposing a familiar and easily recognizable environment, i.e., a living room, going beyond the typical VC [21]. This setting could facilitate the transfer of skills from immersive VR to daily life contexts thanks to ecologically valid task designs that might ease the generalization process. Finally, this study was designed to consider gender equality and enable the evaluation of how neurotypical developing individuals perform in the same virtual environment [51].

Methods

Recruitment

The study was conducted between September 2023 and January 2024. The project was approved by the Ethics Committee of the University of Milan (ID MP_77.21, 28^th June 2021) and by the Territorial Ethics Committee (CET) Lombardy 3 (ID 4288_S_N, 13^th December 2023). The study was carried out in compliance with the Declaration of Helsinki. Through purposive sampling, ten children of both sexes were diagnosed for ADHD, through an assessment made by clinical professionals following established guidelines (e.g., according to the International Classification of Diseases 11th Revision, ICD-11 [52], and/or the Diagnostic Statistical Manual of Mental Disorders, DSM-5; [14]; ADHD Rating Scale [53], Conners’ Rating Scale-Revised [54], Child Behavior Check List [55], Continuous Performance Test [56], Behavior Rating Inventory of Executive Function [57]). Recruitment took place at the Childhood and Adolescence Neuropsychiatric Unit, ASST Grande Ospedale Metropolitano di Niguarda, Milan, Italy. In addition, ten age-matched children with typical development were recruited as a control group.

Inclusion criteria were age between 7 and 11, absence of major psychopathologies, language disorders, and visual disturbances that would prevent access to the system, knowledge of the Italian language. The only exclusion criterion was the inability to provide written informed consent from a parent or a legal representative.

The enrolment of the participants took place after detailed information was provided to parents and children on the research characteristics and the signing of informed consent by the parents or legal guardians, anticipated by email one week before the trial, so that they could view it. For the choice of the sample size, we relied on studies that document that, to evaluate usability and subjective perceptions, small samples consisting of 8-10 participants are sufficient [58,59]. Moreover, we aligned with previous studies investigating user-experience at early stages in similar contexts [60,61].

Equipment

The immersive VR-based application used in this study, namely VADDAI and formerly presented in [36], was designed and developed by a group of researchers from the University of Milan (UNIMI) and the Institute of Intelligent Industrial Systems and Technologies for Advanced Manufacturing (STIIMA) of the National Research Council (CNR).

The application was developed using Unity and deployed for Meta Quest 2. The VR environment consisted of a furnished living room. A blackboard on which target objects appeared was placed on one of the walls (Figure 1, on the left). The game required the child to look for an object in the room, grab it, and put it in a basket (Figure 1, on the right); such an object was first shown on the blackboard for a certain amount of time, which varies depending on the difficulty level in which the game is articulated.

Figure 1.

Two screenshots of VADDAI VR environment. On the left side, the blackboard the children should watch to know which object has to be found; on the right side, the end of a task, with the placement of the target object in the basket.

The game includes an initial warm-up phase in which the child, through direct experience, becomes familiar with VR technology (HMD and controller) and the game environment. Once the warm-up session had been completed, a synthetic voice informed the child that the game had begun. The artificial voice guided the child during the activity. It supported them in moments of difficulty, i.e., when the child made a mistake or hesitated too long before performing the task. In these situations, the guiding voice invited the child to try again or helped in the search for the object, motivating him and directing him towards the target. When the task was completed correctly, sound feedback was provided and acted as a gratification and reinforcement for the child, who could then continue directly to the next step and the new request.

The game was divided into six levels of increasing difficulty, as the target appeared among an increasing number of objects, and a series of elements were introduced to distract the child (e.g., an unexpected noise, a flying butterfly). Each level consists of three rounds; once the participant has completed them, he/she can move on to the next level.

Protocol

Before starting the experience, demographic data regarding the child was collected.

