Virtual Reality for Neuropsychological Assessment

  • Unai Diaz-OruetaEmail author
  • Beñat Lizarazu
  • Gema Climent
  • Flavio Banterla
Part of the Intelligent Systems Reference Library book series (ISRL, volume 68)


Neuropsychology comprises a set of theoretical and experimental knowledge about relationships between the brain, cognitive processes and human activity. However, in the latest years, several criticism have been raised about the validity of neuropsychological tests for capturing nervous system dysfunctions and predicting the level of decline that individuals may show in their daily lives. Traditional paper and pencil tests lack ecological validity and generalizing its results to describe daily life cognitive functioning of individuals is controversial. In order to overcome this, and in parallel with development and cost decreases of virtual reality (VR) technology, integration of informatics and neuroscience is approaching the achievement of a more objective, precise, and ecologically valid neuropsychological assessment based on VR technology. The current chapter describes the problems faced with classical neuropsychological assessment tools and the need of improvement of their validity; the potential advantages of using VR based neuropsychological tests versus classical tests; and the actual progress made in using VR based tools to measure cognitive functions such as attention, memory or executive functions, with some of these tools already standardized and available in the market. Finally, predicted advantages of these tools for the early diagnosis of different neurological and neurodegenerative conditions and its implications in reduction of healthcare costs are considered.


Neuropsychological assessment Cognitive functions Ecological validity Generalization of results Virtual environment 

