JMIR Serious Games

Correction: Empirical Evidence for the Outcomes of Therapeutic Video Games for Adolescents With Anxiety Disorders: Systematic Review

2026-09-04T17:00:02-04:00

Electroencephalography Functional Network Responses to Immersive Virtual Reality in Alzheimer Disease and Mild Cognitive Impairment: Exploratory Single-Session 3-Group Repeated-Measures Study

2026-09-04T15:00:02-04:00

Background: Alzheimer disease (AD) is increasingly conceptualized as a disorder of large-scale brain network disruption rather than isolated regional dysfunction. Immersive virtual reality (VR) may provide a controlled sensory challenge for neurophysiological assessment, but its association with whole-brain electroencephalography (EEG) functional network organization across AD and mild cognitive impairment (MCI) remains insufficiently characterized. Objective: This study examined whether immersive VR exposure was associated with state-dependent changes in EEG-derived functional network organization among older adults with AD, MCI, and normal cognition (NC). Methods: This exploratory single-session, 3-group repeated-measures EEG study included 60 older adults: 20 with AD, 20 with MCI, and 20 participants with NC. During a single visit, participants underwent repeated within-session EEG recordings during pre-VR resting, immersive VR exposure, and post-VR resting states. VR was delivered through a head-mounted display presenting a passive first-person roller-coaster environment. Functional connectivity was quantified using phase-locking value (PLV) across multiple frequency bands, and global efficiency (GE), modularity, and nodal strength were calculated to characterize network topology. Between-group differences within each state were assessed using 1-way ANOVA with post hoc pairwise comparisons, whereas within-group state changes were evaluated using paired-sample 2-tailed t tests. Benjamini-Hochberg false discovery rate (FDR) correction was applied to inferential graph-theoretical analyses. PLV matrices, nodal strength maps, and connectivity graphs were interpreted descriptively. Results: In the broadband range, GE was higher in the AD group than in the NC group during the pre-VR resting state (raw P=.009; FDR-adjusted P=.04), whereas the AD-NC difference was not statistically significant during VR exposure or the post-VR resting state. Baseline modularity was also higher in AD than in NC and remained significant after FDR correction; no significant between-group modularity differences were detected during VR exposure. Within-group analyses showed an FDR-corrected increase in GE from pre-VR to VR in NC participants and from pre-VR to post-VR in participants with MCI. No within-group GE change in AD remained significant after FDR correction. Descriptive PLV, nodal strength, and connection maps suggested state-associated changes in hemispheric distribution and high-frequency connectivity patterns. However, high-frequency GE findings did not remain significant after FDR correction and were therefore interpreted as exploratory. Conclusions: In this exploratory single-session, 3-group repeated-measures EEG study, immersive VR exposure was associated with short-term, state-dependent changes in PLV-derived EEG functional network organization among older adults with AD, MCI, and NC. Graph-theoretical analysis demonstrated the feasibility of using repeated within-session VR-EEG measurements to characterize acute network responsiveness across cognitive groups. However, descriptive connectivity maps were not treated as confirmatory evidence, and the absence of a non-VR comparison condition and concurrent cognitive or clinical outcomes precludes conclusions regarding causality or therapeutic efficacy. Larger controlled and longitudinal studies are needed to establish the reproducibility and clinical relevance of these findings.

Efficacy of an Interactive Life Simulation Gaming App on Improving HIV Testing Uptake Among Adolescents and Young Adults at Risk for HIV: Results of a Randomized Controlled Trial

