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Article

Improving Emotion Regulation, Internalizing Symptoms and Cognitive Functions in Adolescents at Risk of Executive Dysfunction—A Controlled Pilot VR Study

by
Anna Carballo-Marquez
1,
Aikaterini Ampatzoglou
1,
Juliana Rojas-Rincón
1,
Anna Garcia-Casanovas
1,
Maite Garolera
1,2,
Maria Fernández-Capo
1,* and
Bruno Porras-Garcia
1,2,*
1
BrainXR Lab, Department of Psychology, Universitat Internacional de Catalunya, 08195 Sant Cugat del Vallès, Spain
2
Brain, Cognition, and Behavior Research Group, Consorci Sanitari de Terrassa-Hospital Universitari, 08227 Terrassa, Spain
*
Authors to whom correspondence should be addressed.
Appl. Sci. 2025, 15(3), 1223; https://doi.org/10.3390/app15031223
Submission received: 2 December 2024 / Revised: 20 January 2025 / Accepted: 21 January 2025 / Published: 25 January 2025
(This article belongs to the Special Issue Recent Advances and Application of Virtual Reality)
Browse Figures
Versions Notes

Abstract

:
Executive functions (EFs) are essential cognitive processes involved in concentration, planning, decision-making, and impulse control during adolescence. Executive Dysfunction (ED) can lead to significant academic and socio-emotional difficulties, particularly with impairments in emotion regulation (ER). This study aims to assess a virtual reality (VR) cognitive training intervention on EFs, ER, and internalizing symptoms in adolescents at risk for ED. Thirty-eight adolescents aged 12–14 years, identified as being at moderate to high risk for ED, were randomly assigned to two groups. The experimental group (n = 22) received gamified VR cognitive training, while the control group (n = 16) received VR nature-based relaxation training. Both interventions lasted five weeks, twice a week for 30 min each. Pre- and post-assessments included ER skills, internalizing symptoms, and cognitive performance measures. Two-way mixed ANOVAs showed significant group × time interactions (p < 0.05) in measures of depression and internalizing symptoms. The experimental group showed significant reductions in these symptoms compared with the control group. Significant main effects of time (p < 0.05) were also found on some measures. Both groups experienced reduced anxiety, improved emotional control and cognitive functioning, and VR cognitive training was particularly effective in reducing internalizing symptoms, while both interventions showed promising results in improving some ER skills and cognitive performance. The findings demonstrate the preliminary effects of VR-based cognitive training in improving the psychological and cognitive well-being of adolescents at risk for ED and suggest that integrating VR technologies into educational settings can effectively address the cognitive and emotional challenges faced by these students.

