JMIR Publications

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  Games for Cognitive Assessment

  Jun 8, 2026

  Serious Game Aimed at Assessing Executive Planning Skills in Children With Autism: Cross-Sectional Design and Formative Evaluation of ShopAutiPlan

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  Authors List:

  • Athmar N M Shamhan  
  • Mohamad Hassan Fadi Hijab  
  • Marwa Qaraqe  
  • Dena Al-Thani  

  Abstract:

  Background: Planning deficits are a common and functionally significant executive function difficulty in children with autism, affecting everyday activities such as organizing tasks, prioritizing goals, and monitoring progress. Traditional neuropsychological assessments often lack ecological validity and may not capture these skills in real-world contexts. Serious games offer promising alternatives by simulating everyday scenarios and enabling observation of planning behaviors during interactive tasks. However, most existing systems focus on training rather than theory-driven assessment, and are rarely evaluated for usability before deployment with children with autism. Objective: This study aimed to design and evaluate ShopAutiPlan, a supermarket-based serious game intended to assess executive planning skills in children with ASD by conducting a formative expert evaluation before its use in clinical or research settings. The evaluation sought to identify usability strengths and limitations, ensuring that the system aligns with planning theory and accommodates the unique needs of autistic users. Methods: A theory-driven design approach grounded in the Hayes-Roth cognitive model of planning was used to map planning subcomponents—including goal formulation, strategy generation, sequencing, execution, and monitoring—to in-game tasks and logged behavioral metrics. A cross-sectional, formative expert-based usability evaluation was conducted using inspection and think-aloud protocols. Six domain experts (2 psychologists, 2 human-computer interaction researchers, and 2 game developers) participated in individual evaluation sessions. Usability assessment was guided by ASD-specific usability heuristics, and experts completed the System Usability Scale (SUS). SUS scores were summarized using descriptive statistics, and qualitative feedback was analyzed through deductive coding mapped to heuristic categories. Results: Across experts, 45 usability issues were identified, spanning cognitive accessibility, feedback clarity, realism, and technical performance. Severity ratings varied according to disciplinary perspectives: psychologists highlighted cognitive load, sensory accessibility, and task clarity, whereas developers focused on system responsiveness, interaction consistency, and technical reliability. The overall SUS score (mean 70.4, 95% CI 45.2‐95.7) exceeded the standard benchmark of 68, supporting the acceptability of the system and complementing the qualitative findings from the heuristic evaluation. Recommendations from the evaluation informed iterative refinements to interface design, interaction flow, and task representation to enhance alignment between planning constructs and user experience. Conclusions: To the best of our knowledge, this study introduces the first shopping-based serious game specifically designed to assess executive planning skills in children with autism. Unlike many existing autism-related serious games that primarily focus on intervention or training, ShopAutiPlan adopts a theory-driven assessment-oriented design grounded in a cognitive model of planning and supported by gameplay-based behavioral measures. By integrating cognitive theory, serious game design, and interdisciplinary usability evaluation, the study proposes a structured framework for developing ecologically valid digital assessment tools that may complement conventional neuropsychological approaches in autism research and clinical practice.

  • JMIR Serious Games 2026;14(1):e90444

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  Serious Games for Health and Medicine

  Jun 5, 2026

  Nintendo Switch–Based Exergaming for Subthreshold Depression: Mixed Methods Randomized Controlled Trial

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  Authors List:

  • Kexin Huang  
  • Lei Song  
  • Ariadna Albajara Sáenz  
  • Rendong He  
  • Yongliang Jiao  
  • Yong Jia  
  • Li Chen  

  Abstract:

  Background: Subthreshold depression (StD) increases the risk of progression to major depressive disorder. Although exercise can reduce depressive symptoms, adherence remains challenging. Exergames on platforms such as Nintendo Switch may improve motivation and participation in physical activity; however, evidence for efficacy in StD is limited. Objective: This study aims to evaluate the effects of a Nintendo Switch–based exergaming intervention on depressive symptoms, anxiety, and sleep quality, and to explore participant experiences among adults with StD. Methods: This sequential explanatory mixed methods study comprised a randomized controlled trial followed by semistructured interviews. Eighty-four adults with StD were randomized using computer-generated permuted blocks with concealed allocation to an intervention group (IG; n=42), which received an 8-week Nintendo Switch–based exergame program (2‐3 sessions/week, 50‐60 minutes/session), or a control group (CG; n=42), which continued usual activities. Outcome assessors and data analysts were blinded. Depressive symptoms, anxiety, and sleep quality were assessed at baseline (T0), postintervention (T1, Week 8), one-month follow-up (T2, Week 12), and 2-month follow-up (T3, Week 16). Generalized estimating equations (GEE) were used to analyze longitudinal changes and time×group interactions under the intention-to-treat principle. Semistructured interviews were conducted with a purposive subsample of IG participants (n=17) at T1 and analyzed using thematic analysis. Results: Eighty-four participants were randomized; 81 completed the postintervention assessment, with 3 out of 42 (7.1%) CG participants lost to follow-up at T1. Baseline characteristics were similar across groups (mean age 23.07, SD 1.45 years; 70/84, 83.3% female). Compared with CG, the IG showed significantly greater reductions in depressive symptoms at all time points (T1: =−4.07, 95% CI −5.84 to −2.30; <.001; T2: =−4.29, 95% CI −6.14 to −2.43; <.001; T3: =−3.81, 95% CI −5.54 to −2.08; <.001), along with significant improvements in sleep quality (T1: =−2.98, 95% CI −4.55 to −1.40; <.001; T2: =−2.19, 95% CI −3.58 to −0.80; =.002; T3: =−2.45, 95% CI −3.81 to −1.09; <.001). Anxiety also improved significantly at T1 (=−2.60, 95% CI −4.70 to −0.50; =.02) and T3 (=−2.38, 95% CI −4.62 to −0.14; =.04). Group×time interactions were significant for depressive symptoms (Wald =28.18; =.001) and sleep quality (Wald =23.21; <.001), confirming sustained intervention effects. Qualitative findings supported these results, highlighting immersive engagement, perceived psychophysiological benefits, and adherence facilitators. No adverse events were reported. Conclusions: A Nintendo Switch–based exergaming intervention was associated with improvements in depressive symptoms, anxiety, and sleep quality in adults with StD. Using mixed methods design, this study provides evidence integrating effectiveness and participant experience, extending prior research focused on other populations or quantitative outcomes. These findings suggest that commercially available exergaming platforms may serve as accessible, engaging tools for early mental health support in real-world settings. Trial Registration: Chinese Clinical Trial Registry ChiCTR2300068970; https://www.chictr.org.cn/showproj.html?proj=180172

  • JMIR Serious Games 2026;14(1):e80937

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  Gamification

  Jun 3, 2026

  Gamified Assessment of Cognitive Impulsivity in Eating Disorders and Mental Ill-Health: Mixed Methods Study Incorporating Lived Experience Co-Design and...

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  Authors List:

  • Emily Colton  
  • Courtney McLean  
  • Alexandra Anderson  
  • Lauren Hanegraaf  
  • Antonio Verdejo-Garcia  

  Abstract:

  Background: Cognitive impulsivity is a multifaceted construct associated with symptom severity, functional impairment, and poor quality of life in eating disorders (EDs) and mental ill-health. However, objective assessment of cognitive impulsivity is piecemeal and complex, with many assessment tools lacking psychometric evaluation and ecological validity. Furthermore, validated assessment tools are rarely perceived to be engaging or meaningful by individuals who complete them, limiting their utility in research and forming a barrier to clinical translation. Thus, although cognitive impulsivity predicts treatment engagement and outcomes, it is rarely assessed or addressed in a clinical context. Objective: We aimed to redesign and evaluate the Cognitive Impulsivity Suite (CIS), a validated gamified assessment battery of cognitive impulsivity, through user-centered co-design, agile game development, and user-centered evaluation. This collaborative study partnered researchers with individuals with lived experiences (LEs) of EDs and commonly co-occurring mental ill-health, and game development experts. Methods: In a sequential mixed methods design, we first defined user requirements through inductive thematic analysis of data from 2 focus groups incorporating 7 individuals with LE of EDs and commonly co-occurring mental health conditions (mean age 27.6, SD 7.03 y; 4 women, 2 men, 1 nonbinary), researchers, clinicians, and technology professionals. Agile game development was achieved through 6-week-long sprints, involving game developers and a play-testing team of researchers. During LE evaluation, we collected and analyzed data from an expanded sample (n=18; mean age 30.5, SD 6.56 y; 12 women, 3 men, 2 nonbinary), using a pragmatic blending of qualitative and quantitative research methods. This included inductive and deductive thematic analysis of “thinking aloud” data, descriptive statistics, and ANOVA tests of the Game User Experience Satisfaction Scale, short version (GUESS-18) surveys. Results: We co-designed guiding principles and ideas for aesthetics, story concepts, and gameplay features, which closely aligned with leading theories of psychological well-being, clinical evidence concerning ED recovery, and gamification frameworks. Qualitative evaluations of the new tool, CIS , showed user engagement and motivation were driven by opportunities for autonomy, personal accomplishment, and simulated interpersonal relationships, aligning with approaches to gamification based on self-determination theory. In quantitative evaluation, a mean GUESS-18 composite score of 45.9 (SD 9.85) showed CIS achieved sound overall user satisfaction, with subscale scores revealing strengths in usability, narrative, visual and audio aesthetics, and personal gratification. Conclusions: The contributions of this study are grounded in its integration of user-centered co-design and evaluation, agile game development, and theory-driven approaches to cognitive assessment and gamification, to redesign and evaluate a validated online task battery. The resulting CIS combines appealing aesthetics, gamification elements that address cognitive, emotional, and social needs, and accessible playing experiences, which maximized user satisfaction and engagement while prioritizing psychological safety. Next steps involve psychometric evaluation and dissemination.

