Effectiveness and User Experience of Immersive Virtual Reality in Cognitive Rehabilitation for Attention-Deficit/Hyperactivity Disorder: Systematic Review

Introduction

Background

Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder characterized by persistent difficulties with attention, impulsivity, and hyperactivity [1,2]. ADHD predicts psychosocial and occupational dysfunction, and increased health care and education costs [3]. Common treatments for ADHD include pharmacotherapy, behavior therapy, cognitive behavior therapy, behavioral teacher and parent training, organizational and social skills training, lifestyle change, or combination therapies [4-6]. These treatments can assist with cognitive rehabilitation, which aims to improve functional deficits in cognitive abilities, such as perception, attention, memory, and executive functions [7]. In recent years, innovations in immersive virtual reality (VR) technology have been integrated into cognitive rehabilitation treatments for ADHD [8].

Immersive VR commonly uses a computerized head-mounted display (HMD) to obscure the external environment and immerse individuals in a digital environment [9]. In contrast, nonimmersive VR provides digital environments displayed on monitors or projected onto screens, which do not obscure the surrounding environment. Interacting in nonimmersive environments is typically mediated by mouse, keyboard, or touchscreen [10]. Immersive VR technology holds greater promise for procuring therapeutic gains than nonimmersive VR due to its capacity to induce presence—the sense of being physically present in the digital environment [10]. For example, greater presence has been linked to enhanced memory performance in immersive VR [11], but not in nonimmersive VR interventions [12]. This may be because the heightened sense of presence in immersive VR is associated with increased enjoyment, emotional engagement, and attention; factors that can support information processing and retention, although findings remain mixed [13,14].

Immersive VR flexibly delivers cognitive rehabilitation treatment for ADHD [8,15-19]. For instance, HMDs can deploy customizable VR environments that contain distracting stimuli, simulated social interactions, and tasks that require multitasking in common settings such as work, home, and school [20-22]. Individuals with ADHD can practice their skills for focusing and coping in these controlled digital environments [15,16]. Immersive VR can minimize exposure to uncontrolled external distractions that interfere with focus, while also reducing reliance on inconsistent or delayed reinforcers, such as praise or outcomes contingent on facilitator availability [14,23,24]. Instead, it can incorporate strategically designed and controlled distractors [25,26] along with structured, immediate rewards, such as points or visual effects, to strengthen cognitive abilities through targeted training [27,28].

Immersive VR training experiences complement other cognitive rehabilitation treatments, such as pharmacotherapy and cognitive behavior therapy [8,19,29]. However, immersive VR may be uniquely beneficial compared with traditional treatments. For example, VR-based biofeedback has outperformed standard 2D hemoencephalographic biofeedback in treating attention deficits in children with ADHD [26]. The effectiveness of VR likely stems from its ability to heighten motivation and engagement during cognitive rehabilitation training [25,26,30,31]. Increased motivation may result from immersion [26], novelty in the virtual environment [12], or gamification elements such as material rewards (eg, coins, tokens) [27].

The motivational features of VR not only increase engagement but may also stimulate dopaminergic activity in brain regions involved in memory and executive functions [12,27,31]. This is particularly beneficial for children with ADHD who have dopamine deficits that contribute to impairments in cognitive functioning [12,27,31,32]. For example, children with ADHD typically show weaker memory encoding due to low dopamine levels in the substantia nigra and ventral tegmental area, midbrain structures that help regulate dopamine release into the hippocampus [12,33]. However, exposure to novel digital environments during a critical postlearning period can enhance dopamine release, triggering protein synthesis necessary to stabilize and consolidate memory traces [12].