To enhance participant comfort and usability, a dedicated familiarization phase with the VR setup was included, consistent with existing recommendations [46]. The child was then introduced to the VR room and instrumentation, the game dynamics, and how to use the controllers. An initial training phase (‘warm-up’) was performed at the beginning of each VR experience. During this phase, the therapist, who has the task of explaining the game and showing how to use the controller, guided the child and checked the correct wearing of the HMD and the application’s functionality. The game session began following the warm-up with the various levels and rounds. Throughout the game, both therapists and researchers monitored the session via PC, intervening when necessary to support the child. Every request for help was documented.

At the end of the VR experience, each participant completed a series of questionnaires aimed at investigating their subjective feelings and perceptions.

The total duration of the experiment was approximately 60 min for each child, with the VR experience lasting around 10 to 15 min.

Outcome measures

The following instruments were used to investigate the VR-related user experience. First, a series of questions was elaborated on the basis of the Technology Acceptance Model [62,63]. This questionnaire is widely used in the literature to analyze the acceptance and use of information technologies in virtual reality experiences [64–66] and to assess the patient’s acceptance of the device in rehabilitation settings [67]. In particular, five items were re-formulated to make the questions appropriate to the child’s age, resulting in five questions addressing the following domains: clarity, fatigue, ease-of-use, quality of the interaction, and pleasantness of the experience. Scores were given via a Likert scale ranging from 1 (most negative response) to 10 (most positive response).

Child satisfaction was assessed with a 5-level Likert scale, where 1 indicated ‘not at all’ and 5 ‘very much’, using smileys with different expressions and colours to highlight the various response categories [68]. Open questions investigating children’s engagement, satisfaction with the experience, and general suggestions for improvement were also included.

Finally, a checklist was created ad hoc to investigate the quality of the child’s performance, considering the following objective variables: efficiency of use (i.e., number of errors, time required to complete the tasks, task completion), and the number of times in which assistance was requested outside of the game. The time, the number of hints provided by the application, and the number of errors were stored in a .txt file saved on the HMD. Additional observations not directly inferred from these variables, such as the child’s general behavior while wearing the HMD, requests for help, and verbal comments during the experience, were also noted by the experimenters for further analysis. All data were collected in pseudonymized form, with the participants’ identities accessible only to the research’s scientific contact person and designated team members.

After the end of the study, ad-hoc designed questions were administered to the researchers and therapists who attended the experimental session (N = 3) to collect additional qualitative data that can inform possible future improvements of VADDAI application. More in detail, these questions were investigating: (i) the VR application issues and their possible solutions; (ii) the children’s behaviour they have observed throughout the experimental campaign; (iii) any other opinion or suggestion for improving the application.

Statistical analysis

Data descriptive statistics are presented as medians and interquartile ranges (IQR). As the sample was small, non-parametric tests were employed to examine the differences between the children with normotypic development and those with ADHD. In particular, the differences between groups were analyzed using the Mann-Whitney test for continuous variables and the Fisher exact test for gender. Correlations between continuous variables (i.e., age, time needed to complete the app, and subjective data collected via questionnaire) were assessed using Spearman’s correlation coefficients, while correlations between binomial (i.e., gender, ADHD yes/no, number of errors, requests of assistance, maximum level reached) and continuous variables were calculated using Point biserial correlations.

Data from the open questions administered to the experimental session supervisors were analyzed using thematic analysis.

Results

Nineteen children were enrolled in the study, with ten in the healthy group and nine diagnosed with ADHD. The demographic and personal characteristics of the participants are summarized in Table 1.

Table 1.

Demographic characteristics of the participants. Age is reported as median (IQR).

	Healthy	ADHD
No.	10	9
Age (yrs.) (mean ± SD)	9.58 (0.00)	9.01 (0.00)	Mann Withney U = 37 p = 0.54
Gender (M/F)	6/4	5/4	odds ratio: 1.2 CI [0.19-7.44]

In the sample of children with ADHD, six had undergone either speech therapy (n = 4) or psychomotricity (n = 1) or both (n = 1), and four were still enrolled in a rehabilitation program at the time of the test. Only one child underwent pharmacological therapy. All the participants completed the experience, except one child in the healthy group, who asked for the help of the therapist to interrupt the experience due to the occurrence of cybersickness; subjective and observational data of this child were collected too.