1. Introduction

Executive functions (EFs) are critical cognitive abilities that underpin tasks such as maintaining focus, orchestrating plans, making decisions, regulating impulses, and managing behavior. These functions are essential for filtering out distractions, assimilating new information, adjusting plans when necessary, sustaining prolonged effort, deferring immediate rewards, and inhibiting impulsive actions [1]. When executive dysfunction (ED) occurs, it can impair self-regulation, coping strategies, anger management, task sequencing, short-term memory retention, efficient time management, task initiation, and multitasking skills, often leading to academic challenges and worsening people’s quality of life and well-being [2,3,4]. Identifying and treating ED in early adolescence can improve mental health, enhance academic outcomes, and promote better social integration. However, without sufficient awareness, educators may misinterpret students’ behaviors as mere lack of interest or effort [5].
Emotional regulation (ER) is another critical process during adolescence that enables young people to identify and manage emotions, understand the relationship between emotions, thoughts, and behaviors, and develop strategies to tolerate frustration and generate positive emotions [6,7]. Emotional dysregulation includes difficulty accepting and controlling emotional responses, suppression of emotions and ruminative thoughts, and a lack of emotional clarity and awareness [8]. Adolescence is a critical period for ER challenges as individuals apply strategies learned in childhood. Adolescents with emotional dysregulation may face difficulties in identity formation and, later in adulthood, in interpersonal relationships and emotional management [9].
ER difficulties have also been associated with internalizing symptoms such as anxiety (i.e., excessive, disproportionate, and anticipatory fear) and depression (i.e., sadness, loss of interest in previously enjoyed activities), the most common mental health problems in adolescents [10,11,12]. Some studies have shown that emotional dysregulation may mediate the onset of this internalizing symptomatology [13], which has a strong comorbidity with suicidal ideation in adolescents [14]. These mental health problems and emotional dysregulation often co-occur with impairments in EFs, such as working memory and inhibitory control, because low cognitive control could limit ER and high emotionality could impair cognitive functioning [15,16]. In this sense, ER and internalizing symptoms can also be targeted by cognitive interventions such as VR cognitive training.
The interaction between emotions and cognitive processes plays a key role in ER. This includes how we process information, control ourselves, and remain flexible in our thinking—all of which are components of EFs [17]. The impact of executive performance in adolescents has been studied in different countries and cultural contexts, although most studies have been conducted in the United States and Europe [18]. Previous research has found that people who are better at EFs tend to use more effective strategies to manage their emotions [19,20,21,22]. Therefore, training in EFs can increase brain plasticity (i.e., the brain’s ability to adapt and change) and strengthen connections between different brain areas, such as those in the prefrontal cortex (responsible for higher-level thinking) and subcortical regions (involved in basic emotions and needs) [23]. This allows individuals to gain more conscious control over automatic, involuntary responses such as emotions, desires, and basic needs [24]. While most research has focused on clinical populations (such as people with neurodevelopmental, neurodegenerative, or mental health disorders), these training programs have also shown promising results in healthy, non-clinical populations [25].
The relationship between EFs and ER is based on the dual-process framework, which suggests that ER strategies can depend on either implicit or explicit processes. Implicit and automatic forms of ER can be more efficient and effortless than explicit forms, but they are also less flexible and can run to completion without monitoring [26]. Explicit ER strategies, such as cognitive reappraisal, depend on neural circuits in the prefrontal cortex [27,28], and these cortical areas have been implicated in both EFs and ERs in clinical [29] and healthy populations [30].
Cognitive training programs include a variety of exercises that challenge different cognitive abilities. For example, exercises that require focusing attention while ignoring distractions (i.e., inhibitory control), managing multiple stimuli simultaneously (divided attention and working memory), switching between tasks, and solving different dynamic problems (i.e., cognitive flexibility) [31]. However, these exercises are often criticized for having low ecological validity. That is, they do not always mimic real-life situations well and are sometimes described as unstimulating, repetitive, and even boring [32,33,34,35].
Recently, new studies using technology, like virtual reality (VR) games, have shown that these immersive programs can have positive effects on training cognitive functions, including EFs. These VR-based cognitive training programs have shown promising results in both clinical and healthy populations, improving various cognitive skills, psychological well-being, and even mental health issues in both childhood and adolescence [5,36,37,38,39]. For instance, VR cognitive rehabilitation and stimulation has been shown to enhance paper- and/or computer-based cognitive training for adults and older adults with cognitive impairments and dementia [40].
The immersive and engaging nature of this technology could also make it an attractive educational tool within the school curriculum. By replicating realistic scenarios, VR-based cognitive training can help individuals train cognitive skills while managing emotions in triggering contexts [38,40], for example, recognizing and managing negative emotions in a simulated stressful home- or school-based environment. In addition, VR-based cognitive programs can harness motivational factors, reduce dropout rates, and promote greater engagement [41]. This, in turn, may increase adolescents’ motivation and participation, thereby increasing their likelihood of completing the program and reaping the benefits of the intervention. This is particularly important for school-based interventions, where maintaining ongoing participation can be a challenge [42].
This pilot study will implement VR-based cognitive training focused on improving the cognition and mental health of school-aged students at risk for developing EDs during early adolescence. As mentioned earlier, students at risk for ED face greater challenges in adapting to the school environment, which requires the proper development of these functions for both academic learning and socio-emotional adjustment [2,3,4]. Therefore, this study aims to evaluate the preliminary effects of VR-based gamified cognitive training on improving EFs, ER skills, internalizing symptoms, ruminative symptoms, and self-efficacy levels. The VR cognitive training will be compared to an active control condition (nature-based VR relaxation training). This intervention was chosen as the active control because relaxation techniques, such as deep breathing, are considered a traditional method for improving ER [43,44,45] and also have moderately positive effects on internalizing symptoms in adolescents [46]. Furthermore, we ensured that both groups received a similar immersive VR experience (i.e., in terms of number and duration of sessions, as well as the technological hardware).
Specifically, we expected that the experimental group would show significantly greater improvements in EFs, ER, self-efficacy, and internalizing symptoms than the active control group. Although we also expected to observe improvements in ER, self-efficacy, and internalizing symptoms, but not in EFs, in the control group.

