Innovative Methodologies for Neuroplasticity in Developmental Age With the Use of Virtual Reality

The primary outcome will be assessed using the Attention and Memory subtests of the Leiter International Performance Scale - Third Edition (Leiter-3), a standardized nonverbal cognitive assessment tool commonly used in children and adolescents.

These subtests evaluate sustained attention, selective attention, visual working memory, immediate memory recall, and delayed memory recall.

Higher raw and standardized scores indicate better cognitive performance in the assessed domains.

Gross motor function will be assessed using the Gross Motor Function Measure-66 (GMFM-66), a standardized observational assessment tool designed to evaluate changes in gross motor abilities in children with motor disabilities.

The GMFM-66 provides an interval-level total score derived from 66 items covering key domains of gross motor function, including lying and rolling, sitting, crawling and kneeling, standing, walking, running, and jumping.

Higher scores indicate better gross motor function.

Muscle spasticity will be assessed using the Modified Ashworth Scale (MAS), a standardized clinical rating scale used to measure resistance to passive soft-tissue stretching as an indicator of muscle spasticity.

The MAS is scored on a 5-point ordinal scale ranging from 0 to 4, where 0 indicates no increase in muscle tone and 4 indicates affected parts rigid in flexion or extension.

Higher scores indicate greater muscle spasticity, reflecting a worse outcome.

Balance will be assessed using the Balance Subscale of the Tinetti Assessment Tool, a standardized clinical scale designed to evaluate postural stability as part of functional mobility and fall risk assessment.

The Balance Subscale is scored on a range from 0 to 16, with higher scores indicating better balance and a lower risk of falls. Lower scores indicate reduced mobility and higher fall risk.

The outcome will be assessed using the Attention and Memory domain of the NEPSY-Second Edition (NEPSY-II), a standardized developmental neuropsychological assessment battery designed to evaluate cognitive functioning in children.

The Attention and Memory domain includes subtests assessing sustained attention, selective attention, auditory and visual attention, immediate and delayed memory, and working memory.

Scores are reported as age-normed scaled scores derived from standardized test performance. Higher scores indicate better attention and memory functioning.

Executive functioning will be assessed using the Tower of London Test, a standardized neuropsychological assessment designed to evaluate executive functions, particularly planning ability, problem-solving, and working memory.

Outcome parameters include the total number of correct solutions, number of moves, and task completion time.

Higher performance scores indicate better executive functioning, whereas a greater number of errors or longer completion times indicate poorer performance.

Executive functioning will be assessed using the Behavior Rating Inventory of Executive Function - Second Edition (BRIEF-2), a standardized caregiver-report questionnaire designed to evaluate everyday executive function behaviors in children and adolescents aged 5 to 18 years.

The BRIEF-2 yields three index scores-Behavior Regulation Index, Emotion Regulation Index, and Cognitive Regulation Index-as well as a Global Executive Composite (GEC) score, derived from nine clinical scales.

All outcomes are reported as age-normed T-scores. Higher T-scores indicate greater executive function difficulties, reflecting worse outcomes.

Behavioral, emotional, and attention-related symptoms will be assessed using the Conners' Rating Scales - Third Edition (Conners 3), a standardized caregiver- and teacher-report questionnaire designed to evaluate behavioral and attentional difficulties in children and adolescents.

The Conners 3 provides T-scores across multiple clinical scales, including Inattention, Hyperactivity/Impulsivity, Executive Functioning, Learning Problems, Aggression, and Peer Relations, based on age- and sex-normed data.

Higher T-scores indicate greater severity of behavioral and attention-related symptoms, reflecting worse outcomes.

This outcome will be assessed using the Child Behavior Checklist (CBCL), a standardized caregiver-report questionnaire designed to evaluate emotional and behavioral problems in children and adolescents. The CBCL provides syndrome scale scores (e.g., Anxious/Depressed, Withdrawn/Depressed, Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, Aggressive Behavior) and broad-band composite scores (Internalizing, Externalizing, and Total Problems).

Scores are reported as T-scores, derived from age- and gender-normed data. Higher T-scores indicate greater behavioral or emotional difficulties, representing a worse outcome.

Motor competence in children and adolescents will be assessed using the Movement Assessment Battery for Children - Second Edition (Movement ABC-2), a standardized test.

The Movement ABC-2 evaluates three motor domains: Manual Dexterity, Aiming and Catching, and Balance (static and dynamic).

The assessment provides age-standardized scores, a Total Motor Score, and percentile rankings.

Higher scores indicate better motor performance, whereas lower scores reflect greater motor coordination difficulties, representing a worse outcome.

System usability will be assessed using the System Usability Scale (SUS), a standardized 10-item questionnaire designed to measure users' perceived usability of a system or device.

The SUS provides a total score ranging from 0 to 100, calculated according to the standard scoring method. Higher scores indicate better perceived usability, with scores above 68 generally considered above average usability.

Behavioral safety will be assessed using the Behavioral Safety Event Rating Scale (B-SERS), based on a behavioral risk assessment framework.

The B-SERS evaluates the frequency and severity of safety-related behavioral events, such as behaviors that may pose a risk to oneself, others, or the environment.

The scale includes 5 items, each scored from 0 to 4 (0 = no event; 1 = mild; 2 = moderate; 3 = marked; 4 = severe).

The total score ranges from 0 to 20, with higher scores indicating worse safety outcomes.