  • JMIR Serious Games 2026;14(1):e79784

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  Games for Cognitive Assessment

  May 26, 2026

  Cognitive Load Across Interaction Formats in Digital Attention Assessment for Children: Within-Subject Neuroimaging and Behavioral Comparison Study

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  Authors List:

  • Harim Jeong  
  • Yong Jeon Cheong  
  • Jihyeong Ro  
  • Jihyun Cha  
  • Jongkwan Choi  
  • Minyoung Jung  

  Abstract:

  Background: Digital health technologies increasingly use tablet-based cognitive assessments for children, yet interaction design choices can substantially influence cognitive load and measurement validity. Although cognitive load has been extensively studied in educational settings, its impact on patient-facing digital assessment tools for pediatric populations remains underexplored. Objective: This study examined how the interaction format influences cognitive load and measurement validity in a tablet-based Stroop task for children, comparing text-based with color-based response selection to determine which format better supports valid attention assessment. Methods: Using a within-subject design, 127 typically developing children (n=55, 43.3%, girls; n=72, 56.7%, boys) aged 6-12 (mean 9.15, SD 1.56) years were recruited via convenience sampling from local communities in the Republic of Korea. Participants completed both a text-based and a color-based Stroop task on a tablet. Cognitive load was indexed using prefrontal functional near-infrared spectroscopy (fNIRS), measuring functional connectivity (FC) and global network efficiency. Behavioral outcome measures included accuracy, reaction time, and the composite efficiency score. Clinical validity was assessed by correlating task performance with parent-reported attention problems using a standardized behavioral rating scale. General cognitive ability was controlled using a standardized intelligence measure. Condition differences were analyzed using paired-sample t tests (α=.05), clinical associations using Pearson correlations with Fisher r-to-z transformation, and predictor contributions using random forest regression. Results: In the paired-sample t tests, the color-based format yielded significantly higher accuracy (0.91 vs 0.86; mean difference 0.05, 95% CI 0.03-0.08; t₁₂₆=3.81, Cohen d=0.34, P<.001), faster reaction times (1183 vs 1269 ms; mean difference −85.4 ms, 95% CI −107.2 to −63.5; t₁₂₆=−7.72, Cohen d=–0.69, P<.001), and superior composite performance (t₁₂₆=6.81, Cohen d=0.62, P<.001). Pearson correlations revealed that color-based performance was significantly associated with parent-reported attention problems (r=−0.20, 95% CI −0.37 to −0.03; P=.03), whereas text-based performance was not (r=−0.05, 95% CI −0.23 to 0.12;’ P=.56); the Fisher r-to-z test indicated this difference was not statistically significant (z=1.54, P=.12). fNIRS-derived neural indices (ΔFC, global efficiency) did not differ significantly between conditions (P>.05). Random forest analyses indicated that after controlling for age and general cognitive ability, individual variations in prefrontal efficiency accounted for 40% to 44% of residual performance variance. Conclusions: This study provides some of the first empirical evidence that the interaction format substantially influences task demands and measurement validity in pediatric digital assessments, extending cognitive load theory into digital health assessment design. Color-based response formats that minimize extraneous semantic processing yield superior performance and stronger clinical validity compared to text-based formats. These findings suggest that prioritizing response modalities aligned with children’s developmental capabilities may improve the clinical utility of digital attention assessments. Trial Registration:

  • JMIR Serious Games 2026;14(1):e93468

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  Serious Games for Health and Medicine

  May 25, 2026

  Using Eye Tracking to Measure Video Game–Assisted Therapy for Improved Visual Outcomes in Pediatric Strabismus: Randomized Control Trial

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  Authors List:

  • Ahmad F Klaib  

  Abstract:

  Background: Strabismus, commonly known as crossed eyes, is a condition characterized by the misalignment of the eyes, leading to impaired binocular vision and depth perception. Traditional management often involves occlusion therapy, which can be hindered by poor compliance. Video game therapy has emerged as a promising adjunct to traditional treatments, potentially improving compliance and directly stimulating visual and cognitive functions. Objective: This study compares the effectiveness of traditional occlusion therapy with and without the addition of video game therapy in improving visual outcomes among children with strabismus. Methods: This randomized, controlled clinical trial included 30 children aged 5 to 10 years diagnosed with various types of strabismus. Participants were randomly assigned to 2 groups: the control group (eye patching alone) and the treatment group (eye patching combined with video game therapy). The intervention lasted 3 months, with data collected at baseline and after the treatment. Primary outcomes included visual acuity, angle of deviation, and stereoacuity, while fixation stability was measured using the Tobii eye tracker. Data were analyzed using paired 2-tailed tests, independent 2-tailed tests, Mann-Whitney tests, and multivariate analysis of variance, with a significance level set at <.05. Results: The treatment group showed significant improvements across all measured outcomes. Visual acuity improved significantly in both the amblyopic (<.001) and fellow or nonamblyopic eyes (<.001). The angle of deviation decreased (<.001), and stereoacuity improved (<.001). Fixation stability, as measured by the eye tracker, also showed significant improvement and was higher in the treatment group (mean 2.87, SD 0.56 seconds) compared with the control group (mean 1.88, SD 0.42 seconds; <.001). The control group, which received only eye patching, also exhibited significant improvements, though to a lesser extent. Posttreatment visual acuity in the amblyopic eye was significantly better in the treatment group compared to the control group (<.001), with similar results for the fellow or nonamblyopic eye (<.001). Stereoacuity also showed superior improvement in the treatment group (=.01). Fixation stability was significantly better in the treatment group (<.001), and multivariate analysis of variance indicated a highly significant overall difference between the 2 groups across multiple outcomes (<.001). Conclusions: The combination of traditional eye patching with video game therapy significantly enhances treatment outcomes in children with strabismus, particularly in improving visual acuity, stereoacuity, and fixation stability. While both interventions effectively reduce the angle of deviation, video game therapy offers additional benefits by engaging in and improving the functional aspects of vision. These findings suggest that incorporating video game therapy into traditional treatment regimens could lead to more effective and engaging interventions for pediatric strabismus, potentially improving compliance and long-term outcomes. Future research should focus on understanding the underlying mechanisms and optimizing therapy for diverse patient populations. Trial Registration: Thai Clinical Trials Registry TCTR20251125008; https://www.thaiclinicaltrials.org/show/TCTR20251125008

  • JMIR Serious Games 2026;14(1):e66538

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  Serious Games for Education

  May 25, 2026

  Exploring the Effects of Serious Games (Immersive Virtual Reality Versus Web-Based Platforms) on Interprofessional Education Among Undergraduate Health Care...

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  Authors List:

  • Justina Yat Wa Liu  
  • Rina Wing Yan Wong  
  • Sabina Margaret Pinto  
  • Curtis Ka Ho Wong  
  • Patrick Pui Kin Kor  
  • Shanshan Wang  
  • Kitty Chan  

  Abstract:

  Background: Interprofessional education (IPE) is essential for developing teamwork and communication skills in health care training. Building interprofessional competency involves acquiring knowledge, cultivating readiness to engage in teamwork, and fostering effective collaboration. However, challenges include geographical barriers and faculty resistance that can hinder progress. Innovative solutions to enhance engagement and collaboration include serious games played using immersive virtual reality (IVR) and web-based platforms. Despite their potential, research comparing the effectiveness of these approaches for IPE remains limited. Objective: This study aimed to identify effective implementation methods by evaluating the impact of IVR and web-based serious games on health care students’ interprofessional competencies and learning experiences. Methods: A multimethod approach was used to evaluate students’ pre- and postlearning outcomes and experiences. Nursing and physiotherapy students were randomly assigned to either the IVR group or web-based group. The Readiness for Interprofessional Learning Scale (RIPLS), Brief Sense of Community Scale (BSCS), and Intrinsic Motivation Inventory (IMI) were used to measure learning experiences. Learning outcomes were examined through multiple-choice questions (MCQs). After the outcome assessments, groups switched modalities to allow all students to experience both learning approaches. Four focus groups (n=34) provided qualitative insights into learning experiences. Results: The study included 271 students (IVR group: 125; web-based group: 146). Both groups showed significant improvements in community building (BSCS; IVR: =−0.29, 95% CI 0.06-0.31; =.001; web-based: =−0.27, 95% CI 0.07-0.31; =.001). The IVR group showed improvements in only the pressure/tension subscale of the IMI (=−0.45, 95% CI −0.05 to −0.25; <.001), while the web-based group showed improvements across all IMI subscales, including interest/enjoyment (−0.17, 95% CI 0.00-0.30; =.043), perceived competence (=−0.19, 95% CI 0.00-0.50; =.02), and pressure/tension (=−0.46, 95% CI −0.75 to −0.50; <.001). Both groups showed significant improvements in knowledge-checking MCQ scores (IVR: =−0.64, 95% CI 2.00-3.00; <.001; web-based: =−0.80, 95% CI 4.50-6.00; <.001), with the web-based group outperforming the IVR group (=−0.34, 95% CI −3.00 to −2.00; <.001). RIPLS scores showed no significant difference in both groups, suggesting that greater exposure is required to enhance IPE readiness. A qualitative analysis revealed 6 themes: valuing collaboration opportunities, fostering trust and shared learning, promoting engagement and authenticity, enhancing knowledge retention, balancing innovation with practicality, and improving realism and inclusivity. No adverse events were noted. Conclusions: To our knowledge, this is the first study to compare the effects of 2 different modalities (IVR and web-based approaches) on a technology-enabled IPE program. These findings highlight the practical potential of both approaches in supporting IPE. The web-based approach’s superior performance in enhancing learning outcomes and motivation suggests that its flexible format better accommodates diverse learning preferences. These findings support technology-enhanced IPE, offering educators scalable, evidence-based strategies to develop collaborative, patient-centered professionals who are equipped for real-world practice. Trial Registration: ClinicalTrials.gov NCT07474701; https://clinicaltrials.gov/study/NCT07474701

  • JMIR Serious Games 2026;14(1):e80033

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  Reviews

  May 19, 2026

  Effectiveness of Virtual Reality Interventions on Perioperative Anxiety, Depression, Blood Pressure, and Heart Rate: Systematic Review and Meta-Analysis of...