2. Materials and Methods

2.1. Participants

The study involved 38 girls and boys, aged 12 to 14. All participants were first-year high school students enrolled in two private schools located in the metropolitan area of Barcelona, Catalonia, Spain.
Participants had to be in their first year of secondary school. They also had to be at moderate to high risk of developing ED, as determined by a transformed global score of 65 or higher on the Behavior Rating of Executive Functions (BRIEF-2) [47]. The BRIEF-2 is a standardized questionnaire that assesses EFs in everyday settings, such as home and school. A score of 65 or above is considered clinically significant and indicates a higher likelihood of experiencing difficulties related to executive functioning. This cut-off score is widely accepted and has been validated in previous research to identify individuals at risk of developing ED [48,49].
Participants were excluded if they had a previously reported diagnosis of serious psychiatric disorders, such as those characterized by manic episodes or psychotic symptoms. Similarly, individuals with severe neurodevelopmental disorders were excluded. This included those diagnosed with severe autism spectrum disorder or intellectual disability. Other exclusion criteria included any physical, motor, or sensory disability that might interfere with the VR tests or programs. Finally, understanding Catalan or Spanish was required for participation. Participants who were unable to understand these languages were excluded, as all instructions, assessments, and interactive components of the VR program were conducted in Catalan or Spanish.

2.2. Measures

Baseline and Post-Assessment

Participants underwent a baseline and post-assessment five weeks later, covering mental health, ER, and cognitive performance measures.
ER skills assessment: Emotion suppression and cognitive reappraisal skills were assessed with the Emotion Regulation Questionnaire for Children and Adolescents (ERQ-CA) [50]. Emotional control was assessed through the BRIEF-2 self-report assessment, and rumination symptoms were assessed with the Ruminative Responses Scale (RRS) [51]. Poorer ER skills were indicated by higher scores on emotional suppression, emotional control, and rumination, and lower cognitive reappraisal scores.
Mental health assessment: Anxiety, depressive, and internalizing symptoms were assessed with the Child Anxiety and Depression Scale (RCADS-47) [52], Higher internalizing scores were associated with poorer mental health. Self-efficacy was assessed with the General Self-Efficacy Scale (GSE) [53], where higher scores suggested better outcomes.
Cognitive functions: The neuropsychological assessment included the Stroop Color and Word Test (SCWT) [54], the Trail Making Test (TMT A-B) [55], the Digit Forward and Backward Span [55], and the Wisconsin Card Sorting Test (WCST) [55]. Those measures assessed simple selective attention (TMT-A; SCWT colors or words), auditory attentional capacity (Digits forward), and EFs, including cognitive flexibility and set-shifting ability (repetitive errors and responses from the WCST) and working memory (SCWT colors and words, TMT-B and digit backward). All neuropsychological measures reported T-scores. Higher scores indicated better cognitive performance.
Age-validated Spanish versions were used for all the measures, with good-to-excellent psychometric properties, for instance, good-to-excellent internal consistency, with Cronbach alpha values in mental health and ER measures ranging from 0.79 (i.e., emotion suppression scale of the ERQ-CA; [50]) to 0.93 (i.e., internalizing total score of the RCADs [52] or the GSE scale [53]).

2.3. Procedure

The study was approved by the Institutional Review Board of the Universitat Internacional de Catalunya (PSI-2023-04), and all data were de-identified to ensure participant confidentiality. The research team and the school psychology team conducted presentations with families and participants to inform them of the study procedures and assessments. In addition, and in accordance with Spanish law, legal guardians signed informed consent forms for all interested participants. The study used a convenience sampling method in which students who voluntarily expressed interest in participating were screened to determine eligibility. Researchers, together with the school psychologist, determined participant suitability using an eligibility checklist.
Those participants who met the eligibility criteria were randomly assigned to either the experimental group (n = 22), which received the gamified VR program Enhance VR by Virtuleap, or the active control group (n = 16), which received a comparable VR nature-based relaxation training.

Interventions

The experimental and control interventions were conducted over five weeks, with sessions held twice a week for 30 min each, for a total of 10 sessions per participant, aligned with similar research parameters [56]. Each participant was provided with an individual standalone VR Meta Quest 3 headset (Meta, Menlo Park, CA, USA). Interventions were delivered face-to-face in groups of four to six participants under the supervision of a mental health professional with a master’s or doctoral degree. Study completion was defined as participants attending at least 80% of the scheduled sessions. At the end of the interventions, all participants in both the experimental and control conditions completed at least 90% of the sessions.
The experimental group used the Enhance VR software (v.2.7.0.0, Virtuleap, Lisbon, Portugal) [56,57], a gamified VR cognitive training that consisted of six games (two games per session) designed to target specific cognitive functions. Some of these games were previously validated in an adult sample with Attention-Deficit/Hyperactivity Disorder [56], and it was decided to use games that target very similar cognitive constructs. For example, one game focused on cognitive flexibility, requiring participants to quickly switch between different tasks and problem-solving strategies. Another game centered on planning, asked participants to make a series of decisions to achieve a specific goal. Other games engaged targeted working memory, divided and sustained attention, and processing speed. All the games involved adapted the difficulty level to the user’s performance. To assess the user’s initial level of performance, each game session began with a baseline session. Subsequent sessions resumed from the user’s most recent skill level, allowing for individual progression. A detailed description of the sessions and the content of each game is shown in Figure 1.
The active control group used the Nature-Trek VR software (v.1.27, Greener Games Company, Telford, UK), which simulates natural environments like tropical islands, forests, lakes, and snowy landscapes over 10 sessions, each featuring a different environment. In the first session, there was a brief training of the VR environment (training stage), then participants personalized their virtual environment by adding elements such as trees and changing the weather, and selecting their preferred navigation method, such as teleportation or arm swing locomotion(tailor stage); then, they engaged in structured deep breathing exercises with a visual aid to promote relaxation (deep breathing stage), and in the last 6 min, participants were relaxed and immersed themselves in the virtual environment, exploring and identifying personal relaxation strategies without specific instructions or visual cues (immerse stage).