Similarly, material rewards delivered through VR can stimulate dopamine release in the brain’s reward system [27]. Dopaminergic activity reinforces behavior by increasing motivation and enhancing prefrontal cortex activity, thereby supporting executive functions such as attention regulation and inhibitory control, which are essential for suppressing inappropriate actions and facilitating goal-directed behavior [27]. These mechanisms help explain how immersive VR uniquely engages dopaminergic and executive function networks impaired in ADHD, offering a neurobiologically grounded rationale for its therapeutic potential. VR-based interventions may also drive neuroplastic changes by repeatedly engaging neural networks involved in attention, inhibition, and working memory over time, facilitating functional reorganization in these circuits [25,28]. Thus, immersive VR may activate and strengthen underlying neural pathways disrupted in ADHD, supporting cognitive change.

VR-based interventions can improve cognitive deficits among individuals with ADHD [8,17,18,29,34]. For example, samples of ADHD-diagnosed children exposed to VR-based interventions show improved attention from pretest to posttest, with Hedges g of 0.09 to 1.21 [35] and g=1.46 [36]. Similar benefits of VR-based interventions are reported when compared against empty control groups, g=1.77 [36], and a psychotherapy intervention, g=0.57 to 1.4 [35], although not compared with pharmacological treatment, g=–0.28 to −0.31 [35]. In the same population, similar improvements in impulsivity are observed after VR-based interventions, g=0.48 to 0.91 [35], and g=1.77 [36]. Such improvements exceed empty control groups, g=1.27 [36], and both psychotherapy intervention, g=0.46 to 0.52, and pharmacological treatment, g=0.8 to 0.81 [35]. VR-based intervention combined with biofeedback decreases impulsivity, g=2.31, and increases attention, g=1.21 to 1.85, pretest to posttest [26]. For both impulsivity (g=0.77 to 0.82) and attention (g=0.66 to 1.05), gains exceed those of biofeedback alone [26]. VR-based interventions also increase memory function pretest to posttest g=0.8 to 1.56 [33,37], exceeding both an empty control group, g=3.36, and pharmacological treatment, g=1.27 [33]. Hence, VR-based interventions can improve attention, impulsivity, and memory in children diagnosed with ADHD, and in some cases, do so as effectively, or more effectively than psychotherapy, pharmacological treatment, and biofeedback.

Despite emerging positive effectiveness outcomes for cognitive rehabilitation with VR-based interventions, this technology may not be appropriate for all people with ADHD [8,38]. For instance, the financial cost of VR equipment may be prohibitive for some clinicians and individuals [39]. Some individuals may experience safety issues with immersive VR technology, such as physical collisions with real-world objects and simulator sickness, which includes symptoms of nausea, fatigue, eye strain, blurred vision, headache, dizziness, and vertigo [40-42]. Emotion dysregulation may also occur during the use of VR. This may include dissociation, panic, and anxiety, posing problems for safe containment, particularly if individuals use VR in a self-help format without the supervision and support of a trained clinician to assist them [43]. Some people may also experience usability issues when interacting with new technology, such as finding it hard to learn, being inefficient in performing tasks, being prone to errors, being unmemorable, and being dissatisfying to use [44]. These issues can impact user acceptability, which refers to the willingness of a person to use a VR intervention [45]. If a user finds an intervention unacceptable, they may reject using it, which can lead to attrition within research studies and poorer therapeutic outcomes [46].

This Study

Available research broadly supports the effectiveness of VR-based treatments for ADHD. However, the scope of previous reviews has tended to include nonimmersive VR intervention types, while being limited by treatment population (eg, focusing solely on children with ADHD), study design (eg, limiting to randomized controlled trials [RCTs] only), and measured outcomes (eg, focus on effectiveness outcomes rather than accompanying user experience outcomes) [8,15,16,19,29]. This exposes a deficit of collated knowledge on the effectiveness and user experience of immersive VR-based treatments for cognitive rehabilitation of people of all ages with ADHD. Therefore, a systematic review was conducted to (1) comprehensively explore all research designs conducted in the use of immersive VR in the cognitive rehabilitation for people of all demographics with ADHD, (2) to establish the full range of cognitive rehabilitation interventions being used with immersive VR, (3) report on concomitant outcomes of effectiveness and user experience (ie, safety, acceptability, usability, and attrition), and (4) identify research gaps and make suggestions that can inform clinical practice and future research in this domain.