2026-09-04T13:15:13-04:00

Background: Adolescents and young adults account for a disproportionate number of new HIV diagnoses in the United States due to missed opportunities for education, testing, and prevention. Objective: We tested the efficacy of an interactive life-simulation gaming intervention to provide HIV education and improve HIV testing uptake and preventive services among youths ages 13‐24 years in the Washington, DC area. Methods: We conducted a parallel randomized controlled trial testing the efficacy of an HIV-focused gaming intervention app to a control app in increasing HIV testing uptake. Participants were recruited via social media and peer referral. Eligible participants were randomized 1:1 by age (13‐17 vs 18‐24 years) and sexual orientation (lesbian, gay, bisexual, or “other” vs heterosexual). Participants accessed their assigned app for 3 months and completed baseline, 1-, 3-, and 6-month surveys. The primary outcome was self-reported HIV testing within 6 months after enrollment; secondary outcomes included intent to test for HIV, HIV knowledge, and intention to start pre-exposure prophylaxis (PrEP). Analyses were conducted as intent-to-treat and stratified by sexual orientation. Results: From November 2023 to May 2024, we randomized 309 participants (intervention: n=156; control: n=153) with 80% and 88% retention at 6 months, respectively. Among the analyzed participants (intervention: n=150; control: n=149), the mean age was 20.7 (SD 1.84) years, 49% (145/299) were women, and 34% (103/299) were non-Hispanic White. Overall, 53% (158/299) self-reported as gay, lesbian, bisexual, or “other” sexual orientation. A total of 48% (144/299) had previously tested for HIV. Compared to the control app, game participants were 32% less likely to test for HIV within 6 months (relative risk 0.68, 95% CI 0.47‐0.98). The two groups showed no statistically significant differences regarding their intention to get tested for HIV or to start PrEP. A significantly higher difference in mean HIV knowledge scores at 3 months (0.99, 95% CI 0.33‐1.65; <.01) and 6 months (0.81, 95% CI 0.14‐1.48; =.02) was observed in the game arm compared to the control arm. Additionally, heterosexual participants in the game arm had statistically significant increases in PrEP intention (0.53, 95% CI 0.05‐1.00; =.03) across all time points compared to controls. Conclusions: Our interactive gaming app was less effective than an information control app in increasing HIV testing and changing testing and prevention intentions among adolescents and young adults. In the game arm, we did observe increased HIV knowledge and increased PrEP intention among heterosexual adolescents and young adults. Few life-simulation apps integrating HIV testing and prevention features have been rigorously tested among adolescents and young adults. Our efficacy findings suggest that while these interventions are feasible and acceptable to adolescents and young adults, they require additional tailoring to improve their reach, use, and potential effectiveness in real-world settings. Trial Registration: ClinicalTrials.gov NCT04917575; https://clinicaltrials.gov/ct2/show/NCT04917575 International Registered Report Identifier (IRRID): RR2-10.2196/29792

Behavioral and Physiological Responses to Sensory and Cognitive Demands in an Immersive Virtual Reality Shopping Task in Unimpaired Young Adults: Within-Subjects Experimental Study

2026-08-28T16:00:20-04:00

Background: Immersive virtual reality (IVR) is increasingly used for task training. Adjusting sensory and cognitive complexity to individual capacity is important for effective training, yet it remains unclear how varying visual, auditory, and cognitive demands influence behavioral responses, physiological activity, and task performance during goal-directed activities in IVR. Objective: This study aimed to examine how 2 levels (low and high) of visual, auditory, and mental demands affect self-reported mental demand and effort (MDE), task performance, heart rate, gaze behavior, and head movements during a virtual grocery shopping task. Methods: A within-subjects study was conducted with 22 unimpaired university students (11 women, 11 men; aged 23-27 years) recruited via convenience sampling at TU Delft, the Netherlands. Participants completed a grocery shopping task (collecting products from shelves during 122-second trials) under 7 conditions: baseline, visual low/high (background characters), auditory low/high (background sounds), and mental low/high (0-back/2-back tasks), in random order. Outcome measures included MDE (0-100), task performance (products placed in the cart), mean heart rate (from electrocardiography), head-stillness duration, and gaze duration on areas of interest (via integrated eye-tracking). Two-tailed paired-samples t tests with Bonferroni correction (α=.008) were supplemented by linear mixed-effects models. Results: The mental high condition produced the largest effects: MDE increased relative to baseline (mean difference [M_diff] 52.73, 95% CI 44.01-61.44; t₂₁=12.58; P<.001), performance decreased (M_diff –8.00 products, 95% CI –9.57 to –6.43; t₂₁=–10.58; P<.001), head-stillness duration increased (M_diff 13.54 s, 95% CI 9.94-17.14; t₂₁=7.83; P<.001), and gaze on the shopping list increased (M_diff 9.89 s, 95% CI 5.36-14.43; t₂₁=4.54; P<.001). Auditory high demands increased MDE (M_diff 17.05, 95% CI 9.15-24.94; t₂₁=4.49; P<.001) without significantly affecting performance. Visual high demands redistributed gaze away from the main shelves (M_diff –6.11 s, 95% CI –8.70 to –3.52; t₂₁=–4.91; P<.001) without reducing performance. Heart rate increased under mental low demand (M_diff 4.02 bpm, 95% CI 1.69-6.34; t₂₁=3.59; P=.002); the mental high effect did not reach corrected significance in the paired-samples test (P=.02), possibly due to reduced physical activity in this condition. Under high cognitive load, participants spent more time checking the shopping list and showed greater head-stillness, consistent with task-serialization and memory-offloading strategies. Conclusions: Cognitive demands strongly impacted workload, performance, and behavior, while sensory demands affected attention distribution and perceived workload, with no significant performance decrements at the Bonferroni-corrected threshold. By comparing 2 demand levels against a no-demand baseline and incorporating gaze and head-movement measures not previously examined, this study extends prior work in this domain. The findings suggest IVR environments can incorporate sensory richness without large performance reductions in unimpaired young adults, and that behavioral strategies under cognitive load may support real-world workload monitoring and adaptive task adjustment, pending clinical validation.