2.4. Data Analysis

Analyses were performed using SPSS software (v.29). Independent sample t-tests for continuous variables and their non-parametric counterpart, the Mann–Whitney U test, were used to examine significant differences in continuous baseline/pre-assessment outcomes, while Chi-square tests of homogeneity were run for categorical variables (such as sex and family status).
For the primary objective of the study, two-way mixed ANOVAs were used, with group condition (experimental vs. control) as the between-subjects factor and assessment time (pre- vs. post-assessment) as the within-subjects factor. These analyses were applied to neuropsychological, ER, and mental health measures. Bonferroni corrections were used to adjust for multiple comparisons. The significance level was set at α = 0.05, and the effect sizes were calculated using partial eta squared (partial η2).
Graphs and descriptive statistics were used to test the assumptions of the tests. Levene’s test indicated that homogeneity of variance was met for most variables. Although some variables did not meet normality as assessed by the Shapiro–Wilk test, it was determined that the robustness of ANOVA to departures from normality justified continuing with the analyses [58].

3. Results

Descriptive statistics revealed an uneven distribution of adolescent girls and boys among the participants, with 70.28% being girls and 29.72% boys. Within the groups, four boys (25%) were assigned to the control group and seven boys (31%) to the experimental group. Fisher’s exact test was used to evaluate the sex distribution across groups, as the Chi-square test of homogeneity was not performed due to insufficient sample size, consistent with prior recommendations [59]. The results indicated no statistically significant difference in sex distribution between the control and experimental groups (p = 0.237). Participants’ ages ranged from 12 to 14 years (Mage = 12.51 years, SD = 0.43). An independent sample t-test showed no significant difference in age between the two groups (MD = 0.13 years, t(26) = 0.994, p = 0.327). Regarding parental marital status, most participants (75.8%) reported that their parents were either married or cohabiting, while 12.1% had separated parents, and another 12.1% had divorced parents.
Independent-samples t-test or Mann–Whitney U tests showed that there were no significant differences between the groups at baseline in any of the study measures (p > 0.05; see Table 1). The mean and standard deviations of primary and secondary measures of the study are reported in Table 1.
ER measures: As could be revised in Table 2, mixed ANOVA analyses did not show statistically significant interactions (p > 0.05) between group and assessment time in any of the ER measures. However, there were statistically significant main effects of assessment time (p < 0.05) in emotional control, assessed by the BRIEF-2 self-report and in ruminative symptoms, as assessed by the RRS. Overall, there was a reduction in the scores of both maladaptive ER skills on both groups, from pre- to post-assessment (see Figure 2A,B), while no significant main effects of time (p > 0.05) were observed in other maladaptive ER measures (i.e., emotional suppression) or adaptative ER strategies (i.e., cognitive reappraisal).
Mental health measures: Mixed ANOVA analyses revealed significant interactions (p < 0.05) between group and assessment time for depressive symptoms. A marginally significant interaction was also found for global internalizing symptoms (p = 0.054), as shown in Table 2. To explore these findings further, follow-up analyses were conducted to compare pre- and post-intervention differences within each group. These analyses provided mean differences (MD) and standard errors (SE) to quantify the changes observed. The results showed that the experimental group experienced significant improvements: their internalizing symptoms decreased (MD = 11.90, SE = 2.99, p = 0.001) and their depressive symptoms also decreased (MD = 3.09, SE = 0.95, p = 0.003) from pre- to post-intervention. In contrast, the control group showed no significant changes in either internalizing or depressive symptoms from pre- to post-intervention, as shown in Figure 2C,D. These findings suggest that the experimental intervention was effective in reducing both internalizing and depressive symptoms, whereas the control group did not show such improvements.
Cognitive measures: Mixed ANOVA analyses did not show statistically significant interactions between group and assessment time in any of the cognitive function’s measures. On the other hand, statistically significant main effects of time were found on measures of cognitive flexibility (such as total errors, or perseverative responses and errors), as assessed by the WCST, simple selective attention, as assessed by the SCWT Colors subtest and TMT-A, as well as in working memory scores, as assessed by the TMT-B, and SCWT Colors and words subtest, with significant increases on cognitive performance on the both groups, from pre- to post-assessment (see Table 2). In Figure 3, the global mean T-scores from the pre-and post-assessments for each subgroup of cognitive functions assessed have been visually represented.