The results of the questionnaire on technology acceptance are displayed in Figure 2. Despite the different distributions of the two sets of data for the variables investigating application clarity, perceived fatigue, and ease of the interaction, no significant difference emerged with the Mann-Withey test (p > 0.05 for all questionnaire items). Figure 3 shows the results for satisfaction; also in this case, no significant statistical differences emerged, even if for the learning component, healthy children gave more sparse and lower judgements.

Figure 2.

The responses of the two groups of children (n = 9 ADHD, n = 10 healthy) to the questionnaire investigating technology acceptance. No significant differences emerged between the two groups.

Figure 3.

The responses of the two groups of children (n = 9 ADHD, n = 10 healthy) to the questionnaire investigating their satisfaction. No significant differences emerged between the two groups.

No significant correlations were found between age or condition (healthy vs. ADHD) and objective (total time, errors, maximum reached level, and requests for assistance) and subjective variables.

Besides the child who interrupted the test, other complaints of cybersickness included only slight symptoms. In particular, 6, of which 3 children with ADHD, out of 18 reported some slight symptoms; these were all known symptoms related to the experience of immersive virtual environment. These comments, along with other children’s answers, are summarized in Table 2. It has to be noted that not all children answered the open questions and reported additional information about their experience.

Table 2.

Comments referred by the two groups (n = 9 ADHD, n = 10 healthy) of children after the VR experience as a result of the open questions.

	Topic	Group	Quote(s)
Dislikes	Voice	Healthy	‘[I did not like] that the voice was always repeating the same things’
	Virtual boundaries	Healthy	‘[I did not like] that I saw virtual walls’
	Missing object	Healthy	‘In the last part, I was a bit annoyed because I could not find the target object’ ‘The target object disappeared all the times’
		ADHD	‘[I did not like it when] I could not find the book’ ‘Can you tell me when the last object was?’
	Interaction	ADHD	‘I could not grab the cube’ ‘I tried to grab the cube, but it was not working’
	Other	ADHD	‘I felt like the cube was staring at me’
Expectations	Setting	Healthy	‘I was expecting to meet with other children’
	VR application	Healthy	‘It was very well-structured’
		ADHD	‘It is good for children’ ‘It was fun’
Symptoms	Eye disturbance	Healthy	‘My eyes hurt a little’ (n = 2, in one case, it led to test interruption)
	Disorientation	Healthy	‘At the beginning, it was a little weird’
		ADHD	‘I felt dizzy’
	Ergonomics	Healthy	‘My neck was hurting’
		ADHD	‘I sweated’ ‘The HMD was a little annoying’

The objective data collected during the test are presented in (Table 3). No significant differences were present between the two groups.

Table 3.

Objective performance variables in the two groups of participants (n = 9 ADHD, n = 10 healthy) reported as medians (iqr). # indicates the number of occurrences of a certain event.

Variable	Healthy (median, IQR)	ADHD (median, IQR)	Mann Whitney U	p-value
Max level reached	5.5 (3)	6 (1.5)	42.0	0.86
Total time [min]	12 (2.5)	12 (3.5)	35.5	0.45
Total errors [#]	4 (2.25)	6 (9.5)	38.5	0.61
Commission errors [#]	3 (2.25)	5 (5.75)	30.0	0.23
Omission errors [#]	3 (1)	2 (3.5)	35.0	0.43
Assistance: in-app [#] external [#]	1 (1) 6 6	2 (2.25) 8 5	30.0	0.35
Reasons for interruption (#)	Low battery (1) Target outside virtual room (5) Asked for interruption (1)	Target outside virtual room (5)

This data includes what was recorded by the VR application and what was noted by the researchers supervising the session. One of the reasons that led to the interruption of the experience was the drained device battery. In other cases, the experience had to be interrupted because the target object to collect was outside the game area and thus no longer reachable by the child. This issue occurred for two reasons: the first was that the children intentionally threw the object outside the game area. Instead, in the second case, the incorrect placement of the object, either outside the safety boundaries or below the floor, was caused by the unintentional incorrect handling of the object. Such a situation is thus ascribable to a bug of the application that did not emerge during the previous validation phases of VADDAI [36].

