Heart-Smart Games for Youth Mental Health

This post explores a new systematic review on biofeedback-based digital games and well-being in childhood, which synthesizes 16 empirical studies using playful, sensor-based tools to support youth mental health. 

The context is sobering: globally, around 14–20% of adolescents live with a mental health disorder, and many never receive adequate care due to cost, access, stigma, and workforce shortages. Traditional models built around weekly, one-to-one therapy simply cannot keep up with the current demand. Digital health tools have stepped into this gap, and among them, biofeedback-based games occupy a sweet spot: they are engaging like commercial games, but grounded in psychophysiology.

In general terms, biofeedback is a self-regulation method in which sensors track bodily signals—such as heart rate, heart rate variability (HRV), breathing, or skin conductance—and translate them into visual or auditory cues that people can learn to influence. Neurofeedback is the same principle applied to brain activity, typically measured by EEG. In both cases, the body becomes the controller: by relaxing, focusing, or breathing differently, the child literally changes the game.

The review we’re looking at focuses deliberately on scalable, accessible biofeedback—especially cardiac measures—embedded in digital games that children can play on computers, tablets, VR systems, or mobile devices. The central questions: What games exist? What physiological signals do they train? Which mental health domains respond? And can we trust these results enough to inform real-world practice in clinics, schools, and homes?

Methods

How the studies were selected

The authors conducted a comprehensive search across four major databases (CINAHL, PsycInfo, PubMed Central, and Web of Science) from their inception through May 2023. The search terms were deliberately broad: biofeedback-related terms (e.g., biofeedback, visual feedback, wearable devices), digital/game terms (e.g., video games, gamification, virtual reality), and youth terms (e.g., child, adolescent, preschool, youth).

To be included, a study had to:

• Be peer-reviewed and empirical.

• Use a biofeedback mechanism based on a scalable measure of bodily function (e.g., heart rate, HRV, respiration, skin conductance).

• Embed that biofeedback in a digital, gamified experience (e.g., computer game, mobile game, VR game).

• Target a domain of mental health or well-being (e.g., anxiety, anger, externalizing behavior, emotion regulation, general functioning).

• Focus on a pediatric sample (mean age ≤17 years; young adults could be included if the mean age was still in the youth range).

Crucially, the authors excluded neurofeedback/EEG-based interventions, explicitly on the grounds that such systems typically require more expensive hardware and trained technicians and therefore are less scalable in low-resource settings. That decision impacts how we interpret the paper for neurofeedback practice: the focus is on peripheral physiology, especially the heart, not directly on brainwaves.

From an initial 762 articles, 604 unique studies were screened after removing duplicates. A three-stage PRISMA process (titles, then abstracts, then full texts) progressively eliminated studies that: were not in English; focused on physical or voiding disorders; lacked biofeedback; lacked a game component; involved adults; or were not empirical. Ultimately, 16 studies met all inclusion criteria.

Who was included and where

Across the 16 studies, sample sizes ranged from 8 to 1,045 participants, with average ages typically between 9 and 17 years. Most samples were mixed-gender, though several studies had limited reporting of race and ethnicity, which is an important limitation when we start talking about equity and generalizability.

The settings were refreshingly diverse:

• Hospital-based programs (inpatient and outpatient child psychiatry).

• School-based interventions in mainstream classrooms.

• Residential care settings for youth with complex needs.

• University and community programs.

• One large observational study of home-based play with a commercial system.

What kinds of biofeedback and games were used

Ten distinct digital games appeared across the 16 studies. The majority used cardiac biofeedback (heart rate or HRV), sometimes combined with respiration or skin conductance. A few used respiratory biofeedback alone.

Key examples include:

• Wild Divine (computer): kids wear finger or earlobe sensors; calm and steady heart/breathing patterns allow them to progress through a fantasy world and complete tasks like building a bridge.

• Dojo (computer): HRV biofeedback embedded in an anxiety-reduction game; adolescents learn deep breathing, progressive muscle relaxation, positive imagery, and cognitive strategies, then practice them in increasingly challenging in-game scenarios.