4. Discussion

This study is the first to compare VR-based cognitive training with an active VR-based nature exposure intervention to improve ER, EFs, and psychological well-being in adolescents at risk for ED. The immersive nature of VR tends to be effective in capturing student attention and improving student engagement. This was evidenced by the lack of attrition in both VR interventions, further supporting the use of VR to reduce dropout rates in cognitive training or general rehabilitation programs [38].
In terms of mental health measures, the experimental group showed significant reductions in global internalizing and depressive symptoms compared to the control group. These findings are consistent with previous research indicating that VR-delivered and traditionally delivered cognitive training interventions can reduce internalizing symptoms, including depressive symptoms [36,60,61]. In this sense, many recent studies have shown that immersive VR cognitive training programs can significantly reduce depression symptoms in older adults [62], middle-aged adults [63], and adolescents [64].
Difficulties in a wide range of cognitive functions, such as EFs, are associated with depressive symptoms in children, adolescents, and adults [65,66,67]. Early difficulties with EFs are a prominent feature of several clinical conditions with childhood or adolescent onset, including internalizing disorders such as anxiety and depression [67,68]. Thus, this study provides further evidence that interventions targeting EFs may also alleviate associated depressive symptoms, as other review studies have shown [69,70]. On the other hand, although our results did not show significant group differences in the improvement of anxiety symptoms after the interventions, the experimental group still showed a more pronounced reduction in these symptoms compared to the control group. This positive trend in the experimental group is consistent with previous meta-analyses and systematic review studies reporting that cognitive training targeting EFs, including working memory training, can reduce anxiety symptoms [12,22].
Our results also indicated significant improvements in emotional control and reductions in ruminative symptoms, with no significant changes in emotional suppression and cognitive reappraisal skills. These improvements were particularly pronounced in the experimental group, while the control group did not show significant improvements. Training EFs improves cognitive processes essential for ER, such as inhibitory control, goal-directed focus, and behavioral flexibility. This is consistent with previous theoretical models that emphasize the role of conscious and voluntary strategies in achieving goals and managing emotional responses [31]. These findings also support previous studies highlighting that EFs training can lead to improvements in explicit ER skills in both clinical [71] and healthy population [19,22].
Internalizing symptoms often result from maladaptive ER strategies that amplify or suppress emotional expression, leading to emotional dysregulation [72,73]. Stimulating EFs across sessions may strengthen connections between fronto-parietal brain areas involved in the development of ER skills [73,74,75] and promote more effective and cognitively integrated ER strategies [76,77]. In this sense, previous studies have shown that EFs training programs, such as working memory training, could improve ER ability in children, adolescents, and adults [78,79]. Working memory training could improve cognitive efficiency and neural efficiency, thereby increasing the availability of cognitive resources at times when ER is needed [80].
Significant improvements were observed in both groups on several cognitive measures, including cognitive flexibility, working memory, and simple selective attention. The improvements found in the experimental group are consistent with research demonstrating the benefits of computerized or VR-based cognitive training for improving EFs in children and adolescents with clinical EDs, such as Attention-Deficit/Hyperactivity Disorder [81,82,83,84], as well as in healthy children and adults [20,36]. Unexpectedly, improvements in these measures were also found in the control condition. Previous research has found that interactions with natural environments and nature-related stimuli (such as those in the VR control condition) can benefit cognitive performance and directly influence EFs [85,86]. According to Attention Restoration Theory, natural environments restore cognitive resources by reducing demands on directed attention and engaging involuntary attentional mechanisms [87]. Therefore, exposure to VR-based nature may improve attention and EFs by reducing cognitive load and facilitating involuntary attention. EFs that involve cognitive processes that require conscious effort and control, such as task switching, working memory operations, and maintaining focus amidst distractions, may benefit from this reduced cognitive load.