Serious Game–Based Attention Assessment for Attention-Deficit/Hyperactivity Disorder in Children and Adolescents: Preliminary Cross-Sectional Convergent Validation Study

2026-08-28T16:00:03-04:00

Background: Attention-deficit/hyperactivity disorder (ADHD) is a common neurodevelopmental disorder in children, characterized by inattention, hyperactivity, and impulsivity that significantly disrupt daily functioning. Comprehensive ADHD assessment requires multimethod and multi-informant evaluation, and objective attention measures can complement this process. Serious game–based assessments may further support this process by combining structured task mechanics and dynamic audiovisual guidance in a child-oriented digital environment. Objective: This study aimed to develop and validate Attention Robots, a serious game designed for assessing behavioral attention indicators in children and adolescents. The goal was to examine whether its outputs corresponded with indicators from the widely used D2-R Test of Attention as preliminary evidence of convergent validity. Methods: In this preliminary cross-sectional convergent validation study, 58 participants (34 male and 24 female individuals) aged 6-18 years, recruited through clinical referral and community sources, completed Attention Robots followed by the D2-R test. The original group variable, assigned by the project psychologists, identified 19 participants in the experimental group and 39 participants in the control group. Attention Robots presents timed rows of robot stimuli and asks participants to identify and select predefined target robots. Spearman and Pearson correlations compared working speed, omissions, commissions, concentration, and precision across both instruments. Results: Primary cross-test correlations were positive. Spearman correlations were observed for working speed (ρ=0.905, 95% CI 0.84-0.94; P<.001), omissions (ρ=0.333, 95% CI 0.08-0.54; P=.01), commissions (ρ=0.496, 95% CI 0.27-0.67; P<.001), concentration (ρ=0.926, 95% CI 0.88-0.96; P<.001), and precision (ρ=0.607, 95% CI 0.41-0.75; P<.001). Pearson correlations showed a similar pattern for working speed (r=0.911, 95% CI 0.85-0.95; P<.001), omissions (r=0.278, 95% CI 0.02-0.50; P=.04), commissions (r=0.396, 95% CI 0.15-0.59; P=.002), concentration (r=0.922, 95% CI 0.87-0.95; P<.001), and precision (r=0.574, 95% CI 0.37-0.72; P<.001). These findings support preliminary convergent correspondence between corresponding behavioral indicators, but they do not establish interchangeability, discriminative validity, diagnostic use, or superior engagement or acceptability. Conclusions: Attention Robots provides preliminary evidence of convergent validity with the D2-R for behavioral attention indicators in children and adolescents. The innovative aspect of this study is the translation of D2-R–based attentional demands into a child-oriented serious game environment with robot-based stimuli, dynamic audiovisual guidance, and structured behavioral data capture. Unlike previous digital or serious game approaches, this study empirically compares game-derived indicators with corresponding indicators from an established attention test rather than evaluating only task feasibility, engagement, or intervention effects. This work contributes to the field by providing a preliminary validation of a serious game format that may support the collection of objective attention-related data in children and adolescents. In applied contexts, Attention Robots could be further developed as a complementary tool within multimethod ADHD assessment, although larger studies are required to evaluate subgroup performance, agreement, diagnostic use, and user experience before clinical adoption. Trial Registration:

Immersive Virtual Reality for Patient Education in Orthodontics: Cross-Sectional Feasibility and Acceptability Study

2026-08-27T13:15:11-04:00

Background: Patient education is central to orthodontic care; however, most patients still learn about their malocclusion from conventional records, such as 2D image records. Immersive virtual reality (VR) allows patients to view and manipulate 3D dental models in a head-tracked environment, as part of the serious-games and extended reality family for health education. Evidence on patient-facing immersive VR in orthodontics remains limited, as most dental VR work has addressed student training rather than patient education. Objective: This feasibility study aimed to evaluate acceptance, perceived educational value, self-rated experience, ease of use, and self-reported preference regarding an immersive VR consultation room among patients undergoing orthodontic treatment. Methods: This cross-sectional, single-arm feasibility and acceptability study was conducted in a university orthodontic clinic between August and September 2024. Patients undergoing active orthodontic treatment completed a single, approximately 15-minute immersive VR educational experience using a Meta Quest 3 headset and a Unity3D-developed consultation room presenting a 3D rendering of each participant’s own intraoral scan, followed by an investigator-developed postexperience questionnaire. The questionnaire combined a Likert scale and two 10-point numeric items with open-ended prompts. Closed-ended responses were summarized as counts, percentages, and 95% CIs, and numeric items were summarized as means with 95% CIs; open-ended comments were grouped into themes. No inferential testing was performed. Results: Twenty-eight patients completed the study (mean age 21.6, SD 4.3, range 13‐33 y; 18 males, 10 females; 5 minors). Sixteen (57%) patients had no prior VR experience, 22 (79%) were interested in using VR to learn about their teeth, and 24 (86%) agreed that VR could help patients understand their teeth and braces. The mean overall experience rating was 7.9 (SD 1.6; 95% CI 7.3‐8.5) on a 10-point scale, and the mean ease-of-use rating was 6.6 (SD 2.6; 95% CI 5.7‐7.6). Twenty (71%; 95% Wilson score CI 53‐85) patients felt VR was a better learning modality than conventional 2D images; 19 (68%; 95% Wilson score CI 49‐82) preferred VR with the current setup, and 25 (89%; 95% Wilson score CI 73‐96) preferred VR under a hypothetically improved technology scenario. Positive comments emphasized interactivity, 3D visualization, and engagement; negative comments centered on controller difficulty, latency, and motion discomfort. Two (7%) patients reported mild, transient, motion-related discomfort; none discontinued. Conclusions: Patients were generally receptive to an immersive VR consultation room. This work is novel in evaluating patient-facing immersive VR using each patient’s own intraoral scan and in identifying actionable usability and motion-comfort barriers. Because the design was single arm and the comparison with conventional 2D image records was self-reported, the findings represent preliminary acceptability evidence, not learning effectiveness. If confirmed in more rigorous studies, immersive VR may serve as an adjunct to communication with patients undergoing orthodontic treatment, warranting controlled studies with an interactive flat-screen 3D comparator; validated usability, presence, and cybersickness instruments; and objective knowledge-gain measures.