Methods

Overview

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) method was adopted for this systematic review (Checklist 1) [47]. The review protocol was not registered.

Eligibility Criteria

To be eligible for inclusion in this review, studies needed to be written in English; published in a peer-reviewed journal article; to have examined the treatment effects of any immersive VR-based intervention (ie, using a HMD or cave automatic virtual environment) on any cognitive ability; and have a sample comprised mostly of participants with ADHD (ie, 80% or above proportion) or reported subset analyses for participants with ADHD. All comparators and study designs were eligible for inclusion. No gray literature was included in this review, and no studies were excluded based on quality appraisal.

Search Strategy

The following databases were searched up until November 2024: Cochrane Library, IEEE Explore Digital Library, PsycINFO, PubMED, Scopus, and Web of Science. Search strategy keywords included: (“virtual reality” and (“ADHD” or “attention deficit” or “hyperactivity disorder”). A manual search was also conducted on the reference lists of included studies.

Article Selection

Search results were extracted and deduplicated. Records were initially screened based on title and abstract information. Potential articles underwent full-text appraisal to determine whether they met the inclusion criteria. Differing views on study inclusion were resolved through discussion and consensus on inclusion by the full research team.

Data Charting

Data extracted from included studies (by one author, NS) included full reference citation, participant details (country of origin, sample size, age, sex, and ADHD diagnosis), intervention details (name, aim, software, hardware, treatment focus, treatment length, and tasks), study details (methodology, measures, comparators, and measurement time points), and main findings (pertaining to effectiveness, safety, usability, acceptability, and attrition).

In this review, the acceptability of immersive VR is defined in terms of participants’ willingness to use, actual usage, and satisfaction after use of VR [46]. Usability in this review refers to how easy it is to learn, efficient, memorable, error-free, and subjectively pleasing the immersive VR experience is to the users [44]. Extracted data were tabulated and then checked by 2 other reviewers (DS and WG), and any divergent views on inclusion were resolved through discussion and agreement by the full research team.

Quality Assessment

Included studies were critically appraised with the Mixed Methods Appraisal Tool [48]. With this tool, each study is subjected to 2 screening questions and then assigned to one of 5 study categories: qualitative research, RCT, nonrandomized, quantitative descriptive, or mixed methods. Each category has 5 questions that can be answered to appraise the quality of the studies.

Data Analysis

Due to the required integration of qualitative and quantitative findings to answer our research questions, a narrative synthesis approach was adopted. This approach summarizes the findings in text and explains them in a descriptive manner.

Results

Study Selection

Our search generated 1046 records (Figure 1). A total of 572 (54.7%) records remained after deduplication. Of these 572 records, 15 (2.6%) met the inclusion criteria for this review.

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Participant Characteristics of Included Studies

There were 754 participants across all included studies (Table 1). Participants primarily came from Italy (n=119), followed by Hong Kong (n=90), Spain (n=89), Poland (n=87), Greece (n=80), Romania (n=59), France (n=51), Iran (n=48), South Korea (n=40), Germany (n=36), United States (n=27), Portugal (n=25), and Taiwan (n=3). Sample sizes ranged from 3 to 90 participants with a median of 51 (IQR 25‐80). Participant ages ranged from 5 to 25 years. Participants were primarily boys and men (n=501). The average female sample proportion was 41.8% (SD 22.7%; range 16.1%‐96.0%). Most participants had diagnosed ADHD (n=703) or exhibited symptoms indicative of ADHD (n=25).

Details of the Virtual Reality Interventions

All included studies tested a unique VR-based intervention (Table 2). Immersive HMDs were used to host digital environments with a focus on treating various cognitive abilities. No studies used cave automatic virtual environment technology. Individual VR treatment session lengths varied from 3 to 60 minutes. Overall intervention length varied from a single session (50 min) to 6 months, with a median time of 7 weeks (IQR 4‐12 wk). The number of VR treatment sessions ranged from 1 to 36, with a median of 10 (IQR 8‐12). All VR-based interventions were tested with therapist or facilitator guidance.

