Virtual Reality Exposure Therapy for Emotion Regulation Difficulties in Adolescent Inpatients

The "Selbsteinschätzung Emotionaler Kompetenzen" (SEK-27; Emotion Regulation Skills Questionnaire) is a 27-item self-report questionnaire assessing adaptive emotion-regulation skills. Items are rated from 0 to 4. The mean total score is calculated as the average of all 27 items and ranges from 0 to 4. Higher scores indicate better emotion-regulation skills. Change is calculated as the post-intervention score minus the baseline score; positive values indicate improvement.

The Children's Glasgow Sensory Questionnaire (C-GSQ) is a 42-item pictorial self-report questionnaire assessing hyper- and hyporeactivity across seven sensory modalities. Items are rated from 0 ("never") to 4 ("always"), yielding a total score ranging from 0 to 168. Higher scores indicate more pronounced sensory-processing differences and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Social Responsiveness Scale, Second Edition (SRS-2) is a 65-item caregiver-report questionnaire assessing social-communication difficulties and restricted or repetitive behaviours. Items are rated from 0 to 3 and summed to produce a total raw score ranging from 0 to 195. Higher scores indicate greater impairment in social responsiveness and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Adolescent Dissociative Experiences Scale II (A-DES-II) is a 30-item self-report questionnaire assessing dissociative experiences. Each item is rated from 0 ("never") to 10 ("always"). The mean total score is calculated as the average of all items and ranges from 0 to 10. Higher scores indicate more frequent dissociative experiences and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Child Behavior Checklist for Ages 6-18 (CBCL/6-18) is a caregiver-report questionnaire assessing emotional and behavioural problems. The Total Problems raw score is calculated by summing the scored problem items and ranges from 0 to 236. Higher scores indicate greater overall emotional and behavioural difficulties and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Youth Self-Report for Ages 11-18 (YSR/11-18) is a 112-item self-report questionnaire assessing emotional and behavioural problems. Items are rated from 0 ("not true") to 2 ("very true or often true"). The Total Problems raw score ranges from 0 to 224. Higher scores indicate greater overall emotional and behavioural difficulties and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Strengths and Difficulties Questionnaire (SDQ) is a 25-item caregiver-report questionnaire assessing emotional symptoms, conduct problems, hyperactivity/inattention, peer problems, and prosocial behaviour. The Total Difficulties score is calculated by summing the Emotional Symptoms, Conduct Problems, Hyperactivity/Inattention, and Peer Problems subscales. Scores range from 0 to 40. Higher scores indicate greater emotional and behavioural difficulties and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Extreme Demand Avoidance Questionnaire (EDA-Q) is a 26-item caregiver-report questionnaire assessing demand-avoidant behaviours, need for control, emotional reactivity to perceived demands, and related behavioural characteristics. Items are rated from 0 to 3 and summed to produce a total score ranging from 0 to 78. Higher scores indicate more pronounced demand-avoidant behavioural characteristics and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Camouflaging Autistic Traits Questionnaire (CAT-Q) is a 25-item self-report questionnaire assessing social camouflaging strategies, including compensation, masking, and assimilation. Items are rated from 1 to 7 and summed to produce a total score ranging from 25 to 175. Higher scores indicate more frequent use of camouflaging strategies and are interpreted as a less favourable outcome in this study. Change is calculated as the post-intervention score minus the baseline score; negative values indicate a reduction in camouflaging.

The Sozialphobie und -angstinventar für Kinder (SPAIK; Social Phobia and Anxiety Inventory for Children) is a self-report questionnaire assessing cognitive, somatic, and behavioural symptoms of social anxiety. Responses are rated from 0 ("never or rarely") to 2 ("mostly or always"). The total score ranges from 0 to 52. Higher scores indicate greater social-anxiety symptom severity and therefore a worse outcome. Change is calculated as the post-intervention score minus the baseline score; negative values indicate improvement.

The Multidimensional Assessment of Interoceptive Awareness, Version 2 (MAIA-2) is a 37-item self-report questionnaire assessing the awareness, interpretation, and regulation of internal bodily sensations. It comprises eight subscales: Noticing, Not-Distracting, Not-Worrying, Attention Regulation, Emotional Awareness, Self-Regulation, Body Listening, and Trusting. Items are rated from 0 ("never") to 5 ("always"), and each subscale is calculated as the mean of its respective items, producing scores ranging from 0 to 5. Higher scores generally indicate more adaptive interoceptive awareness and are interpreted as a better outcome. Change is calculated as the post-intervention score minus the baseline score; positive values indicate improvement.

Speech-in-noise perception is assessed using a computerised task in which participants listen to short sentences presented with auditory noise or competing speech and identify the corresponding number-colour combination. Performance is calculated as the percentage of correctly identified combinations across trials, ranging from 0% to 100%. Higher percentages indicate better speech perception and functional performance under sensory load and are interpreted as a better outcome. Change is calculated as post-intervention accuracy minus baseline accuracy; positive values indicate improvement.

Fear learning and extinction are assessed using a computerised conditioning task involving a conditioned threat stimulus (CS+) that is paired with an aversive auditory stimulus during acquisition and a safety stimulus (CS-) that is never paired with the aversive stimulus. Participants rate the expected likelihood of the aversive stimulus following each conditioned stimulus. A differential threat-expectancy score is calculated by subtracting the expectancy rating for the CS- from the expectancy rating for the CS+. Higher positive scores indicate stronger differential threat expectancy. A greater reduction in the differential score during extinction indicates more effective safety updating and is interpreted as a better outcome. Change is calculated by comparing the task-derived differential expectancy measure at baseline and post-intervention.

Learning under uncertainty and adaptive rule inference are assessed using the Object Manipulation Task. Participants explore and manipulate virtual objects and receive positive or negative feedback based on their actions. Through repeated trials, participants must infer the hidden rules governing successful performance. Rule-inference accuracy is calculated as the percentage of actions that are consistent with the correct hidden rule, ranging from 0% to 100%. Higher percentages indicate more accurate rule inference, more efficient learning, and better behavioural adaptation and are interpreted as a better outcome. Change is calculated as post-intervention accuracy minus baseline accuracy; positive values indicate improvement.

The Emotion Expression Interview is a structured, approximately 15-minute audio-recorded assessment designed to elicit speech relating to emotional processing and emotion regulation. The interview includes neutral speech, sentence reading, open-ended questions about emotions, descriptions of emotionally salient pictures, and sentence-completion prompts. Exploratory measures derived from the recordings include content-based indicators of emotional clarity, emotional insight, and articulated regulation strategies, as well as speech- and language-based features such as pitch, intensity, speech rate, lexical diversity, syntactic complexity, and discourse-level organisation. The measures have different units and ranges, and higher values do not uniformly indicate a better or worse outcome. Changes in the prespecified features from baseline to post-intervention will be examined exploratorily.

Heart rate is recorded continuously during virtual reality exposure sessions using a Polar H10 heart-rate sensor. Mean heart rate is calculated in beats per minute for each session and used as an exploratory indicator of autonomic arousal during exposure. Higher values indicate greater physiological arousal but are not inherently interpreted as a better or worse outcome. Changes in mean heart rate across treatment sessions and associations with intervention progress and symptom change will be examined exploratorily.