Executive Dysfunction—A Serious Game for Assessment in Real-Life Contexts: Development and Cross-Sectional Usability Study

2026-08-27T11:00:18-04:00

Background: Traditional neuropsychological assessments often lack ecological validity and have limited sensitivity for detecting executive dysfunction (ED) in daily life. Although grounded in standardized tasks, they do not represent the complexity of real-world contexts. Serious games (SGs) have emerged as a promising approach by simulating ecologically valid environments involving dynamic, emotional, and socially embedded interactions. Objective: This study aimed to (1) describe the development of a clinically oriented SG for assessing executive functioning in ecologically valid scenarios, and (2) evaluate its usability in clinical and healthy populations. Methods: We conducted a cross-sectional usability study using a theory-driven SG set in a restaurant environment, developed through an iterative process based on neuropsychological theory and expert input. Participants assumed the role of a waiter and completed tasks targeting multiple executive domains (eg, planning, working memory, decision-making, contextual control, social cognition, prospective memory, and multitasking), with embedded emotional and social cues. A total of 181 participants (43 with traumatic brain injury [TBI], 49 post–COVID-19, and 89 healthy controls), aged 21 to 66 years, were recruited through convenience sampling from clinical and community settings. ED was classified based on standardized neuropsychological assessment and clinical consensus involving neurologists and neuropsychologists. Usability and perceived difficulty were assessed using the System Usability Scale and Perceived Difficulty Scale. Group differences were analyzed using Kruskal-Wallis tests with post hoc comparisons, and generalized linear and ordinal logistic regression models adjusted for age, sex, and education (α=.05). Results: A novel SG designed to support the assessment of executive functioning provides a more ecologically valid context than traditional neuropsychological tests. Usability was rated as good across groups, with mean System Usability Scale scores of 73.9 (SD 17.6) in TBI, 76.5 (SD 14.5) in post–COVID-19, and 81.7 (SD 13.5) in controls. Significant differences were observed across groups (²=9.18, =.01), with lower usability in TBI compared to controls. Participants with ED (n=59) showed lower usability (mean difference −8.6, 95% CI −13.2 to −4.0; <.001) and higher perceived difficulty (mean difference 1.3, 95% CI 0.5‐2.1; <.001), though these differences were no longer significant after adjusting for age and education. Age was associated with lower usability (β=−.27, 95% CI −0.45 to −0.09; =.003) and higher difficulty (odds ratio 1.04, 95% CI 1.02‐1.07; <.001), while higher education was associated with better usability (β=.79, 95% CI 0.04‐1.54; =.04). Conclusions: This study presents a novel SG integrating emotionally and socially embedded tasks to assess executive functioning in ecologically valid contexts, extending prior work through the inclusion of clinical populations and real-world demands. Findings indicate good usability and underscore the influence of demographic factors. This approach enhances the ecological relevance of neuropsychological assessment and supports its application in clinical and digital health settings. Further research should evaluate diagnostic accuracy, reliability, and real-world implementation.

Effects of Virtual Reality–Based Intervention Combined With Conventional Therapy on Upper-Limb Function in Children With Hemiplegic Cerebral Palsy: Systematic Review and Meta-Analysis of Randomized Controlled Trials