• RAGE-Control (computer): designed as an add-on for anger-control therapy; children’s heart rate determines whether their spaceship fires “real” shots or blanks during fast-paced alien attacks.

• Mightier (tablet): a commercial evolution of RAGE-Control; kids wear an HR armband while playing various mini-games. When HR rises more than ~7 beats above baseline, the game introduces a visual handicap (e.g., smoke obscuring targets) that can only be cleared by self-calming.

• emWave (computer): HR/HRV/respiration feedback paired with a structured curriculum teaching paced breathing and emotional awareness, with simple games tied to physiological coherence.

• DEEP and i-Care (VR): immersive environments where breathing or cardiovascular signals control movement through calming underwater or virtual spaces.

Session formats varied but were typically quite short and time-limited compared with classic neurofeedback protocols:

• 5 sessions of about 30 minutes (e.g., RAGE-Control in anger management).

• 6 sessions of 30–60 minutes (e.g., Dojo in schools; Mightier in community camps).

• 8 sessions of 30 minutes (e.g., Dojo or Wild Divine in clinical samples).

• Brief sessions of 10–15 minutes repeated across multiple weeks (e.g., emWave in classrooms).

Most interventions were delivered in small groups or individual formats supervised by staff or research assistants, though one large observational study examined unsupervised, home-based Mightier play.

Study designs and appraisal

Among the 16 included studies:

• 5 were randomized controlled trials.

• 3 were controlled trials without randomization.

• The remainder were pilot, feasibility, case, or observational studies.

Seven controlled trials had equivalent groups at baseline and were considered to have generalizable results. All of these used some form of cardiac biofeedback (HR or HRV), often within the games Wild Divine, Dojo, RAGE-Control, Mightier, or emWave.

Overall reporting quality was reasonable: aims and hypotheses were clear, risk–benefit considerations documented, and no major risks of bias were identified in randomization, missing data, or outcome reporting. That said, most trials still had relatively small samples and short follow-up periods.

Results

What changed for internalizing symptoms

Internalizing symptoms were the most common targets. Across the 16 studies, several anxiety, distress, and mood outcomes were reported, with seven of eight anxiety-related measures showing statistically significant improvement.

In the subset of seven generalizable trials, three studies focused on anxiety:

• Children with elevated anxiety who completed eight sessions of Wild Divine showed significantly lower anxiety (and depression) compared with controls at post-treatment, with large effect sizes.

• Youth in residential care who received eight 30-minute sessions of Dojo alongside usual treatment showed large reductions in anxiety, based on both self-report and mentor ratings.

• A school-based trial of Dojo versus a non-biofeedback game found that both groups’ anxiety decreased over six sessions, but the Dojo group showed steeper reductions in individually nominated anxiety symptoms.

Stress-related outcomes also improved in some contexts. For example, parents in a community camp study reported reduced stress after their children played Mightier, and a feasibility trial of a family-focused game (CALMS) showed small to medium improvements in perceived stress and social functioning.

What changed for externalizing behaviors

Externalizing domains—aggression, oppositionality, disruptive behavior, and off-task behavior—also responded to biofeedback games in several trials.

Among the generalizable studies:

• Adding RAGE-Control to anger-control therapy produced larger reductions in overt aggression and oppositional behaviors than anger-control therapy alone, with medium-to-large effects.

• In school settings, emWave combined with a weekly mindfulness curriculum reduced off-task behaviors (fidgeting, chatting, looking away) with a large effect size after roughly a dozen brief sessions.

• In residential care, youth who played Dojo in addition to usual treatment reported reduced externalizing behaviors; mentor ratings showed smaller, but still favorable, shifts.

One excluded controlled study (due to baseline group differences) also reported large improvements in ADHD symptoms when Wild Divine-style biofeedback gaming was added for children with ADHD, hinting at potential for attentional regulation.

