Effects of the ECogFun‑VR program on executive functioning in children and adolescents with ADHD: A randomized controlled trial

BACKGROUND: Executive‑function (EF) difficulties, particularly in planning and organization, substantially limit daily‑life autonomy in children and adolescents with ADHD. Virtual reality (VR)-based interventions offer ecologically valid environments that may enhance strategy learning and promote functional generalization. This study evaluated the efficacy of ECogFun‑VR, a multimodal, manualized program integrating explicit EF strategy instruction with immersive VR practice. METHODS: A parallel‑group randomized controlled trial was conducted with 80 participants aged 9-17 years diagnosed with ADHD. Participants were allocated to ECogFun‑VR (n = 38) or a waitlist control group receiving standard pharmacological care (n = 42). The intervention comprised 12 weekly individual sessions. Assessments were completed at baseline (T0) and post‑intervention (T1). Primary outcomes were functional planning and daily‑life performance (Zoo Map subtest, W‑ADL). Secondary outcomes included parent‑reported EF (BRIEF‑2), emotional competencies (EQ‑i:YV), temporal organization (Time‑S), sensory‑executive functioning (EPYFEI‑Escolar), and neuropsychological indices (WISC‑IV Digit Span; NEPSY‑II Auditory Attention; TMT; Stroop). Analyses followed an ANCOVA‑adjusted intention‑to‑treat approach, complemented by Complier Average Causal Effect (CACE) estimates. RESULTS: No significant between‑group differences were found for primary outcomes (Zoo Map indices; W‑ADL). A significant improvement emerged for working‑memory manipulation (WISC‑IV Digit Span Backward) in the intervention group (p = .030, d = 0.50). Several secondary domains, including emotional‑interpersonal competencies and temporal organization, showed small‑to‑moderate, nonsignificant trends favoring the intervention. CACE analyses were consistent with the intention‑to‑treat results. CONCLUSIONS: The ECogFun‑VR program produced selective cognitive gains, particularly in working‑memory manipulation, but did not yield significant changes in higher‑order functional outcomes over 12 weeks. Findings suggest that planning and organization skills may require longer dosage, increased intensity, or enhanced generalization supports to achieve measurable functional change. VR‑supported EF interventions remain a promising avenue for targeted skill development in youth with ADHD.