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  Authors List:

  • Shijin Wang  
  • Hong Yan  
  • Zhehui Yang  
  • Yan Liu  
  • Tingting Zhang  
  • Yuanyuan Tang  
  • Yuling Luo  

  Abstract:

  Background: Perioperative stress hinders patient recovery and poses significant challenges for clinical nursing. It triggers a vicious cycle of negative psychological emotions and adverse physiological stress responses. Immersive virtual reality (VR), an innovative nonpharmacological intervention, has been gradually incorporated into perioperative care, showing promise in alleviating patient stress. However, comprehensive evaluations of its multidimensional efficacy remain lacking. Objective: This study aims to systematically evaluate the dual regulatory effects of VR interventions on both psychological emotions and objective physiological stress in adult patients undergoing perioperative care. Methods: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines, we comprehensively searched 9 electronic databases for randomized controlled trials (RCTs) published from January 2000 to March 2026. Eligible RCTs evaluated VR combined with routine care vs routine care alone in adult patients (≥18 years). The risk of bias was assessed using the Cochrane Risk of Bias 2 tool (Cochrane Collaboration). Meta-analyses were performed using a random-effects model based on the Hartung-Knapp-Sidik-Jonkman method. We reported 95% CIs and 95% prediction intervals (PIs) to interpret clinical heterogeneity and evaluated evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: We included 42 RCTs involving 4648 participants. Compared to routine care, VR significantly reduced anxiety (standardized mean difference −1.17, 95% CI −1.50 to −0.85; 95% PI −3.16 to 0.81) and depression (standardized mean difference −1.26, 95% CI −1.71 to −0.81; 95% PI −2.39 to −0.13). Physiologically, VR effectively decreased systolic blood pressure (mean difference [MD] −5.12, 95% CI −7.21 to −3.03; 95% PI −11.73 to 1.49), diastolic blood pressure (MD −3.45, 95% CI −5.18 to −1.73; 95% PI −8.63 to 1.72), and heart rate (MD −4.45, 95% CI −5.94 to −2.97; 95% PI −10.15 to 1.24). Subgroup analyses revealed that the anxiolytic effect was more pronounced in Asian populations. Conclusions: VR serves as a safe and effective adjunctive intervention that exhibits a dual regulatory mechanism, simultaneously mitigating psychological distress and stabilizing hemodynamic parameters in perioperative adults. Unlike existing systematic reviews that are predominantly limited to a single psychological metric (eg, anxiety) or focused on pediatric populations, this review integrates both psychological (anxiety and depression) and objective physiological (blood pressure and heart rate) dimensions into a unified evaluation framework. While average benefits are robust, the wide PIs suggest that true effects may vary across individuals due to clinical heterogeneity. Future standardized, large-scale RCTs with strict blinding are warranted to elevate the certainty of evidence. Trial Registration: PROSPERO CRD42025645987; https://www.crd.york.ac.uk/PROSPERO/view/CRD42025645987

  • JMIR Serious Games 2026;14(1):e81799

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  Games for Cognitive Assessment

  May 8, 2026

  Cognitive Function Assessment Using a Virtual Reality Serious Game System in Patients With Stable Schizophrenia: Prospective Cohort Study

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  Authors List:

  • Xingxing Li  
  • Yu Zhuo  
  • Xiandong Meng  
  • Wenting Zhao  
  • Chenxin Wu  
  • Kai Yan  
  • Leiyu Yue  
  • Yu Sun  
  • Qian Xiong  
  • Xi Cao  
  • Xiaomin Kou  
  • Jianying Yu  

  Abstract:

  Background: Cognitive impairment is a core and enduring deficit in schizophrenia, severely affecting social functioning and quality of life. Traditional assessments such as the MATRICS Consensus Cognitive Battery face limitations in validity and engagement. Virtual reality (VR) serious games may offer an immersive alternative, and machine learning (ML) can uncover complex behavioral patterns. However, integrating VR-based assessment with ML for discriminating stable-phase schizophrenia remains unexplored. Objective: This prospective cohort study aimed to examine whether a VR serious game (“Fruit Pioneer”) can effectively assess cognitive function in stable schizophrenia, verify its correlation with the standard Brief Cognitive Assessment Tool for Schizophrenia (B-CATS), and test the discriminative capacity using ML models. We hypothesize that (1) patients with schizophrenia will show poorer VR game performance than healthy controls (HCs), (2) VR metrics will correlate with B-CATS scores, and (3) ML models will help classify patients with schizophrenia and HCs using VR data. Methods: A total of 42 patients with stable schizophrenia and 65 HCs (aged 18-40 years) were enrolled. Exclusion criteria included color blindness, visual impairment, substance abuse, and comorbid chronic physical diseases. Finally, 39 patients with schizophrenia and 64 HCs were included. Materials included the VR serious game “Fruit Pioneer,” B-CATS (Digital Symbol Substitution Test, Trail Making Test Part A, Trail Making Test Part B, and Animal Fluency), Simulator Sickness Questionnaire, and Game Experience Questionnaire. Data were collected via standardized VR gameplay and paper-based assessments. Logistic regression and a support vector machine (SVM) model were built using VR metrics. Results: Patients with schizophrenia performed worse on all B-CATS subtests (all P<.001). They also showed lower VR total scores (median 467, IQR 376-544 vs median 683, IQR 616-753; P<.001), longer reaction times (median 1.11, IQR 0.995-1.23 vs median 1.03, IQR 0.96-1.1; P=.006), lower gaze hit rates (median 0.515, IQR 0.442-0.554 vs median 0.552, IQR 0.497-0.592; P=.01), and higher bomb penalty scores (median 150, IQR 95-170 vs median 108, IQR 85-131; P=.002). In the schizophrenia group, VR metrics correlated with B-CATS results, whereas this relationship was minimal in HCs. Classification performance of the SVM (average area under the curve [AUC]=0.874, 95% CI 0.860-0.888) was comparable to logistic regression (average AUC=0.854, 95% CI 0.838-0.870). Conclusions: This study demonstrates the innovative integration of a VR serious game with ML to assess cognitive function in stable schizophrenia. Unlike prior VR studies focused mainly on validation, our approach combines behavioral metrics with an SVM model, achieving effective classification. The findings support the potential of a scalable digital assessment correlated with standard tests. In clinical practice, this system may serve as an engaging alternative to traditional methods, facilitating long-term cognitive monitoring and personalized rehabilitation strategies.

  • JMIR Serious Games 2026;14(1):e83001

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  Games for Cognitive Assessment

  May 4, 2026

  Brain Structural Covariance Networks in Long-Term First-Person Shooter and Multiplayer Online Battle Arena Players: Cross-Sectional Study

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  Authors List:

  • Zhenggen Lin  
  • Fujia Jiao  
  • Yuanbo Ma  
  • Jie Zhuang  
  • Yu Liu  

  Abstract:

  Background: The relationship between video game experience and cognitive plasticity remains a central focus of research, particularly given its potential applications in clinical rehabilitation. Although both first-person shooter (FPS) and multiplayer online battle arena (MOBA) games have been shown to enhance cognitive functions, the specific associations between the cognitive effects of different game genres and brain network structure remain unclear. Objective: This study aimed to examine whether long-term experience with FPS and MOBA games is associated with genre-specific patterns of cortical thickness covariation across brain regions. Methods: A total of 116 male participants (mean age 21.2, SD 1.9 y) were recruited via online advertisements for this cross-sectional study. On the basis of strict inclusion criteria (gaming experience >5 years, gaming frequency >5 hours per week, and ranking within the top 15%), participants were categorized into FPS players (n=39, 33.6%) and MOBA players (n=40, 34.5%). An additional group of healthy controls (n=37, 31.9%) with no gaming experience in the past 2 years was also included. High-resolution structural magnetic resonance imaging data were acquired using a 3-T scanner. Individualized differential structural covariance networks were constructed based on the cortical thickness values extracted from 68 brain regions using the Desikan-Killiany atlas. Statistical analysis included one-way ANOVA to identify significant structural covariance edges (SCEs), network-based statistic prediction analysis for weekly gaming hours, and support vector machine analysis for group classification. Results: One-way ANOVA identified 30 significant SCEs across the 3 groups (<.001, false discovery rate corrected). Post hoc analysis (<.02, Bonferroni corrected) revealed that, compared to the MOBA and control groups, the FPS group exhibited 2 dominant networks: a temporo-fronto-parietal network anchored in auditory regions and a visuo-sensorimotor network. Both gaming groups showed enhanced SCEs in visual-attentional networks compared to the control group. The network-based statistic–predict analysis demonstrated that structural covariance matrices could effectively predict weekly gaming hours in FPS players (=0.34, 95% CI 0.26‐0.42). The positive edges primarily formed a temporo-fronto-parietal-occipital network, whereas the negative edges were centered on the entorhinal cortex. The support vector machine classifier successfully differentiated FPS players from controls (area under the curve=82.95%) and from MOBA players (area under the curve=72.37%). Conclusions: Long-term FPS and MOBA gaming experiences are associated with different brain structural network architectures. The uniqueness of FPS gaming lies in the extensive structural covariance between the primary auditory cortex and regions supporting visual attention and sensorimotor processing, which may reflect higher demands on cognitive skills. This suggests potential utility in auditory-visual rehabilitation and provides a theoretical basis for the assessment and selection of professional electronic sports players. However, the negative edges involving the entorhinal cortex in FPS players indicate that an overreliance on response learning strategies may come at the expense of the spatial memory system. Consequently, caution is warranted when applying such games to ameliorate age-related memory decline.