Emotion regulation and general functioning

Two studies directly assessed emotion regulation as a skill outcome. In a community camp trial, parents of children who played Mightier alongside social–emotional learning groups reported large improvements in emotion regulation compared with a control group. In a large observational sample of over 1,000 users playing Mightier at home, small but significant gains in emotion regulation emerged over time.

General psychopathology and functioning also improved in several trials:

• Clinician-rated overall severity of psychopathology decreased more sharply when RAGE-Control was added to anger-control training.

• Social functioning improved in a family-focused biofeedback game where parents and children had to co-regulate their heart rates to successfully navigate a shared game task.

What didn’t change—or didn’t change enough

Not every outcome shifted dramatically. In some universal samples (where children were not selected for high symptom levels), biofeedback games produced only small or nonsignificant differences compared with control games. This is typical of prevention-style interventions: effects tend to be larger in clinically elevated groups.

There were also inconsistencies between reporters. For example, self-reported externalizing behavior sometimes improved more than teacher or mentor ratings, underscoring how context and observer can shape our sense of “what changed.”

Finally, the small number of high-quality randomized trials, short exposure (often only a handful of sessions), and limited follow-up windows mean we must interpret the results as promising but preliminary—not definitive.

Discussion

Taken together, this review suggests that cardiac biofeedback-based games are more than just clever gadgets—they can meaningfully shift emotional and behavioral functioning in children and adolescents. The clearest impacts appear in youth who start with elevated symptoms of anxiety, anger, or externalizing behavior, and in settings where games are structured, repeated, and integrated with some form of psychoeducation or therapy.

Translating the findings into real-world support

From a practical standpoint, these interventions rarely stand alone as a “magic bullet.” In the strongest studies, games like Dojo, RAGE-Control, Mightier, and emWave are woven into broader programs:

• In hospitals and residential care, games are embedded in anger-management groups, milieu therapy, or standard psychiatric care.

• In schools, they augment social–emotional learning or mindfulness curricula.

• In community or home settings, they are framed for families as tools for practicing calm together.

This echoes a pattern we see across biofeedback and neurofeedback more generally: the technology amplifies learning when it sits inside a supportive relational and educational context. The sensors are not the therapy; they are amplifiers of attention, motivation, and feedback.

Why these games make sense for kids

For young people, especially those who struggle to sit through traditional talk therapy, these systems solve several neurodevelopmental problems at once.

First, they make internal states visible. The heartbeat that races with anger or anxiety suddenly appears on-screen as a spaceship that misfires, a fog that obscures targets, or a dragon that slows down when the player tenses up. This concretizes otherwise abstract ideas like “emotion regulation” or “staying in your window of tolerance.”

Second, they provide immediate, contingent feedback—exactly the kind of learning signal that the nervous system is good at using. When a child experiments with slower breathing, they see the game become easier within seconds. Over repeated trials, this reinforces a body-based sense of agency.

Third, they harness intrinsic motivation. Most children do not wake up excited for another worksheet on coping skills. But “beat the level” or “fly the ship without overheating” taps into curiosity and play, which are powerful drivers of neuroplasticity.

Benefits compared with (and alongside) other treatments

Compared with standard psychoeducation or relaxation training, biofeedback games offer richer, multi-sensory learning. They seem particularly well suited to:

• Children who find language-heavy interventions difficult.

• Youth who are skeptical of “therapy” but open to “games.”

• Settings where one-to-one therapy time is scarce, such as busy schools or overstretched clinics.

The review also points toward several strategic uses:

• As a universal preventive tool in schools, layered onto existing social–emotional curricula, to normalize physiological self-regulation and potentially narrow socioeconomic gaps in access.

• As an interim support for families on waitlists, giving them something active and skills-focused to do while they wait for formal treatment.

• As an adjunct to evidence-based therapies (CBT, parent training, trauma-focused therapy), particularly when emotion regulation and anger management are central targets.

Importantly, these interventions are not mutually exclusive with neurofeedback. In many ways, they can act as preparatory stages—introducing youth to the idea that physiology is trainable—before moving into EEG-based work.