All of the errors committed by healthy children were due to exchanging the target object with a similar one (e.g., vase instead of plant, Android vs. iPhone), or with the same object, but with a different color/material (e.g., wood vs. grey ruler, green book instead of red agenda). In only one case, the objects were very different from the target ones, but they were errors committed during the third, fourth, and fifth attempts to collect the iPhone object, after having picked the Android phone twice, possibly indicating that the child was frustrated or annoyed by that search task. It has also to be underlined that these errors occurred in the final level of the application, where the most challenging tasks occurred.

The same pattern was also approximately preserved by most of the children with ADHD. However, in one case especially, the recorded errors showed completely wrong associations (a bowl instead of a pen, a vase instead of a red agenda, etc.). For another participant with ADHD, errors were high because s/he took all the most similar distracting objects mentioned above. In one case, even a typically developing child showed signs of distraction and disorganized behaviour, ignoring the task and instead interacting chaotically with the distractor objects in the room, ultimately obscuring the target object and making it impossible to proceed with the session.

The answers collected by researchers and therapists supervising the test sessions with children could be grouped into three topics: app-related comments, general children’s behaviour, and ergonomics issues. As for the first topic, the main problem that emerged was that the highlighting of the target object was a hint that was often misunderstood or not noticed by children; indeed, several participants (14 out of 19) asked for help when the target object was highlighted because they did not know how to move forward. The second relevant app-related aspect was related to the use of a stand-alone device. Although the affordability and the easy setup drove this choice, the Meta Quest did not allow the operators to intervene directly while the child was playing with the app. They could only observe the scene (via the mirroring function provided by Meta) and guide the child toward solving the issue. Furthermore, when the target object was pushed outside of the virtual boundaries, the researchers could not reset the environment to the previous state. Instead, they could only restart the application.

Regarding the general children’s behaviour, the researchers noted that all participants were involved in the game and committed to completing the task. However, in the case of children with ADHD, their head and body movements were faster and more fragmented; in one case, it was difficult for the researcher to watch the application mirrored on the computer screen because the motion was too frantic. In a couple of cases, this specific behaviour of two children with ADHD led to the throwing of the target object outside the virtual game boundaries, making it impossible to continue the session. In some other cases, children were more cautious and took a long time at the beginning to get used to natural walking in the virtual scenario; this was, however, mostly attributable to personal characteristics, rather than group belonging.

Finally, researchers pointed out that some of the ‘smallest’ children had difficulty in wearing the headset (the participant had to hold it or re-adjust its position frequently), and handling and using the controller, especially when it came to coordinating hand motion and pressing the trigger button to grab and move objects around.

Discussion

Principal results

This study investigated the usability and acceptance of an immersive VR application by a sample of children diagnosed with ADHD and a group of typically developing children. Previous research [8,69] has highlighted the importance of evaluating VR applications in clinical populations for their potential therapeutic benefits.

The questionnaire investigating technology acceptance revealed no significant differences between the two groups. Previous studies reported that technology use in children with ADHD may be impacted by motor coordination challenges [10]; however, in our case, this did not emerge as an issue for this specific population. Instead, researchers noted that children with smaller anatomical sizes, regardless of their conditions, were the most challenged ones in using the Meta Quest controllers.

In general, satisfaction with the experience was high in both groups. However, there was a greater appreciation for the usefulness of the game among ADHD children compared with the group of normotypic peers. The higher ratings in the learning scale assessment were probably driven by the fact that children with ADHD found the application more challenging and, therefore, more potentially helpful.

Among the generally least appreciated aspects of the application in both groups were the repetitive voice, virtual boundaries, difficulties finding the target objects, and interruption of the game due to application bugs. The presence of the guiding voice, which repeated the instructions of the tasks at the end and beginning of each round, was linked to the need to draw the child’s attention to the task, a strategy that can be particularly useful in ADHD.

From the analysis of the open answers regarding satisfaction, generally speaking, positive observations emerge about the serious game: some children specified that they found the game very fun, well-organized, and suitable for use with children. One participant reported that he expected a different activity involving other children.

