E-Emotio. Effects of immersive virtual reality training on emotion regulation, executive functioning and internalizing symptoms in adolescents: A pilot randomized controlled trial

BACKGROUND: Internalizing symptoms are prevalent in youth and predict poorer long-term outcomes. Immersive virtual reality (IVR) offers a scalable platform for gamified executive function (EF) and emotion regulation (ER) training, but whether EF-targeted content adds benefit beyond an equally immersive VR experience has rarely been tested. OBJECTIVE: To test whether gamified IVR training (Enhance IVR) improves ER, internalizing symptoms, and EF relative to an active-control IVR relaxation program (Nature Treks VR). METHODS: This single-blind pilot RCT (NCT06236919) randomized 165 adolescents (81 boys, 84 girls, 10-16 years) from six Barcelona schools to 10 sessions of either program. Primary (emotional suppression, cognitive reappraisal, internalizing symptoms, rumination) and secondary outcomes (anxiety, depression, affect, self-efficacy, EF) were assessed pre/post using mixed ANOVAs and available-data mixed models; session-level immersion/enjoyment and usability were also examined. Sex/gender and baseline symptoms were explored as moderators. RESULTS: The suppression Time × Group interaction was nominally significant in the ANOVA (p = .018; Holm-adjusted p = .072) and the mixed model (p = .012; Holm-adjusted p = .048). Rumination, internalizing symptoms, and EF improved in both groups without between-group differences; reappraisal did not change. Immersion and enjoyment trajectories differed by group, without sex/gender differences, and usability was comparable. Baseline symptoms did not moderate gains. CONCLUSIONS: In this exploratory pilot, gamified IVR training showed a preliminary signal for reduced emotional suppression relative to an active relaxation control, sensitive to the analytic approach and multiplicity correction. Both programs were feasible; larger trials including minimal-contact controls are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT06236919; https://clinicaltrials.gov/study/NCT06236919.