Limitations and equity considerations

The authors are appropriately cautious about the limits of the current evidence. Only seven trials with solid group equivalence and controls exist; sample sizes are modest; follow-up is short; and very few studies report detailed racial or ethnic demographics.

This raises key questions:

• Do these games work similarly across cultures, languages, and socioeconomic contexts?

• How do families with limited technology access or lower digital literacy fare?

• What happens when the novelty wears off—do gains sustain?

Interestingly, large-scale surveys suggest that access to basic digital devices and internet is now high across most youth demographics in the United States, including lower-income groups. But “having a device” is not the same as having a quiet space, time, and parental support to engage in therapeutic play. Future research will need to specifically examine the role of these social and environmental factors.

Connecting with broader research on biofeedback and self-regulation

Beyond this review, meta-analytic work on HRV biofeedback has repeatedly shown reductions in stress and anxiety in adults and emerging evidence in youth. Experiential learning theories highlight that embodied, trial-and-error practice—exactly what these games provide—consolidates new skills more robustly than didactic teaching alone.

Put simply: when kids repeatedly experience “I can change my body, and that changes my feelings,” they’re not just memorizing coping strategies; they are rehearsing a new self-concept of control.

For neurofeedback practitioners, the message is clear. Cardiac biofeedback games are not competitors to EEG training, but companions. They occupy a different tier in the self-regulation stack: breathing, heart rhythm, and interoceptive awareness on one layer; cortical timing and network dynamics on another. Used together, they can form a vertically integrated training environment where heart, breath, and brain all become part of a coherent regulation curriculum.

Brendan’s perspective

In clinical neurofeedback work, I often think of physiology training as three overlapping rings: body, breath & heart, and brain. This review sits squarely in the middle ring—heart-centered training delivered through playful digital ecosystems. For practitioners used to working mainly with EEG, there are several practical ways to bring these findings into day-to-day work.

Using biofeedback games as an on-ramp to EEG neurofeedback

For many kids, especially those who are anxious, oppositional, or simply game-obsessed, starting with a full EEG cap, conductive gel, and a quiet chair is a big ask. Cardiac biofeedback games offer a softer entry point.

A typical flow might look like this:

1. Session 1–2: Physiological orientation. Introduce a heart-rate based game (e.g., systems like Mightier, or in-clinic equivalents) while you quietly observe. The focus is not on “fixing symptoms” yet but on curiosity: “Watch how your ship changes when your breathing changes.”

2. Sessions 3–4: Structuring the skill. Once the child has discovered the basic rule (“slower, smoother breathing makes the game easier”), you begin to formalize it—naming the skill (e.g., “smooth breathing,” “dragon breath”), linking it to moments of anger or anxiety, and weaving in brief reflection between rounds.

3. Transition to EEG. Only after the child has a lived sense that physiology is trainable do you introduce EEG neurofeedback: “We’ve been training your body and heart; now we’re going to train your brain in the same way.”

This sequence does three things: it normalizes the idea of being connected to sensors; it builds early wins and self-efficacy; and it reduces drop-out when you later transition to longer, perhaps less inherently “fun” EEG sessions.

Tailoring EEG protocols to the themes in the review

The games in this review mostly targeted anxiety, anger/aggression, externalizing behavior, and broad emotion regulation. In EEG language, that naturally points us toward a few core protocol families:

• Overarousal and anxiety. Consider protocols that enhance posterior or central alpha (8–12 Hz) and/or inhibit high beta (22–30 Hz) at sites like POz. The goal is to shift the system from high vigilance toward relaxed, stable attention.

• Impulsivity and aggression. Classic SMR training (12–15 Hz) at C3, C4 or Cz, often with concurrent theta (4–7 Hz) or high-beta inhibition, can support behavioral inhibition and motor control. For children with pronounced externalizing behavior, pairing this with heart-rate based games that reward steady physiology reinforces inhibition at both cortical and autonomic levels.

• Depressive or internalizing patterns. Where appropriate, frontal alpha or asymmetry protocols (e.g., encouraging more balanced left–right activity around F3/F4) may align with the mood-focused aspects of the biofeedback games that reduced anxiety and depression in the review.

