Cognitive performance in adults with ADHD assessed through virtual reality: Differences across ADHD presentations

Background

Attention-deficit/hyperactivity disorder (ADHD) in adulthood is characterized by persistent difficulties in attention, impulsivity, executive functioning, and emotional regulation. Traditional neuropsychological assessments, while widely used, may lack ecological validity because they do not fully capture the complexity and dynamic nature of real-world cognitive demands. In recent years, virtual reality (VR) has emerged as a promising tool for cognitive assessment, offering environments that more closely resemble everyday situations. VR-based instruments, such as the Nesplora Aquarium task, allow for the simultaneous evaluation of multiple cognitive domains, including sustained attention, inhibitory control, and working memory.

Objective

The present study aimed to examine attentional and executive functioning profiles in adults diagnosed with ADHD using the Nesplora Aquarium VR assessment. Specifically, the study sought to: (1) identify potential differences in cognitive performance across ADHD presentations (Combined, Predominantly Inattentive, and Predominantly Hyperactive/Impulsive), (2) explore whether engagement in psychotherapy is associated with differences in neurocognitive functioning, and (3) investigate the relationships between VR-derived attentional measures and self-report assessments of emotional dysregulation, anxiety, and retrospective childhood ADHD symptoms.

Methods

A total of 37 adults diagnosed with ADHD participated in the study. Participants were classified into three groups: Combined presentation (n = 20), Predominantly Inattentive presentation (n = 13), and Predominantly Hyperactive/Impulsive presentation (n = 4). All participants completed the Nesplora Aquarium VR task, which provides objective measures of attentional performance and executive functioning. In addition, participants completed a battery of self-report questionnaires, including the Wender Utah Rating Scale (WURS) for retrospective childhood ADHD symptoms, the Difficulties in Emotion Regulation Scale (DERS), the State-Trait Anxiety Inventory (STAI-Y2), and the Multidimensional Emotional Disorder-related or temperament-related measure (MEWS). Given the sample size and distribution characteristics, non-parametric statistical analyses were employed, including Kruskal–Wallis tests, Mann–Whitney U tests, and Spearman rank-order correlations.

Results

Significant differences across ADHD presentations were found in total response time (H(2) = 9.41, p = .009) and response time variability (H(2) = 6.43, p = .040). Post hoc analyses indicated that individuals in the Combined presentation group demonstrated significantly slower response speed compared to those in the Predominantly Inattentive group. No significant differences were observed between participants currently engaged in psychotherapy and those not receiving psychotherapy. Furthermore, six significant correlations emerged between VR-based cognitive variables and self-report measures. Notably, perseverative errors were strongly and positively correlated with MEWS scores (ρ = .638, p < .001), indicating a relationship between cognitive inflexibility and emotional or temperament-related difficulties. Commission errors were also positively associated with both MEWS and DERS scores, linking inhibitory control deficits with emotional dysregulation. In contrast, working memory performance was negatively associated with retrospective childhood ADHD symptoms as measured by the WURS.

Conclusions

These findings demonstrate that VR-based cognitive assessment can effectively detect meaningful differences in attentional and executive functioning across ADHD presentations in adults. Moreover, the observed associations between VR-derived measures and emotional, temperamental, and anxiety-related constructs provide further support for the ecological validity of VR tools. Overall, VR-based neuropsychological assessments represent a valuable and innovative approach for improving the evaluation of ADHD in adulthood.

References

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