List of Acronyms




Alzheimer’s disease


Attention deficit hyperactivity disorder


Continuous performance test


California verbal learning test


Look for a match test


Mild cognitive impairment


Traumatic brain injury


Rivermead behavioral memory test


Virtual store test


Virtual action planning supermarket


Virtual mall


Virtual multiple errands test


Virtual reality


Wisconsin card sorting test


Wechsler intelligence scales for children


Wechsler intelligence scales for children—revised


  1. 1.
    Adams, R., Finn, P., Moes, E., et al.: Distractibility in attention/deficit/ hyperactivity disorder (ADHD): the virtual reality classroom. Child. Neuropsychol. 15, 120–135 (2009)CrossRefGoogle Scholar
  2. 2.
    Attree, E.A., Dancey, C.P., Pope, A.L.: An assessment of prospective memory retrieval in women with chronic fatigue syndrome using a virtual-reality environment: an initial study. Cyberpsychol. Behav. 12, 379–385 (2009)CrossRefGoogle Scholar
  3. 3.
    Baheux, K., Yoshizawa, M., Yoshida, Y.: Simulating hemispatial neglect with virtual reality. J. Neuroeng. Rehabil. 4, 27 (2007)CrossRefGoogle Scholar
  4. 4.
    Bioulac, S., Lallemand, S., Rizzo, A., et al.: Impact of time on task on ADHD patient’s performances in a virtual classroom. Eur. J. Paediatr. Neurol. 16, 514–521 (2012)CrossRefGoogle Scholar
  5. 5.
    Bohbot, V.D., McKenzie, S., Konishi, K., et al.: Virtual navigation strategies from childhood to senescence: evidence for changes across the life span. Front Aging Neurosci. 4, 1–10 (2012)CrossRefGoogle Scholar
  6. 6.
    Brooks, B.M., McNeil, J.E., Rose, F.D., et al.: Route learning in a case of amnesia: a preliminary investigation into the efficacy of training in a virtual environment. Neuropsychol. Rehabil. 9, 63–76 (1999)CrossRefGoogle Scholar
  7. 7.
    Brooks, B.M., Rose, F.D., Potter, J., et al.: Assessing stroke patients’ prospective memory using virtual reality. Brain Inj. 18, 391–401 (2004)CrossRefGoogle Scholar
  8. 8.
    Brown, D., Neale, H., Cobb, S., et al.: Development and evaluation of the virtual city. Int. J. Virt. Reality 3, 27–38 (1998)Google Scholar
  9. 9.
    Christiansen, C., Abreu, B., Ottenbacher, K., et al.: Task performance in virtual environments used for cognitive rehabilitation after traumatic brain injury. Arch. Phys. Med. Rehabil. 79, 888–892 (1998)CrossRefGoogle Scholar
  10. 10.
    Climent, G., Banterla, F.: AULA Nesplora. Ecological Evaluation of Attention Processes. Nesplora, San Sebastian (2011) (book in Spanish)Google Scholar
  11. 11.
    Cornblatt, B., Risch-Neil, J., Faris, G., et al.: The continuous performance test, identical pairs version (CPT-IP): I. new findings about sustained attention in normal families. Psychiatry Res. 26, 223–228 (1988)CrossRefGoogle Scholar
  12. 12.
    Cromby, J., Standen, P., Newman, J. et al.: Successful transfer to the real world of skills practiced in a virtual environment by students with severe learning disabilities. In: Proceedings of the 1” European Conference on Disability, Virtual Reality and Associated Technologies Reading, pp. 103–107. University of Reading, UK (1996)Google Scholar
  13. 13.
    Crosbie, J.H., Lennon, S., Basford, J.R., et al.: Virtual reality in stroke rehabilitation: still more virtual than real. Disabil. Rehabil. 29, 1139–1146 (2007)CrossRefGoogle Scholar
  14. 14.
    Cushman, L.A., Stein, K., Duffy, C.J.: Detecting navigational deficits in cognitive aging and Alzheimer disease using virtual reality. Neurology 71, 888–895 (2008)CrossRefGoogle Scholar
  15. 15.
    da Costa, R., de Carvalho, L., de Aragon, D.F.: Virtual reality in cognitive training. In: Proceedings of 3rd International Conference on Disability, Virtual Reality and Associated Technology, Alghero, Italy, pp. 221–224 (2000)Google Scholar
  16. 16.
    Davies, R.C., Johansson, G., Boschian, K. et al.: A practical example using virtual reality in the assessment of brain injury. In: Sharkey, P., Rose, D., Lindstrom, J. (eds.) Proceedings of the 2nd European Conference on Disability, Virtual Reality and Associated Techniques, Reading, pp. 61–68. University of Reading, UK (1998)Google Scholar
  17. 17.
    Díaz-Orueta, U., Garcia-López, C., Crespo-Eguílaz, N., et al.: AULA virtual reality test as an attention measure: convergent validity with Conners’ Continuous Performance Test. Child Neuropsychol. (2013). doi: 10.1080/09297049.2013.792332 Google Scholar
  18. 18.
    Doyle, A.E., Biederman, J., Seidman, L.J.: Diagnostic efficiency of neuropsychological test scores for discriminating boys with and without attention deficit-hyperactivity disorder. J. Consult. Clin. Psychol. 68, 477–488 (2000)CrossRefGoogle Scholar
  19. 19.
    Elkind, J.S., Rubin, E., Rosenthal, S., et al.: A simulated reality scenario compared with the computerized Wisconsin Card Sorting Test: an analysis of preliminary results. Cyberpsychol. Behav. 4, 489–496 (2001)CrossRefGoogle Scholar
  20. 20.
    Garcia-Molina, A., Tirapu-Ustarroz, J., Roig-Rovira, T.: Ecological validity in exploration of executive functions. Anales de Psicología 23, 289–299 (2007). (article in Spanish)Google Scholar
  21. 21.
    Goldberg, E.: The Executive Brain: Frontal Lobes and the Civilized Mind. Oxford University Press, New York (2001)Google Scholar
  22. 22.
    Iriarte, Y., Diaz-Orueta, U., Cueto, E. et al.: AULA—Advanced virtual reality tool for the assessment of attention: normative study in Spain. J. Atten. Disord. (2012). doi:  10.1177/1087054712465335
  23. 23.
    Kim, J., Kim, K., Young, K.D., et al.: Virtual environment training system for rehabilitation of stroke patients with unilateral neglect: crossing the virtual street. Cyberpsychol. Behav. 10, 7–15 (2007)CrossRefGoogle Scholar
  24. 24.
    Knight, R.G., Titov, N.: Use of virtual reality tasks to assess prospective memory: applicability and evidence. Brain Impairment 10, 3–13 (2009)CrossRefGoogle Scholar
  25. 25.
    Knight, R.G., Titov, N., Crawford, M.: The effects of distraction on prospective remembering following traumatic brain injury assessed in a naturalistic environment. J. Int. Neuropsychol. Soc. 12, 8–16 (2006)CrossRefGoogle Scholar
  26. 26.
    Ku, J., Cho, W., Kim, J.J., et al.: A virtual environment for investigating schizophrenic patients’ characteristics: assessment of cognitive and navigation ability. Cyberpsychol. Behav. 6, 397–404 (2003)CrossRefGoogle Scholar
  27. 27.
    Lengenfelder, J., Schultheis, M.T., Al-Shihabi, T., et al.: Divided attention and driving: a pilot study using virtual reality technology. J. Head. Trauma. Rehabil. 17, 26–37 (2002)CrossRefGoogle Scholar
  28. 28.
    Lezak, M.D., Howieson, D.B., Loring, D.W., et al.: Neuropsychological Assessment, 4th edn. Oxford University Press, New York (2004)Google Scholar