The key is individualisation. A child whose anxiety is driven by sensory overarousal and sleep problems may benefit from SMR and posterior alpha work, while another whose distress is more rumination-based might need different frontal protocols. Heart-based games introduce a common language of regulation (“calm body, clear signal”) that you can then customize at the EEG level.

Combining modalities and homework creatively

One of the most exciting implications of these findings is how easily biofeedback games can extend training beyond the clinic.

• Between-session practice. Families can use heart-rate based games for 10–15 minutes, several times per week, as homework. In session, you briefly review their experience and link it to EEG metrics: “When you got your heart into the green zone at home, you were also practicing the same kind of stability we’re rewarding in your brain here.”

• Session structure. Short bursts of cardiac biofeedback at the start of a session can act as a “physiology warm-up,” settling arousal and focusing attention before EEG training. Alternatively, they can be used at the end of a neurofeedback block to consolidate calm and send the child out of the office with a sense of mastery.

• Psychotherapy integration. CBT, ACT, or trauma-focused therapies can all anchor their cognitive and narrative work in the child’s new body skills. For example, after a relapse or meltdown, reviewing game data and EEG training graphs can become tangible material for cognitive restructuring: “Notice how your heart and brain learned to calm down here; that capacity is still in you even when yesterday was hard.”

Research protocols vs. clinical reality

The review’s trials typically offered 5–8 sessions of biofeedback gaming. If you’re a clinician used to 20–40 sessions of neurofeedback, that should immediately raise a flag: research designs optimized for feasibility and cost often underestimate what’s possible with richer, longer-term training.

In practice, you might:

• Run cardiac biofeedback and EEG training in parallel over many weeks, rather than treating the games as a brief add-on.

• Adjust game difficulty and thresholds dynamically based on day-to-day clinical impressions and EEG findings, rather than relying on fixed protocols.

• Involve parents more actively in co-regulation games, mirroring promising family-based designs like CALMS.

So when you read “large effect sizes after eight sessions,” it’s encouraging—but also an invitation. If a handful of sessions in constrained research contexts can move the needle, a thoughtful, individualized program in the wild may do much more.

A hopeful, critical stance

Overall, I read this review as both a validation and a challenge. It validates what many clinicians already sense: when we make psychophysiology playful, kids learn faster, stick around longer, and carry skills into daily life. It also challenges us to:

• Design culturally responsive, accessible game-based tools.

• Report outcomes rigorously in our own practices.

• Build bridges between heart-based biofeedback and EEG neurofeedback rather than keeping them siloed.

The heart is a beautifully honest bio-signal. It reacts quickly, reflects emotion vividly, and is easy to measure in living rooms and classrooms. When we combine that with the precision of EEG training and the depth of psychotherapy, we move toward a genuinely holistic model of care.

Conclusion

This systematic review of biofeedback-based digital games paints a cautiously optimistic picture: short, playful interventions using cardiac biofeedback can reduce anxiety, depression, anger, aggression, and general distress in children and adolescents, with the strongest effects in those who start out most symptomatic. These games work across hospitals, schools, residential programs, and community settings, often as add-ons to existing therapies.

For practitioners in neurofeedback and broader mental health care, the message is not to abandon what we know works, but to enrich it. Heart-rate based games can act as engaging on-ramps, homework tools, and parallel training streams that strengthen the core self-regulation skills we aim to build with EEG and psychotherapy.

At a time when youth mental health needs are rising faster than traditional services can respond, integrating scalable, game-based biofeedback into our toolkits is less a luxury than a necessity. When we give children ways to play with their physiology—aligning heart, breath, and brain—we open up new, hopeful pathways for growth, resilience, and well-being.

References

Darabi, M. D., Silber, S. P., Slotkin, R., & Peechatka, A. L. (2025). Biofeedback-based digital games and well-being in childhood: A systematic review. Research on Child and Adolescent Psychopathology. Advance online publication. https://doi.org/10.1007/s10802-025-01387-x