Research Designs and Comparators

Participant VR use was appraised in 8 RCT studies, 5 quantitative nonrandomized studies, 1 quantitative descriptive study, and 1 mixed methods study (Table 1). Comparators included medication, psychotherapy, therapeutic chess, hemoencephalography, biofeedback with physical activity training, occupational therapy, speech and psychomotor treatment, social skills training, a healthy control group, and a no-treatment control group. All included studies reported pretest and posttest measurements on user outcomes. One study also reported a 2-month follow-up measurement [33].

Effectiveness Outcomes

Table 3 presents the study measures and outcomes of cognitive rehabilitation with immersive VR for people with ADHD. Effect sizes from the included studies that reported them, or reported sufficient data to permit their calculation, are summarized in Table 4 (always reported as Hedges g to facilitate comparisons). Findings generally indicate that VR-based interventions either improve cognitive performance for children and adults with ADHD or have no significant impact. In Table 4, positive effect sizes denote an improvement from pretest to posttest (ie, better performance, fewer errors, reduced symptoms, etc) or a favorable comparison between the VR group and its comparator. Regarding pre-post comparisons, effect sizes were overwhelmingly in favor of VR having a positive impact on omission and commission errors (−0.089 to 2.283, with 8 of 9 effects being positive [26,35,51]), attention (0.360 to 3.321 [35,54]), executive functioning (−0.159 to 2.775, with 13 of 14 effects being positive [23,26,30,35,49,54]), processing speed (1.250 to 1.527 [25,26]), working memory (0.160‐1.520 [25,33,54]) and impulsivity (0.260 to 2.420 [23,35,54]). Between-groups comparisons of posttest measures returned uniformly positive effect sizes for omission and commission errors (0.462‐1.774 [26,35,51]), executive function (0.235 to 1.037 [23,26]), and processing speed (0.678 to 1.031 [25,26]). Effect size estimates for attention (−2.092 to 0.677 [28,35,50]), working memory (−0.705 to 3.278 [25,33]), and impulsivity (−1.361 to 0.467 [23,35,50]) fell either side of zero.

A total of 10 studies evaluated standalone VR [25,28,30,31,33,35,49,52-54], 4 evaluated adjunctive VR [23,26,50,51], and 1 examined both approaches [32]. Treatment effect sizes exhibited comparable magnitudes across both standalone [25,28,30,33,35,49,54] and adjunctive VR interventions [23,26,50,51]. While most studies used significance levels of P<.05, one study set its significance level at P=.10 [53]. Interventions that included VR outperformed traditional social skills groups [23], stimulant and nonstimulant medications [35,50], a psychomotor program [51], 2D hemoencephalography biofeedback [26], therapeutic chess, and passive control groups [53] in addressing various ADHD symptoms.

When attention is considered more broadly through self-reports, other informants, and performance-based measures, standalone VR currently has a larger body of evidence supporting improvements [28,30,49,53,54]. However, for specific performance metrics such as omission and commission errors on the continuous performance test (CPT), adjunctive VR again shows stronger effects, with 2 studies reporting consistently significant reductions [26,51]. Evidence from standalone VR on the CPT is limited to a single study, which found significant improvements in commission errors but not omissions compared with a control group [35].

Beyond attention, some standalone VR studies demonstrate improvements in hyperactivity, impulsivity [54], and inhibitory control [30,53], though others show no effect on inhibitory control [31,54]. Standalone VR has demonstrated effectiveness in improving functioning across various cognitive and executive domains, such as planning, memory, and problem-solving [30,33,53,54]. In contrast, findings for adjunctive VR are mixed; one study reported moderate improvements in emotional control [23], while another found inconsistent outcomes for reasoning and information processing [32]. One adjunctive VR study reported a small, significant deterioration in inhibition based on parent ratings from pretest to posttest [23]. Notably, standalone VR produced a large effect on memory in one study and outperformed medication [33].