4.1. Practical Contributions of the Study

Regarding the practical implications of the present study, it has been shown how the introduction of VR interventions aimed at improving EFs in school contexts can help to improve ER and mental health problems in adolescents. These improvements can have an important impact on adolescents’ well-being, but also potentially reduce their academic anxiety [88] and improve their academic performance in both students with [89] and without [90] learning disabilities, although this was not assessed in this study. VR interventions are easy for teachers and educators to implement, and significant improvements can be achieved in a short period of time, especially for those at risk for ED, as observed in previous studies [33]. Students must face different academic, personal, and social challenges in the school context, and many of them will require a good executive performance. In this sense, it is relevant to provide scientific evidence on the importance of introducing tools aimed at improving EFs of children and adolescents in everyday activities in school settings, as previous studies have pointed out [32,91,92].

4.2. Limitations and Future Research Directions

Despite some promising findings discussed above, this study has several limitations that may affect its validity and generalizability. The small sample size limits the extent to which these findings can be generalized to a broader population (other adolescent age groups, adolescents from different socioeconomic backgrounds, etc.). Similarly, the study did not collect specific socioeconomic information about our participants, and we did not establish a predefined sample size, due to the pilot nature of the study. The sample size was determined based on practical considerations (i.e., convenience sampling) such as participant availability and logistical feasibility. While this approach was suitable for a pilot study, it introduces inherent limitations. Convenience sampling may result in a sample that is not fully representative of the target population, potentially introducing selection bias. This limitation can reduce the generalizability of the findings to broader populations. Additionally, the small sample size may have limited the statistical power to detect smaller effects, thus impacting the robustness of the study’s conclusions. Last, the lack of a passive control condition means that the possibility of practice effects influencing some cognitive measures cannot be completely excluded.
Future research should aim to include a larger adequately powered sample to confirm and extend the results observed in this preliminary study, and to also include a passive control condition. Also, students from different socioeconomic backgrounds, ethnicities, and ages should be included to have a more representative sample. In addition, individual differences, such as prior gaming experience, were not explicitly controlled for in this study, but represent an important factor that may have influenced participants’ performance, familiarity, and comfort with the gamified VR tasks. Future research should consider users’ prior gaming experience before beginning the VR intervention.
The study also lacked both short-term and long-term follow-up measures, limiting the ability to assess the lasting effects of the intervention. The study also used the BRIEF-2 questionnaire to assess the risk of ED, as has been done in previous research [47], by examining its daily impact as reported by parents and within school settings. While the BRIEF-2 provides valuable insight into everyday manifestations of ED and is recognized as an ecologically valid screening tool, it may lack the rigor and precision of other neuropsychological assessments based on experimental laboratory tasks. Future research should incorporate more rigorous neuropsychological methods to improve ED risk classification. In addition, although VR technology provides an immersive and realistic experience, some of the virtual environments used did not closely resemble real-life situations, potentially reducing the ecological validity of the intervention [93]. Finally, the requirement for a continuous Wi-Fi connection during the intervention was a potential concern, as connectivity issues could disrupt the consistency of the program and the overall dynamics of the study.

5. Conclusions

This study demonstrates the preliminary effects of VR-based cognitive training in improving the psychological and cognitive well-being of adolescents at risk for ED. The experimental group showed significantly stronger reductions in depressive and internalizing symptoms as compared with the control group, while both VR interventions (i.e., cognitive training and nature-based relaxation) similarly reduced anxiety, improved emotional control, and enhanced cognitive functioning, including EFs.
The immersive nature of VR provides an attractive opportunity to implement these interventions in school settings, with high student engagement and low attrition. Integrating VR technologies into educational settings may address cognitive and emotional challenges faced by at-risk students, although further research with larger samples, with different socioeconomic backgrounds, and with different learning disabilities and educational needs, and long-term follow-up is needed.

Author Contributions

Conceptualization, A.C.-M., M.F.-C., M.G. and B.P.-G.; methodology, B.P.-G.; validation, A.C.-M., A.A., J.R.-R. and A.G.-C.; formal analysis, A.C.-M. and B.P.-G.; investigation, A.C.-M., A.A., J.R.-R. and A.G.-C.; resources, B.P.-G., M.F.-C. and M.G.; data curation, A.C.-M., A.A., J.R.-R. and A.G.-C.; writing—original draft preparation, A.C.-M., A.A., J.R.-R. and A.G.-C.; writing—review and editing, M.G., M.F.-C. and B.P.-G.; visualization, B.P.-G.; supervision, M.F.-C., M.G. and B.P.-G.; project administration, B.P.-G.; funding acquisition, B.P.-G. All authors have read and agreed to the published version of the manuscript.