2026-08-26T14:00:52-04:00

Background: Hemiplegic cerebral palsy (CP) commonly affects upper-limb function in children and may limit functional use of the affected arm and hand. Virtual reality (VR)–based rehabilitation can provide interactive, feedback-based, and task-oriented practice, but whether adding VR-based intervention to conventional therapy provides additional benefits remains uncertain. Previous reviews have often included broader CP populations, mixed comparators, or broad upper-limb outcome labels, limiting domain-specific interpretation. Objective: This systematic review and meta-analysis evaluated VR-based intervention combined with conventional therapy versus conventional therapy alone for upper-limb–related outcomes in children with hemiplegic CP. Methods: This review was prospectively registered with PROSPERO (CRD420261486172). PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception to April 15, 2026. Eligible randomized controlled trials included children aged ≤12 years with hemiplegic CP and compared VR-based or interactive game–based intervention plus conventional therapy with conventional therapy alone. Outcomes were grouped into upper-limb activity, dexterity, motor control and movement quality, activities of daily living (ADLs), and grip strength. Risk of bias was assessed using the revised Cochrane risk-of-bias 2 tool. Random-effects meta-analyses with Hartung-Knapp-Sidik-Jonkman adjustment were performed; Nagashima-corrected prediction intervals (PIs) were calculated where applicable; and certainty of evidence was assessed using Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Results: Thirteen randomized controlled trials involving 458 children were included. Pooled estimates generally favored VR combined with conventional therapy, but no outcome reached statistical significance; effect estimates were as follows: upper-limb activity (standardized mean difference [SMD] 0.28, 95% CI −0.07 to 0.64), dexterity (SMD 0.26, 95% CI −0.34 to 0.86), motor control and movement quality (SMD 0.29, 95% CI −0.22 to 0.80), ADLs (SMD 0.17, 95% CI −0.22 to 0.55), and grip strength (mean difference 0.89, 95% CI −1.93 to 3.72). PIs also crossed the null value for all outcomes, ranging from −0.51 to 1.04 for upper-limb activity and from −4.89 to 6.45 for grip strength, suggesting variable effects across settings. Heterogeneity was low to moderate for most outcomes but substantial for grip strength. Most trials had some risk-of-bias concerns. Certainty of evidence was low for all outcomes except grip strength, which was very low. Conclusions: VR-based intervention combined with conventional therapy did not provide clear evidence of additional benefits over conventional therapy alone. Although effects generally favored the combined intervention, CIs, PIs, risk-of-bias concerns, and low to very low certainty of evidence support cautious interpretation. VR may be considered a potentially engaging adjunct, but current evidence does not support its use as a replacement for therapist-led rehabilitation or as a definitively effective intervention. Larger, adequately powered trials with clearer reporting of VR characteristics, intervention dose, task specificity, and longer follow-up are needed. Clinical Trial: PROSPERO CRD420261486172; https://www.crd.york.ac.uk/PROSPERO/view/CRD420261486172

Active Video Gaming Intervention in Adults With Mobility Impairments: Concurrent Mixed Methods Single-Arm Pilot Study

2026-08-26T11:30:03-04:00

Background: Adults with mobility impairments have limited opportunities for physical activity due to environmental barriers and lack of accessible exercise options. Active video games (AVGs) have shown promise for increasing physical activity by integrating movement into engaging gameplay. However, most commercial AVG controllers are not usable by those with severe mobility limitations. The GAIMplank is a novel adaptive game controller that translates trunk movements into gameplay, addressing this accessibility gap and enabling seated participation for individuals with limited lower-extremity function. Objective: This study aimed to assess feasibility and acceptability of a 6-week GAIMplank-based intervention in adults with mobility impairments and to evaluate participants’ perceived exertion, enjoyment, and engagement during gameplay. In addition, qualitative feedback was used to characterize participants’ experiences with the intervention and to provide insight into implementation considerations for adapted exergaming in this population. Methods: In total, 6 adults (2 female; mean age 65.2, SD 12.4 years) with mobility impairments due to stroke or Parkinson participated in a concurrent mixed methods single-arm pilot study. The intervention consisted of twice-weekly AVG sessions over 6 weeks using the GAIMplank controller to play video games. Self-report baseline measures included physical function, exercise expectations, and level of physical activity. During gameplay sessions, ratings of perceived exertion (RPEs), engagement, and enjoyment (0-10 rating scale) were collected. Additionally, physical activity and exergame enjoyment surveys were completed after sessions 1, 5, and 12. After the intervention, acceptability, appropriateness, and feasibility of the intervention (0-5 rating scale) were assessed. Qualitative data were collected through session comments and postintervention semistructured interviews. Descriptive statistics were used to summarize quantitative data, thematic analysis for qualitative data, and integration to examine convergence. Results: Participants reported moderate RPEs during gameplay (median RPE 5, IQR 3-6) and high levels of enjoyment and engagement (median scores of 9, IQR 6-10 and median 10, IQR 8-10, respectively). The intervention was well-received, with high scores on the acceptability, appropriateness, and feasibility measures. Qualitative findings highlighted engagement and enjoyment of the games, as well as participants’ perceptions of mental stimulation, sustained attention, and positive emotional experiences during gameplay. Several participants also described a “masking effect,” in which physical effort was not perceived as traditional exercise due to immersion in gameplay. Technical challenges related to controller responsiveness were reported, but they did not appear to substantially reduce overall engagement. Conclusions: Findings from this mixed methods pilot study suggest that AVGs, delivered using an adapted controller such as the GAIMplank, appear feasible and enjoyable in this small pilot sample, supporting the need for further evaluation in larger, controlled studies. While standardized cognitive or mental health outcomes were not assessed, participant feedback indicates potential psychological benefits that warrant further investigation. Future studies should explore the long-term effects of AVG interventions and identify strategies for maximizing their benefits. Trial Registration: ClinicalTrials.gov NCT05310279; https://clinicaltrials.gov/study/NCT05310279

