Vr game–based episodic future thinking training for school-age children with adhd: a randomized controlled trial examining its added effects on executive function

Abstract

Attention-deficit/hyperactivity disorder (ADHD) affects a large number of children worldwide and exerts long-term impacts on learning, social interaction, and daily functioning. Current treatments focus primarily on medication and behavioral therapy, while complementary cognitive training approaches targeting executive functioning have gained increasing attention. Virtual reality (VR)–based interventions have recently emerged as a potentially ecologically valid platform for executive-function training. Episodic future thinking (EFT)—the capacity to anticipate future outcomes and use such representations to guide present behavior—has been theoretically linked to executive control and self-regulation, yet remains underexplored as an additive mechanism within executive-function (EF) training for children with ADHD. To address this gap, the present study developed a VR-based EFT training paradigm designed to operationalize future-oriented executive control within immersive, consequence-based scenarios. Parent-reported rating scales were used to examine changes in children’s executive functioning following intervention.A randomized controlled trial was conducted with 80 children with a confirmed diagnosis of ADHD (ages 5–12), who were assigned to either an EF training plus VR-based EFT condition (n = 40) or an active EF-only control condition (n = 40). Both conditions were delivered over a two-week intervention period, with training sessions administered six times per week. Outcome assessments were conducted at two assessment occasions (pre-intervention and post-intervention) using standardized parent-report measures, including the Behavior Rating Inventory of Executive Function (BRIEF), the Executive Function Scale (EFAS), and the Childhood Executive Functioning Inventory (CHEXI). Behavioral symptom scales (CBCL and Vanderbilt) were included as secondary outcomes. Mixed-design analyses of variance revealed significant main effects of Assessment Occasion across most executive-function domains assessed by the BRIEF, EFAS, and CHEXI (ps < .01), indicating overall improvement following EF training across both conditions. Critically, significant Assessment Occasion × Training Condition interactions were observed for the BRIEF and EFAS, indicating greater pre-to-post improvements in the EF + VR-EFT condition for higher-order executive functions, including inhibition, planning/organization, task initiation, and metacognitive regulation. In contrast, CHEXI subscales demonstrated significant time effects but no condition-specific interaction effects, suggesting comparable improvements across training conditions on measures of everyday executive-function difficulties. Behavioral symptom measures similarly showed improvement over time without VR-specific advantages. Overall, the addition of a VR-based episodic future thinking module to conventional executive-function training yielded selective, domain-specific benefits, particularly for higher-order executive processes. These findings support VR-supported EFT as a complementary mechanism for enhancing executive control, rather than a global enhancement of everyday behavioral functioning, in children with ADHD.