User Experience With the VR Interventions

Table 5 shows that attrition rates during VR-based treatment (mean 7.0%, SD 8.1%, range 0%‐41%) were lower than overall study attrition rates (mean 11.7%, SD 12.2%, range 0%‐41%). Three studies used an intention-to-treat analysis [23,50,53]. Most studies used nonstandardized measures (ie, questions and observations) of VR user experience factors such as immersion, acceptability, adverse effects, cybersickness, and engagement. Two studies used a standardized measure of VR user presence [51,52], and one study [30] relied on biometric indicators. There were limited cases of cybersickness reported, including motion sickness [49], headaches [49], nausea [50], dizziness [50], and eye strain [49], as well as discomfort due to the headset [25,49]. Three studies reported an absence of cybersickness symptoms and other adverse events [31,33,35].

Quality Assessment Results

All RCTs reported the use of randomization to assign participants to treatment groups [23,25,26,33,35,50,53,54]; however, the randomization method was only specified in 4 RCTs [23,26,50,53]. In all the RCT studies, participants reportedly adhered to their assigned VR intervention. With the exception of 4 studies [23,35,53,54], the remaining RCT studies reported comparable baseline group analyses and complete outcome data defined as >80% [25,26,33,50]. Two studies had blinding of outcome assessors, which was applied at pretest measurements [23,50]. In the quantitative nonrandomized studies [28,30,31,51,52], participants were recruited in a way that minimized selection bias, measures were appropriate, the intervention was administered as intended, and there was complete outcome data in most cases [28,31,51,54]. Participant groups were not comparable in one study, as the control group did not consist of ADHD participants [52]. In the quantitative descriptive study [32], the sampling strategy was relevant to address the research question, the sample was representative of the target population, measurements and statistical analyses were appropriate, and the risk of nonresponse bias was low. In the mixed methods study [49], questionnaires were administered before and after VR sessions, and data were analyzed using t tests, which was an appropriate statistical method. A thematic analysis was performed on interview data, which was appropriate to answer the research questions. Quantitative and qualitative findings were well integrated, and any inconsistencies were addressed.

Discussion

Principal Findings

Overview

This systematic review sought to comprehensively identify studies that examined the use of immersive VR technology for people with ADHD, report on available treatment and user experience evidence regarding cognitive rehabilitation, and also identify research gaps for future exploration in this domain. A total of 15 eligible studies were found in this review. The reported effectiveness outcomes from immersive VR-based interventions were generally positive, with improvements in ADHD cognitive symptoms. It was also found that immersive VR technology is well-received with positive user experiences reported by participants and a low attrition rate observed across all studies. However, the low number of relevant studies available reveals key treatment and research gaps for future studies to address.

Effectiveness Outcomes

Immersive VR-based interventions procured significant improvements in cognitive abilities for children with ADHD [26,30,32,33,35,51,54]. Consistent improvements were observed for omission and commission errors, executive functions (including inhibitory control, planning, organization, and problem-solving), and processing speed. Attention, working memory, and impulsivity also benefited across most comparisons. In 5 studies, VR-based interventions outperformed active controls, including medication [35,50] and standard therapies [26,30,35,51]. Treatment effect sizes were most often medium to large across studies, which is congruent with previous research on the observed magnitude of VR treatment effectiveness [8,55,56]. There were a few instances in which postintervention effects were marginally in favor of non-VR treatment groups compared with VR-based interventions with respect to cognitive performance or ADHD symptoms [25,35,50]. However, these only constituted a minimal proportion of the total observations reviewed. In general, VR-based interventions constitute a benign-to-beneficial modality for ADHD cognitive rehabilitation. Furthermore, positive effectiveness outcomes were obtained from treatment sessions that ranged from 3 to 50 minutes. This supports the integration of immersive VR interventions into standard clinician treatment sessions, which typically have a time length of 50 to 60 minutes [57].