  29. 29.
    Lynch, W.J.: Everyday living assessment in cognitive evaluations. J. Head. Trauma. Rehabil. 23, 185–188 (2008)CrossRefGoogle Scholar
  30. 30.
    Matheis, R.J., Schultheis, M.T., Tiersky, L.A., et al.: Is learning and memory different in a virtual environment? Clin. Neuropsychol. 21, 146–161 (2007)CrossRefGoogle Scholar
  31. 31.
    McGeorge, P., Phillips, L.H., Crawford, J.R., et al.: Using virtual environments in the assessment of executive dysfunction. Presence Teleoperators Virt. Environ. 10, 375–383 (2001)Google Scholar
  32. 32.
    Money, J.: A standardized Road-Map Test of Direction Sense. Johns Hopkins University Press, Baltimore (1972)Google Scholar
  33. 33.
    Morganti, F., Gaggioli, A., Strambi, L., et al.: A virtual reality extended neuropsychological assessment for topographical disorientation: a feasibility study. J. Neuroeng. Rehabil. 4, 26 (2007)CrossRefGoogle Scholar
  34. 34.
    Novell, R., Rueda, P., Salvador, L.: Mental Health and Behavioral Disorders in Individuals with Intellectual Disabilities. Practical Guide for Technicians and Caregivers. FEAPS, Madrid (2003) (book in Spanish)Google Scholar
  35. 35.
    Parsons, T.D., Bowerly, T., Buckwalter, J.G., et al.: A controlled clinical comparison of attention performance in children with ADHD in a virtual reality classroom compared to standard neuropsychological methods. Child. Neuropsychol. 13, 363–381 (2007)CrossRefGoogle Scholar
  36. 36.
    Parsons, T.D., Rizzo, A.A.: Initial validation of a virtual environment for assessment of memory functioning: virtual reality cognitive performance assessment test. Cyberpsychol. Behav. 11, 17–25 (2008)CrossRefGoogle Scholar
  37. 37.
    Piper, B.J., Acevedo, S.F., Craytor, M.J., et al.: The use and validation of the spatial navigation memory island test in primary school children. Behav. Brain Res. 210, 257–262 (2010)CrossRefGoogle Scholar
  38. 38.
    Plancher, G., Gyselinck, V., Nicolas, S.: Age effect on components of episodic memory and feature binding: a virtual reality study. Neuropsychology 24, 379–390 (2010)CrossRefGoogle Scholar
  39. 39.
    Plancher, G., Tirard, A., Gyselinck, V., et al.: Using virtual reality to characterize episodic memory profiles in amnestic mild cognitive impairment and Alzheimer’s disease: influence of active and passive encoding. Neuropsychologia 50, 592–602 (2012)CrossRefGoogle Scholar
  40. 40.
    Pugnetti, L., Mendozzi, L., Attree, E., et al.: Probing memory and executive functions with virtual reality: past and present studies. Cyberpsychol. Behav. 1, 151–161 (1998)CrossRefGoogle Scholar
  41. 41.
    Rand, D., Rukan, S.B., Weiss, P.L., et al.: Validation of the virtual MET as an assessment tool for executive functions. Neuropsychol. Rehabil. 19(4), 583–602 (2009)CrossRefGoogle Scholar
  42. 42.
    Riva, G., Mantovani, F., Gaggioli, A.: Presence and rehabilitation: toward second-generation virtual reality applications in neuropsychology. J. Neuroeng. Rehabil. 1, 9 (2004)CrossRefGoogle Scholar
  43. 43.
    Rizzo, A.A., Bowerly, T., Buckwalter, G., et al.: A virtual reality scenario for all seasons: the virtual classroom. CNS Spectr. 11, 35–44 (2006)Google Scholar
  44. 44.
    Rizzo, A.A., Buckwalter, J.G., Van der Zaag, C.: Virtual environment applications for neuropsychological assessment and rehabilitation. In: Stanney, K. (ed.) Handbook of Virtual Environments: Design, Implementation and Applications, pp. 1027–1064. Lawrence Erlbaum Associates, New York (2002)Google Scholar
  45. 45.
    Rizzo, A.A., Schultheis, M.T., Kerns, K., et al.: Analysis of assets for virtual reality applications in neuropsychology. Neuropsychol. Rehabil. 14, 207–239 (2004)CrossRefGoogle Scholar
  46. 46.
    Rose, F.D., Attree, E.A., Brooks, B.M., et al.: Learning and memory in virtual environments—a role in neurorehabilitation? questions (and occasional answers) from UEL. Presence Teleoperators Virt. Environ. 10, 345–358 (2001)Google Scholar
  47. 47.
    Rose, F.D., Brooks, B.M., Rizzo, A.A.: Virtual reality in brain damage rehabilitation: review. Cyberpsychol. Behav. 8, 241–262 (2005)CrossRefGoogle Scholar
  48. 48.
    Schultheis, M.T., Rizzo, A.: The virtual office: assessing and re-training vocationally relevant cognitive skills. Paper presented at the 10th annual medicine meets virtual reality conference, Los Angeles, CA, 2002Google Scholar
  49. 49.
    Stanton, D., Foreman, N., Wilson, P.N.: Uses of virtual reality in clinical training: developing the spatial skills of children with mobility impairments. Stud. Health Technol. Inform. 58, 219–232 (1998)Google Scholar
  50. 50.
    Swearer, J.M., Drachman, D.A., Li, L., et al.: Screening for dementia in “real world” settings: the cognitive assessment screening test: CAST. Clin. Neuropsychol. 16, 128–135 (2002)CrossRefGoogle Scholar
  51. 51.
    Sweeney, S., Kerse, D., Morris, R.G., et al.: The sensitivity of a virtual reality task to planning and prospective memory impairments: group differences and the efficacy of periodic alerts on performance. Neuropsychol. Rehabil. 20, 239–263 (2010)CrossRefGoogle Scholar
  52. 52.
    Tarr, M.J., Warren, W.H.: Virtual reality in behavioral neuroscience and beyond. Nat. Neurosci. 5(Suppl), 1089–1092 (2002)CrossRefGoogle Scholar
  53. 53.
    Tirapu, J., Ríos-Lago, M., Maestu-Unturbe, F.: Manual of Neuropsychology. Viguera, Barcelona (2008). (book in Spanish)Google Scholar
  54. 54.
    Xu, Y., Zhou, X.L., Wang, Y.F.: Effects of distractors on sustained attention in children with attention-deficit hyperactivity disorder. Zhonghua Er Ke Za Zhi 42, 44–48 (2004)Google Scholar
  55. 55.
    Wang, H.I., Gao, T., Wimo, A., et al.: Caregiver time and cost of home care for Alzheimer’s disease: a clinic-based observational study in Beijing, China. Ageing. Int. 35, 153–165 (2010)CrossRefGoogle Scholar
  56. 56.
    Weiss, T., Naveh, Y., Katz, N.: Design and testing of a virtual environment to train stroke patients with unilateral spatial neglect to cross a street safely. Occup. Ther. Int. 10, 39–55 (2003)CrossRefGoogle Scholar
  57. 57.
    Weniger, G., Ruhleder, M., Lange, C., et al.: Egocentric and allocentric memory as assessed by virtual reality in individuals with amnestic mild cognitive impairment. Neuropsychologia 49, 518–527 (2011)CrossRefGoogle Scholar
  58. 58.
    White, T., Davis, M.A., Stern, R.A.: Standardization and norming of the neuropsychological assessment battery (NAB). J. Int. Neuropsychol. Soc. 10(S1), 106 (2004). (abstract)Google Scholar
  59. 59.
    Wimo, A., Winblad, B., Stoffler, A., et al.: Resource utilisation and cost analysis of memantine in patients with moderate to severe Alzheimer’s disease. Pharmacoeconomics 21, 327–340 (2003)CrossRefGoogle Scholar

