Using Virtual Reality to Promote Cognitive Engagement in Rett Syndrome: Eye-Tracking Evidence from Immersive Forest Tasks

Rett syndrome (RTT) is a rare neurodevelopmental disorder that causes severe motor and cognitive impairments, limiting voluntary communication. Gaze-based technologies and virtual reality (VR) offer innovative ways to assess and enhance attention, happiness, and learning in individuals with minimal motor control. This study investigated and compared visual-attentional and emotional engagement in girls with RTT and typically developing (TD) peers during exploration of a virtual forest presented in 2D and immersive 3D (VR) formats across four progressively complex tasks. Twelve girls with RTT and 12 TD peers completed eye-tracking tasks measuring reaction time, fixation duration, disengagement events, and observed happiness. Girls with RTT showed slower responses and more disengagements overall, but VR significantly improved attentional efficiency in both groups, resulting in faster reaction times (η2p = 0.36), longer fixations (η2p = 0.31), and fewer disengagements (η2p = 0.27). These effects were stronger in the RTT group. Both groups also showed greater happiness in VR settings (RTT: p = 0.011; TD: p = 0.015), and in participants with RTT, peaks in attention coincided with peak happiness, indicating a link between happiness and cognitive engagement. Immersive VR thus appears to enhance attention and affect in RTT, supporting its integration into personalized neurorehabilitation.