Adults who received VR interventions also showed significant improvements in attention or concentration after treatment [49] and compared with an active control [28]. However, the control incorporated elements of VR, so further research is needed to compare VR to independent conditions such as medication or psychotherapy in adults. One study found that processing speed and visual-spatial working memory improved post-VR, but no significant differences were found compared with passive controls [25]. Research in adults has focused on reducing distractions and increasing personal drive to perform productive behaviors. VR interventions significantly improve work efficiency and motivation [49] as well as self-efficacy and sense of achievement [28]. However, the impact of providing automated performance feedback during VR remains inconclusive. While studies found no statistical effect of performance feedback, some participants reported that they found feedback frustrating and disruptive, while others believed it helped them regulate and refocus [31,49].

One-third of the reviewed studies (n=5) had predominantly female participant samples. Of these, 3 investigated standalone VR interventions [25,49,52], one examined adjunctive VR [51], and one included both approaches [32]. The remaining 10 studies, which had predominantly male samples, included 7 standalone VR interventions [28,30,31,33,35,53,54] and 3 adjunctive ones [23,26,50]. Most of the female-dominant studies focused on attention (3/5, 60%), all of which reported significant improvements in concentration or reductions in omission and commission errors [32,49,51]. Similarly, most male-dominant studies (8/10, 80%) investigated attention, with the majority reporting significant improvements [26,28,30,35,50,53,54]. However, in some cases, outcomes varied depending on the measure used [35,50,53].

Notably, only one female-dominant study examined hyperactivity-impulsivity symptoms, and none assessed inhibitory control [32]. In contrast, most male-dominant studies (7/10, 70%) included at least one indicator of these symptoms. Among these, 2 participants reported significant improvements in inhibitory control [30,53], and one reported improvement in hyperactivity-impulsivity [53]. However, outcomes on informant-rated ADHD scales were mixed [35,50,53]. In addition to behavioral symptoms, few female-dominant studies investigated executive functions (2/5, 40%), and findings were inconsistent [25,32]. In contrast, a higher proportion of male-dominant studies assessed executive functions (5/10, 50%), with most reporting significant improvements in planning, problem-solving, organization, or working memory [30,33,54].

Collectively, these findings have important clinical implications for psychologists selecting VR-based interventions for children with ADHD. VR appears to be a promising tool for improving attention in both boys and girls. For boys, it also shows potential to enhance executive functioning, with some preliminary evidence suggesting it may also have a beneficial effect on hyperactivity-impulsivity symptoms. In contrast, evidence for these outcomes in girls is limited, indicating that clinicians should proceed with caution and consider supplementing VR with other interventions.

Caution is required in interpreting the effectiveness results. Some studies combined immersive VR with other treatments, such as medication, biofeedback, and occupational therapy [26,32,54], which limits attributions regarding the unique impact of the immersive VR component on cognitive abilities. Nevertheless, conditions containing a VR component reliably outperformed non-VR conditions, which highlights VR’s potential to supplement the treatments clinicians and clients are already using for better cognitive rehabilitation outcomes. Overall, combining VR with nonstimulant medication may be more effective than standalone VR for reducing parent-rated ADHD symptoms [35,50,53]. Standalone VR demonstrates consistent benefits across attention and executive functions, including planning, memory, inhibitory control, and problem-solving [30,33,53,54]. While adjunctive VR may be more effective in reducing specific attention errors [26,51], findings on its impact on executive functions remain limited [23,32].

Inconsistent results were found in some studies that assessed ADHD symptoms using multiple methods or informants (eg, CPT, parent, and teacher rating scales) [35,50,54]. For example, one study found that combined VR and medication outperformed medication alone for the treatment of ADHD based upon parent-rated symptoms but not teacher-rated symptoms [50]. As it stands, there are few studies that obtain teacher ratings for children in school or educator ratings for adults in tertiary education. Finally, no studies obtained follow-up measurements to determine the longevity of the cognitive improvements beyond the 2 months (reported by Tabrizi et al [33]). Therefore, it is unclear how long most of the observed immersive VR-based benefits will persist after treatment cessation.