Coloring-Based Serious Game in Chinese College Students With Alexithymia: Prospective Longitudinal Exploratory Mixed Methods Study

2026-08-19T12:30:02-04:00

Background: Alexithymia, characterized by difficulty identifying, describing, and expressing emotions, is prevalent among Chinese college students. Traditional art therapies face barriers, such as high psychological thresholds and limited accessibility. Accessible, low-threshold digital tools are needed to help address this challenge. Coloring the Emoji, a coloring-based serious game designed as a digital art therapy, offers a low-threshold tool to support emotion regulation for this population. Objective: This study aimed to evaluate the effectiveness of Coloring the Emoji as a digital art therapy in improving alexithymia symptoms and examine the user experience of the game, thereby providing empirical support for the application of coloring-based digital art therapy in alexithymia intervention. Methods: A prospective, exploratory convergent parallel mixed methods longitudinal design was used, involving a 15-day daily game intervention with Chinese college students exhibiting alexithymic tendencies. Participants were purposively sampled from 332 prescreened students. Eligibility criteria included age 18‐30 years, basic smartphone operation, and no ongoing psychotherapy or psychiatric medication. In total, 20 participants completed the intervention. Quantitative assessments used the 20-item Toronto Alexithymia Scale to measure alexithymia and the Game Experience Questionnaire to assess user experience. Statistical analyses comprised Wilcoxon signed-rank tests for pre-post comparisons, Mann-Whitney tests for sex, education, and major comparisons, and Kruskal-Wallis H tests for 20-item Toronto Alexithymia Scale pretest severity comparisons. The qualitative component consisted of 3 longitudinal semistructured interviews conducted across the intervention period (days 1, 8, and 15), analyzed using Colaizzi’s phenomenological method and thematic analysis to explore emotion regulation dynamics, user experience, and in-depth mechanisms underlying intervention changes. Results: Total TAS-20 scores decreased significantly post intervention (=2.425; =.02), with a median reduction of 3.00 points (95% CI 1.00‐4.50, 5000 bootstrap replications). The Difficulty Identifying Feelings subscale showed a marginal improvement (=1.826; =.07). Males exhibited significantly greater Difficulty Identifying Feelings reduction (=−2.137; =.03), and participants with severe baseline alexithymia showed greater improvement in Externally Oriented Thinking (H=8.233; =.02). Game Experience Questionnaire scores indicated high competence and sensory and imaginative immersion. Qualitative results confirmed 2 major themes and 10 subthemes; visual coloring practice helped participants externalize vague emotions, differentiated engagement habits explained subgroup discrepancies, and low-pressure interaction supported sustainable emotional regulation. This study further integrated quantitative and qualitative outcomes through subgroup comparative analysis, revealing distinct intervention response patterns across sex and alexithymia severity. Conclusions: Coloring the Emoji is an effective, acceptable intervention for improving emotional identification in Chinese college students with alexithymia. Its innovation lies in a localized low-threshold design that meets daily emotional needs. Unlike mainstream Western interventions emphasizing open emotional expression and social sharing, this tool adapts to the reserved emotional disclosure norms of Chinese college students. It advances the field by supplementing culturally contextualized evidence for nonverbal digital art therapy. As a low-stress, demedicalized solution, it provides a scalable, feasible supplement to traditional mental health services for campus emotional regulation.