  • JMIR Serious Games 2026;14(1):e79976

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  Serious Games for Health and Medicine

  May 4, 2026

  Gamified Feedback-Based Training System for Pediatric Asthma Inhaler Use: Mixed Methods Randomized Crossover Study

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  Authors List:

  • Haoyu Zhang  
  • Xiaoying Li  

  Abstract:

  Background: Asthma is a prevalent chronic respiratory condition among children worldwide. Inhalation therapy is the primary treatment method, but children often make errors in its use and exhibit poor adherence, which impacts treatment effectiveness. Therefore, interventions to improve inhalation techniques and enhance adherence are urgently needed. Objective: This study aimed to develop and evaluate BreatheBuddy, developed by Haoyu Zhang, a training system incorporating gamified feedback designed to enhance inhalation skills and treatment adherence in children with asthma. Methods: This study used a single-factor repeated-measures design and recruited 20 children aged 6 to 8 years (10 boys and 10 girls), all of whom had prior experience with inhalers. The experimental group used the BreatheBuddy system, which combines a physical inhaler with an interactive game-based software. The system provides real-time animated feedback based on data from inhalation, breath-holding, and exhalation to guide the rhythm and depth of inhalation. The control group used a conventional inhaler method without a gamified system. Inhalation accuracy, adherence, and satisfaction were assessed using the respiration sensor, the Player Experience of Need Satisfaction scale, the Game User Experience Satisfaction Scale (GUESS), and the System Usability Scale (SUS) scales. Statistical comparisons between the groups were conducted using paired tests and Mann-Whitney tests to analyze differences. Results: The experimental group demonstrated significant improvements in inhalation accuracy, with longer breath-holding times and more stable breathing patterns compared to the control group (<.001). The experimental group also exhibited significantly higher engagement and motivation, with Player Experience of Need Satisfaction (standardized score=93.83) and GUESS (median 87.92, IQR 86.54-88.46) scores markedly higher than those of the control group. Usability scores for the experimental group were also superior, with an SUS score of 88.96 (<.001). Additionally, children in the experimental group showed reduced anxiety and improved focus during training. Conclusions: BreatheBuddy effectively optimized children’s inhalation skills, boosted treatment adherence, and relieved inhalation-related anxiety. Different from conventional non-gamified training or simple game-based distraction, this study integrated breathing behaviors into core game interaction. With dynamic respiratory rhythm feedback, the system unifies skill training, motivation promotion, and emotional regulation. Combined with standard inhaler operation and immersive gamified interaction, it presents a novel behavior-oriented design paradigm. This work provides empirical evidence for gamified intervention in pediatric respiratory treatment and offers a practical auxiliary tool for clinical daily training to strengthen children’s self-management. Further research will focus on personalized adjustment and wider clinical application of the system.

  • JMIR Serious Games 2026;14(1):e85673

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  Serious Games for Health and Medicine

  Apr 30, 2026

  Socially Prescribed Perfectionism, Resilience, and Internet Gaming Disorder in Adolescents: 3-Wave Longitudinal Study

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  • Peng Zheng  
  • Zi Tao  
  • Tao Yao  
  • Luoxiang Fang  
  • Min Zhao  

  Abstract:

  Background: Internet gaming disorder (IGD) is increasingly prevalent among adolescents. Although socially prescribed perfectionism (SPP) and resilience are both related to IGD, longitudinal evidence on their temporal relationships and underlying mechanisms remains limited. Objective: This study aimed to examine the longitudinal associations among SPP, resilience, and IGD in Chinese adolescents; test the mediating role of resilience; and explore potential sex differences. Methods: A 3-wave prospective longitudinal study was conducted among students from 4 middle schools in Zhejiang Province, China. Adolescents who had played online games in the past 12 months were recruited using convenience sampling. Data were collected at 6-month intervals: time 1 (T1; March 2024), time 2 (T2; September 2024), and time 3 (T3; March 2025). A total of 1332 Chinese adolescents (875/1332, 65.7% male; mean age 13.61, SD 0.70 years) participated in the baseline survey. SPP, resilience, and IGD were assessed using the Hewitt-Flett Multidimensional Perfectionism Scale-Short Form, the 10-item Connor-Davidson Resilience Scale, and the 9-item (Fifth Edition) IGD Checklist, respectively. Cross-lagged panel model (CLPM) and multigroup analyses across sex were conducted. Results: All statistical tests were 2-tailed with =.05. The CLPM demonstrated good fit to the data (χ²=163.34; comparative fit index [CFI]=0.945; Tucker-Lewis index [TLI]=0.932; root mean square error of approximation [RMSEA]=0.054; standardized root mean square residual [SRMR]=0.047). Higher SPP predicted later IGD (T1→T2: =0.10, 95% CI 0.04 to 0.16, <.001; T2→T3: =0.09, 95% CI 0.03 to 0.15, =.004) and lower resilience (T1→T2: =−0.09, 95% CI −0.16 to −0.02, =.007; T2→T3: =−0.12, 95% CI −0.18 to −0.06, <.001). In contrast, SPP was not significantly predicted by prior IGD nor resilience. Higher resilience predicted lower subsequent IGD (T1→T2: β=−0.09, 95% CI −0.15 to −0.03, =.001; T2→T3: =−0.09, 95% CI −0.15 to −0.03, =.001), whereas higher IGD predicted lower subsequent resilience (T1→T2: =−0.19, 95% CI −0.27 to −0.11, <.001; T2→T3: =−0.09, 95% CI −0.15 to −0.03, =.003). Bootstrapped mediation analysis showed a significant indirect effect of SPP at T1 on IGD at T3 via resilience at T2 (=0.008, 95% CI 0.004 to 0.012, =.005). However, multigroup analyses revealed no significant sex differences. Conclusions: This study provides novel insights into the longitudinal associations among SPP, resilience, and IGD in adolescents. Unlike previous research based mainly on cross-sectional data, this 3-wave CLPM study clarifies the temporal relationships among these variables and shows that resilience mediates the association between SPP and subsequent IGD. These findings advance the field by identifying a temporal psychological pathway underlying adolescent IGD. They also have practical implications for early screening and for developing resilience-focused interventions for adolescents at risk of IGD.

  • JMIR Serious Games 2026;14(1):e93412

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  Game Addiction and Other Unintended...

  Apr 30, 2026

  Associations Between Parental Gaming Behaviors and Conversion From Internet Gaming Disorder Noncases to Cases Among Adolescents: Prospective Longitudinal...

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  • Joseph TF Lau  
  • Yanqiu Yu  

  Abstract:

  Background: Parental factors are known determinants of internet gaming disorder (IGD) among adolescents. However, the associations between gaming-specific parental factors (eg, parental gaming frequency and parental invitations for cogaming) and IGD have been less investigated, and relevant longitudinal evidence is lacking to inform effective IGD interventions. Objective: This study aimed to investigate (1) the prevalence of IGD conversion (from a noncase at baseline to a case at follow-up) and (2) the prospective associations between two parental gaming behaviors and IGD conversion as well as their mediation mechanisms via parental supportive attitude toward adolescents’ gaming behaviors and behavioral intention of increasing gaming time. Methods: A 12-month prospective longitudinal study, with the baseline survey in December 2018 (T1) and the follow-up survey in December 2019 (T2), was conducted among students from 6 convenience-selection junior middle schools in Chengdu and Guangzhou, China. All grade 7 and 8 students of these schools were invited for participation; students self-administered the structured questionnaire on paper and pencil, in classroom settings, and in the absence of schoolteachers. The 9-item DSM-5 Internet Gaming Disorder Symptoms Checklist was used to assess IGD (Cronbach α=0.73). Those with IGD at T1 were excluded, and the final sample size was 2172 (mean age 12.56, SD 0.02, 95% CI 12.52-12.60 years; n=1102, 50.7%, 95% CI 48.7%-52.8% female). The prevalence of IGD conversion was 5.2% (113/2172; 95% CI 4.4%-6.1%). Results: Adjusted for background factors and respective mediator and outcome scores at T1, two path analysis models showed satisfactory model fit indices (ie, root mean square error approximation=0.02 and 0.03, comparative fit index=0.97 for both models, and standardized root mean square residual=0.02 for both models). The prospective associations between perceived parental gaming frequency and perceived parental invitations for cogaming and IGD conversion were significantly and fully mediated by the 1-mediator indirect path via parental supportive attitude (β=0.02, 95% CI 0.01-0.04 and β=0.02, 95% CI 0.01-0.04) and the 2-mediator indirect path first via parental supportive attitude and then via behavioral intention of increasing gaming time (β=0.006, 95% CI 0.002-0.009 and β=0.005, 95% CI 0.001-0.009) but not the 1-mediator indirect path via the behavioral intention (β=0.01, 95% CI −0.01 to 0.03 and β=0.01, 95% CI −0.01 to 0.03), respectively. Conclusions: This longitudinal study revealed the prospective associations between 2 parental gaming behaviors and adolescent IGD conversion, as well as the mediation mechanisms, addressing inconsistencies in previous cross-sectional studies and filling in the knowledge gap in longitudinal studies that overlooked parental gaming behaviors. It suggests that parental gaming behaviors may form important family environments shaping adolescents’ perceptions and behaviors related to internet gaming. Family-based prevention and intervention programs on IGD conversion may hence take into account these findings.

  • JMIR Serious Games 2026;14(1):e80061

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