User Experience

This review found immersive VR-based interventions to be generally safe for cognitive rehabilitation in children and adults with ADHD symptoms. These findings are consistent with past research showing little to no harmful effects from VR treatment [8,16,25]. There was also generally minimal attrition in the active VR treatment phase across the studies, which implies that VR-based treatments were motivating and engaging for the users. Even so, the small number of studies and the fact that most of them did not make use of standardized measures of user experience factors are limiting. Of those who offered commentary, Bioulac et al [35] reported that all participants completed their VR sessions with no adverse effects related to cybersickness. This suggests the technology is suitable for the virtual classroom, in line with previous research [34,58,59]. Nonetheless, several safety concerns were noted [25,49,50]. Some participants reported unpleasant reactions, including motion sickness, nausea, and dizziness, as well as headset discomfort. These adverse effects may have been at least jointly attributable to the participants’ concurrent use of ADHD medications, which can have side effects that mimic symptoms of cybersickness, including nausea, headaches, and increased blood pressure [60,61]. Conservatively, it is reasonably likely that a small minority of clients react negatively, at least initially, to the VR experience.

Several studies reported that VR was acceptable, comfortable, and easy to use [23,28,54] and achieved a high level of presence [52] or good immersion [33,51], which is consistent with previous research [8,62-64]. In one included study [32], enthusiasm diminished once the children mastered the assigned VR games. However, enthusiasm increased when they were given choices regarding which VR game to play next. These findings illuminate the need for clients, especially children, to have variety and choice in VR tasks to enhance enjoyment and effective outcomes [65]. User experience outcomes were not reported in the study, which integrated biofeedback into a VR environment [33]. Overall, evidence of adverse effects was scant, but clinicians should closely monitor VR use to foresee any adverse effects, particularly for those individuals who are also using pharmacotherapy with VR. For example, the study reporting the widest range of adverse effects found they were more prevalent in the combined VR and medication condition than in standalone VR, particularly appetite loss and irritability, suggesting that medication side effects may have contributed [50]. Furthermore, it is recommended that clinicians provide a choice and variety of personally relevant VR tasks to optimize user engagement and effectiveness, as research suggests these factors may increase user satisfaction, motivation, and reduce attrition [66].

All studies reporting no cybersickness symptoms or adverse effects included predominantly male participants [31,33,35]. Only one study reported on side effects in female participants [49], highlighting the need for further gender-specific research on user experience. The limited number of studies precludes the identification of consistent gender-based side effect profiles. Positive feedback regarding acceptability and immersion was reported across studies [23,28,33,51,52,54]. One female-dominant study noted reduced enthusiasm following game mastery [32], while a male-dominant study found lower galvanic skin response after mastery, suggesting reduced emotional arousal and a possible calming effect [30]. Clinicians should therefore consider whether game mastery leads to disengagement or a sense of calm and achievement, as individual responses may vary.

Research Gaps and Future Research

This systematic review reveals several research gaps for further exploration. Included studies focused primarily on boys and children aged 5 to 15 years. As a result, there exists a research gap for girls, older adolescents, and adults of both sexes that could be explored. Moreover, the absence of specifying participants by ADHD presentation subtype (ie, predominantly inattentive, hyperactive-impulsive, or combined) and severity (as denoted in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision) [1], precluded consideration of these factors. Furthermore, studies primarily originated from countries in Europe or Asia, which may limit the generalizability of findings to people with ADHD from other countries (eg, the United States, Canada, the United Kingdom, Australia, and New Zealand).