Resources on Virtual Reality-Based Neuropsychological Assessment and Related Areas

  1. 60.—Webpage of Nesplora, Technology and Behavior (Spain), the company developer of AULA and Ice Cream Seller VR-based neuropsychological tests
  2. 61.—AULA test for evaluation of attention processes in children with ADHD
  3. 62.—University of Southern California—Institute for Creative Technologies (USA)Google Scholar
  4. 63.—Subdivision of Institute for Creative Technologies
  5. 64.
  6. 65.—virtual reality cognitive performance assessment test (VRCPAT)Google Scholar
  7. 66.—two virtual reality-based paced auditory/visual serial addition tests (PA/VSAT) for neurocognitive assessmentGoogle Scholar
  8. 67.—platform to create your own virtual environments, including assessment tools
  9. 68.—Webpage of the president of the international association of cyberpsychology, training, and rehabilitation and member of the steering committee of the society for computers in psychology. Many articles and resources available
  10. 69.—This site contains information about the use of advanced technologies—virtual reality, mixed reality, interreality, ambient intelligence—in health care
  11. 70.—Annual review of cybertherapy and telemedicine, updated continously
  12. 71.—Webpage of the Laboratory of Neuropsychology in Verona (Italy), very active in this area of knowledge
  13. 72.—Applied Neurotechnologies Lab webpage

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • Unai Diaz-Orueta
    • 1
    Email author
  • Beñat Lizarazu
    • 1
  • Gema Climent
    • 1
  • Flavio Banterla
    • 1
  1. 1.Nesplora Technology and BehaviourSan Sebastián, DonostiaSpain

Personalised recommendations