The observations of the operators providing support to the children during the test and monitoring the execution via PC revealed that some children needed more time to adapt to the experience, moving more cautiously and awkwardly. For example, some children extended one arm to protect themselves from the real environment and showed difficulty navigating extra-personal space. Children with ADHD exhibited larger and faster head movements while exploring the environment, in line with visual-attentive difficulties and in shaping an organized exploratory sequence. Such behaviors reflected findings from [41], which described the impact of attentional deficits on spatial navigation in VR environments. In contrast, other participants immediately immersed themselves in the VR environment, demonstrating rapid, effective movements. This variability could be attributed to prior experience with VR or gaming systems (e.g., PlayStation, Nintendo Wii) and individual predisposition.

Performance results showed that only a subset of children in both groups completed the game, with higher variability among typically developing children (IQR = 3) compared to ADHD (IQR = 1.5). Median completion times were similar between groups (12 min), with ADHD participants showing slightly greater variability (IQR = 3.5) than neurotypical children (IQR = 2.5).

Device-related issues were common reasons for interruptions, particularly among children with smaller builds who struggled with controller handling. For example, target objects were occasionally misplaced beneath the floor of the virtual room, making them unrecoverable. Other common issues included the lack of constraints for object interaction, leading to children throwing objects outside safety boundaries. This issue was more frequent among ADHD participants, likely due to clinical characteristics such as hyperactivity and reduced inhibitory control [24].

The total number of errors was not significantly different when comparing the two groups of children. However, results showed that some children with ADHD made several mistakes (up to 21), particularly commission errors, linked to difficulty discriminating target object details (e.g., colour, material). It is thus possible that the lack of statistical significance had to be attributed to the small sample. This would also be consistent with what was previously reported [44], which identified similar challenges in sustained attention and error discrimination in ADHD children. Omission errors were associated with distractibility and challenges in maintaining focused attention. These findings align with existing literature [44,69] and underscore the potential of the VR application as a training tool for key aspects of ADHD, including attention, inhibitory control, and strategic planning.

Very often, it has indeed been observed that children with ADHD tended to pay less attention to the indications provided by the application, becoming distracted when the object to be searched for is shown and therefore not being able to search for the correct target or less capable of maintaining attention on the target shown for a time sufficient to analyse the characteristics of the image accurately. These characteristics relate to ADHD, well-known selective attention and distractibility, as well as executive difficulties, such as reduced inhibitory control and poor strategic planning ability. Specifically, regarding commission errors, it has been observed that the tendency to commit errors is linked to the ability to discriminate the details of the target objects, such as, for example, the materials, dimensions, or other specific characteristics (e.g., colour). This aspect can still be related to the less time children with ADHD dedicate to analysing the details of the target image, listening to verbal requests, and being easily distracted, although it impacted also the performance of healthy children. Nonetheless, the marked lack of sustained attention among children with ADHD emerged in a subgroup of children making more and more severe errors (i.e., the target object was exchanged with a completely different one). Errors of omission probably related to the tendency of these children to distract themselves by exploring the room and the difficulties with focused attention. Therefore, the performance data described so far are in favour of the use of the proposed application for ADHD treatment as an activity that can promote gradual training of the key aspects of this disorder.

Regarding the assistance provided during the test, in both groups, several interventions were provided by the system (in-app), through the illumination of the target object to facilitate its identification, and by the operator (external). In particular, in the ADHD group, the system provided more assistance due to the difficulty in finding the target objects. On the contrary, the support operators offered due to technical problems was comparable to that offered to the control group. The designed aids proved thus effective, enabling the children who used them to find the correct targets.

Overall, this study supports the feasibility of using VR applications for ADHD intervention, emphasizing the importance of tailored designs to address this population’s specific challenges. Similar recommendations have been made in recent literature [24], which advocates for adaptive designs in VR applications to meet the cognitive needs of ADHD users.