Funding

This study was funded and supported by a NARSAD Young Investigator Grant from the Brain & Behavior Research Foundation (ID: 31607) and Foundation Saint-Bernard.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Universitat Internacional de Catalunya (PSI-2023-04; 15 November 2023).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors on request.

Acknowledgments

We would also like to express our sincere gratitude to Amir Bozorgzadeh and Bebiana Moura, Head of Partnerships at Virtuleap, for their crucial technical support in designing the Enhance VR virtual games research protocol. Their expertise and dedication, together with the invaluable support of the Virtuleap team, will be instrumental in tackling the complex technical issues before and during recruitment.

Conflicts of Interest

The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

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Figure 1. Brief description of the games included in the VR cognitive training program (experimental condition).
Figure 1. Brief description of the games included in the VR cognitive training program (experimental condition).
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Figure 2. Emotion Regulation and mental health measures with significant group × time interactions or main effects of time for Emotional Control (A), Rumination (B), Anxiety Symptoms (C), Depressive Symptoms (D), Internalizing Symptoms (E) and Self-Efficacy (F).
Figure 2. Emotion Regulation and mental health measures with significant group × time interactions or main effects of time for Emotional Control (A), Rumination (B), Anxiety Symptoms (C), Depressive Symptoms (D), Internalizing Symptoms (E) and Self-Efficacy (F).
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Figure 3. Global T-scores computed for each subgroup of cognitive function assessed, including cognitive flexibility, with global mean T-scores of all Wisconsin Card Sorting Test (WCST) subtests; working memory, with a global mean T-scores of Trail Making Test (TMT-B) and Stroop Color and Word Test (SCWT) color (C) and word (W) individual subtests; auditory attention, with the mean total Scores of the Digits test, and Simple attention, with global mean T-scores TMT-A and SCWT color and word (C&W) subtest. Standard error of the mean reported.
Figure 3. Global T-scores computed for each subgroup of cognitive function assessed, including cognitive flexibility, with global mean T-scores of all Wisconsin Card Sorting Test (WCST) subtests; working memory, with a global mean T-scores of Trail Making Test (TMT-B) and Stroop Color and Word Test (SCWT) color (C) and word (W) individual subtests; auditory attention, with the mean total Scores of the Digits test, and Simple attention, with global mean T-scores TMT-A and SCWT color and word (C&W) subtest. Standard error of the mean reported.
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Table 1. Mean and standard deviations of ER, mental health and cognitive measures of the study.
Table 1. Mean and standard deviations of ER, mental health and cognitive measures of the study.
Experimental (n = 22)Control (n = 16)
Pre-Assessment
M (SD)		Post-Assessment
M (SD)		Pre-Assessment
M (SD)		Post-Assessment
M (SD)
ERQ-CA Emotional suppression11.95 (3.62)10.59 (3.66)10.56 (3.67)10.81 (4.34)
ERQ-CA Cognitive reappraisal19.59 (4.40)18.86 (5.10)17.19 (3.64)16.94 (7.61)
BRIEF-2 Emotional control10.86 (3.24)9.23 (2.54)11.69 (3.44)11.50 (3.48)
RRS-total rumination24.27 (6.12)20.55 (5.95)25.75 (6.18)25.19 (8.86)
RCADS total anxiety41.68 (20.27)32.86 (13.57)44.69 (18.36)42.06 (20.77)
RCADS total depression11.09 (6.46)8.00 (4.59)12.75 (7.29)12.69 (8.20)
RCADS total internalizing52.77 (23.98)40.86 (16.99)57.44 (23.89)54.75 (27.60)
GSE-self-efficacy total62.27 (17.78)66.68 (15.58)54.75 (18.63)58.75 (20.58)
SCWT-Words40.90 (5.82)43.71 (6.27)43.50 (11.28)47.50 (12.19)
SCWT-Colors36.05 (7.28)38.33 (6.12)38.13 (8.02)40.06 (9.53)
SCWT-Colors and words41.14 (7.06)45.48 (16.69)38.81 (19.16)44.19 (15.98)
TMT-A46.04 (3.93)48.95 (3.93)47.31 (4.59)50.09 (3.40)
TMT-B43.12 (5.14)47.12 (5.24)40.92 (7.26)44.67 (5.78)
Digits_Total44.44 (8.77)44.58 (6.97)46.34 (9.76)47.70 (7.57)
WCST Total Errors55.64 (9.70)65.68 (8.91)52.81 (12.52)60.75 (8.94)
WCST Perseverative Responses56.41 (13.35)71.27 (12.53)52.19 (15.57)65.38 (14.34)
WCST Perseverative Errors55.36 (11.53)69.45 (11.25)51.75 (14.03)65.56 (12.64)
WCST Perseverative No Errors56.14 (11.50)63.64 (9.92)53.44 (11.53)56.75 (8.90)
Notes: ERQ-CA = Emotion Regulation Questionnaire for Children and Adolescents; BRIEF-2 = Behavior Rating Inventory of Executive Functions, Second Edition; RRS = Ruminative Responses Scale; RCADS = Revised Child Anxiety and Depression Scale; GSE = General Self-Efficacy Scale; SCWT = Stroop Color and Word Test; TMT A-B = Trail Making Test; Digits_Total = Digit Forward and Backward Span; WCST = Wisconsin Card Sorting Test. All neuropsychological measures report T-scores. Higher raw scores indicate poorer mental health and emotion regulation skills, except for cognitive reappraisal and general self-efficacy. Higher T-scores on neuropsychological measures indicate better cognitive performance.
Table 2. Two-way mixed analyses results for all measures of the study.
Table 2. Two-way mixed analyses results for all measures of the study.
MeasuresGroup × Time Main Effect Time
Fpηp2Fpηp2
ERQ-CA Emotional suppression1.610.210.040.770.390.02
ERQ-CA Cognitive reappraisal0.040.820.010.200.650.02
BRIEF-2 Emotional control2.780.100.074.410.040.11
RCADS total anxiety2.610.110.078.89<0.010.20
RCADS total depression4.270.040.114.630.040.11
RCADS total internalizing3.980.050.109.98<0.010.22
RRS-total rumination2.260.140.064.160.050.10
GSE-self-efficacy total0.010.910.015.660.020.14
SCWT-Words0.270.60<0.0111.35<0.010.24
SCWT-Colors2.900.100.070.780.380.02
SCWT-Colors and words0.020.890.011.570.220.04
TMT-A0.090.76<0.0113.84<0.010.28
TMT-B0.070.79<0.0111.17<0.010.24
Digits_Total0.230.660.013.930.060.10
WCST Total Errors0.330.570.0124.34<0.010.40
WCST perseverative Responses0.080.77<0.0123.60<0.010.40
WCST perseverative Errors0.000.96<0.0130.73<0.010.46
WCST Perseverative No Errors1.260.270.038.41<0.010.19
Notes: ERQ-CA = Emotion Regulation Questionnaire for Children and Adolescents; BRIEF-2 = Behavior Rating Inventory of Executive Functions, Second Edition; RRS = Ruminative Responses Scale; RCADS = Revised Child Anxiety and Depression Scale; GSE = General Self-Efficacy Scale; SCWT = Stroop Color and Word Test; TMT A-B = Trail Making Test; Digits Total = Digit Forward and Backward Span; WCST = Wisconsin Card Sorting Test.
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Carballo-Marquez, A.; Ampatzoglou, A.; Rojas-Rincón, J.; Garcia-Casanovas, A.; Garolera, M.; Fernández-Capo, M.; Porras-Garcia, B. Improving Emotion Regulation, Internalizing Symptoms and Cognitive Functions in Adolescents at Risk of Executive Dysfunction—A Controlled Pilot VR Study. Appl. Sci. 2025, 15, 1223. https://doi.org/10.3390/app15031223