Consideration of the cost-effectiveness of immersive VR was beyond the scope of this review. However, some studies report lower costs [23,33,50,53] or greater feasibility [49] of VR interventions compared with conventional treatments. One study [50] suggested that moderate to large effect sizes would be needed to justify the cost of VR; thresholds that were met in several studies [23,25,26,33,49,50]. Despite these promising findings, further research into the cost-effectiveness of VR is warranted. Reusing equipment across participants may lower marginal costs, yet high initial expenses, including hardware, software licensing, and staff training, remain barriers to widespread adoption [23,67]. In particular, training clinicians or hiring VR-literate staff poses practical challenges, as such expertise is still uncommon. These challenges are amplified in low- and middle-income countries due to limited internet access, high data costs, and constrained institutional budgets [67]. Partnerships between universities, health care institutions, and technology companies may be critical to supporting sustainable VR implementation in clinical settings [67].

To improve methodological rigor, future research designs could include RCTs with increased sample sizes and follow-up measurements to appraise effect sizes and longer-term outcomes. Further comparisons of immersive VR interventions with standalone or combined psychotherapy and pharmacological treatments will confirm the value-adding potential of combined interventions and treatment. This research can help clarify which cognitive domains are most responsive to adjunctive VR and determine whether specific combinations of interventions yield more consistent benefits. To consolidate user experience findings and facilitate comparisons, the technology acceptance model is recommended [68]. Future research should adopt standardized user experience measures with known psychometric properties, such as the system usability scale [69] and the Simulator Sickness Questionnaire [70]. It is also recommended that future researchers consider using mixed method approaches to examine user experience outcomes of VR. For instance, follow-up interviews and focus groups could help identify aspects of the immersive VR interventions that most influenced user interest, usability, safety, and overall acceptability of VR interventions [71]. A more detailed consideration of economic factors (eg, cost of VR equipment, staff training, and maintenance) would be valuable for health care providers and policymakers considering implementation of these technologies, as it would help assess the feasibility of VR interventions, guide budgeting decisions, and support equitable access across clinical settings.

Presence, the subjective sense of being immersed in a virtual environment, may be critical for the effectiveness of VR-based interventions, but it remains underexplored. Increased presence positively predicts users’ reported usability of VR systems [42], and it is associated with heightened enjoyment and engagement [13,14]. However, our systematic review revealed that only 2 studies quantitatively assessed presence [51,52], one reporting it to be greater in the ADHD group, compared with the control group [52]. The other study described overall presence levels as high [51]. Given the potential for presence to enhance therapeutic outcomes [11], future studies ought to prioritize its assessment with standardized measures to better understand its role in the effectiveness of VR-based interventions for ADHD.

Strengths and Limitations of the Systematic Review

This systematic review has several strengths and limitations. The review made use of a comprehensive search strategy, which included studies using a variety of research methodologies (both qualitative and quantitative), cognitive rehabilitation procedures that incorporated immersive VR for people of all ages with ADHD, and explored user experience outcomes alongside effectiveness outcomes. The review was also based on databases that comprised peer-reviewed publications. However, the review only included English-language research, which means studies in other languages would have been missed. In addition, the quality appraisal process is subjective. Therefore, though unlikely due to the use of multiple reviewers, researcher bias may have influenced the assessment reported in this review. Finally, this review did not include an appraisal of the cost-effectiveness of VR interventions, indicating a need for further research into their economic and practical feasibility in clinical settings.

Conclusions

Immersive VR-based technology shows promise as a standalone or adjunctive treatment modality for rehabilitating cognitive abilities in people with ADHD. Effectiveness results indicate that immersive VR-based interventions can significantly improve attention, memory, and executive functions. Furthermore, VR has the potential to provide a safe, acceptable, and engaging treatment modality for clinicians to use with their child clients and adults who have ADHD. Nonetheless, caution is advised. It is premature to generalize these findings to wider populations due to the paucity of papers available and participants primarily being boys with ADHD. There is also a general absence of follow-up measurements. Therefore, future research using RCTs with mixed methods and longitudinal designs, such as follow-up interviews and focus groups, can verify the long-term effectiveness and user experience of immersive VR interventions in more diverse populations of people with ADHD.