Although the present study did not directly assess whether the use of the VR application translated into measurable improvements in attention or behavioural regulation, the high levels of usability and acceptance observed among the whole sample of children were encouraging and represented critical factors in promoting user engagement. Engagement, in turn, is a well-recognized determinant of treatment adherence, especially in pediatric neurodevelopmental populations, where motivational barriers are common. As such, these preliminary findings offer a rationale for the development of larger-scale clinical trials.

Conclusions

This study is a preliminary investigation of the feasibility of applying VR technology to support clinicians in treating children with ADHD.

VR was found to be both acceptable and enjoyable for children in both groups, with no significant differences between them, except for a perception of greater difficulty in using controls by ADHD participants. Satisfaction with the experience was high across both groups, with ADHD children demonstrating greater appreciation for the game’s usefulness compared to their typically developing peers. This was probably because children with ADHD found the application more challenging and, therefore, more potentially helpful.

These results align with clinical findings that suggest children with ADHD often benefit from structured and interactive environments that provide immediate feedback and reinforce sustained attention and behavioral control [10,69].

The outcomes also echo studies indicating that task-specific challenges can enhance motivation and task engagement in ADHD populations, as seen in environments designed to cater to their unique cognitive and behavioural needs [6,44]. The observed preference for challenging tasks may stem from the enhanced stimulation these tasks provide, which aligns with known characteristics of ADHD children who thrive in high-stimulus contexts [21].

Eventually, the results suggest the potential for retaining high levels of involvement, which can positively influence motivation and treatment compliance, highlighting the potential of the proposed virtual environment for future clinical use.

Limitations

We acknowledge that the sample size of our study was small. Due to this, it was not possible to assess correlations between current or past rehabilitation interventions and the quality of gameplay performance in children with ADHD.

The quantitative analysis of the data regarding the performance of children with ADHD showed high variability, likely attributable to the different levels of severity of manifestation of the disorder in the enrolled participants, which evaluation was not, however, among the objectives of this study. Nonetheless, this study was an early-stage trial not aiming for full efficacy; we were mostly interested in detecting the tendency shown by quantitative variables and by qualitative outcomes, being aware that children with ADHD had different health conditions, technology attitudes, and personal preferences. Moreover, we aimed to enroll a sample that could represent the variability of ADHD populations referring to a general hospital. The study, in this sense, was helpful in identifying potential points of interest that deserve further investigations in future work, e.g., one participant with ADHD for whom pharmacological treatment was in place ended the game with fewer errors.

Despite these limitations, the study achieved its primary aim of assessing the usability, feasibility, and acceptance of an immersive VR application for children. Results across both groups were consistent and satisfactory, suggesting that, beyond individual characteristics, children generally exhibit a positive attitude toward the proposed technology.

Future developments

Several considerations can guide improvements in the application’s usability. Increasing the age threshold or providing extended familiarization sessions with the technology may be beneficial to address controller-related difficulties. Additionally, modifying the virtual environment to include interaction constraints or resetting object positions could resolve issues with misplaced objects, even at the expense of environmental realism. Finally, integrating an eye-tracking system could enable better monitoring and understanding of ADHD children’s zones of interest, further enhancing the application’s effectiveness in supporting clinical objectives.

Further developments should also explore adaptive technologies that account for varying severity levels of ADHD, integrating features such as task-specific feedback and performance analytics. Finally, new ecological scenarios and more adaptability should be introduced to ensure that children can sustain engagement with the VR app over time. In fact, as children with ADHD become increasingly familiar with the application, the task structure, and the progression of levels, the novelty effect may diminish, potentially decreasing their attentional involvement and motivation during repeated sessions and negatively impacting the clinical effectiveness.

These adjustments, informed by findings from clinical ADHD studies [10,22], could in fact optimize the VR environment not only from the usability point of view, but also in terms of therapeutic impact. Future studies in this direction are needed; such studies should adopt longitudinal and controlled designs to evaluate clinical attention and behavioral outcomes and enroll a larger and more homogeneous sample of children with ADHD to assess the application’s effectiveness, determine the optimal intervention strategy, and eventually promote its actual use in clinical settings.

Funding Statement

This work received no funding.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data is available upon a reasonable request.