AMA Style

Carballo-Marquez A, Ampatzoglou A, Rojas-Rincón J, Garcia-Casanovas A, Garolera M, Fernández-Capo M, Porras-Garcia B. Improving Emotion Regulation, Internalizing Symptoms and Cognitive Functions in Adolescents at Risk of Executive Dysfunction—A Controlled Pilot VR Study. Applied Sciences. 2025; 15(3):1223. https://doi.org/10.3390/app15031223

Chicago/Turabian Style

Carballo-Marquez, Anna, Aikaterini Ampatzoglou, Juliana Rojas-Rincón, Anna Garcia-Casanovas, Maite Garolera, Maria Fernández-Capo, and Bruno Porras-Garcia. 2025. "Improving Emotion Regulation, Internalizing Symptoms and Cognitive Functions in Adolescents at Risk of Executive Dysfunction—A Controlled Pilot VR Study" Applied Sciences 15, no. 3: 1223. https://doi.org/10.3390/app15031223

APA Style

Carballo-Marquez, A., Ampatzoglou, A., Rojas-Rincón, J., Garcia-Casanovas, A., Garolera, M., Fernández-Capo, M., & Porras-Garcia, B. (2025). Improving Emotion Regulation, Internalizing Symptoms and Cognitive Functions in Adolescents at Risk of Executive Dysfunction—A Controlled Pilot VR Study. Applied Sciences, 15(3), 1223. https://doi.org/10.3390/app15031223

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