## 4 Discussion  
This study is the first to compare VR-based cognitive training with an active VR-based nature exposure intervention to improve ER, EFs, and psychological well-being in adolescents at risk for ED. The immersive nature of VR tends to be effective in capturing student attention and improving student engagement. This was evidenced by the lack of attrition in both VR interventions, further supporting the use of VR to reduce dropout rates in cognitive training or general rehabilitation programs [38]. In terms of mental health measures, the experimental group showed significant reductions in global internalizing and depressive symptoms compared to the control group. These findings are consistent with previous research indicating that VR-delivered and traditionally delivered cognitive training interventions can reduce internalizing symptoms, including depressive symptoms [36, 60, 61]. In this sense, many recent studies have shown that immersive VR cognitive training programs can significantly reduce depression symptoms in older adults [62], middle-aged adults [63], and adolescents [64]. Difficulties in a wide range of cognitive functions, such as EFs, are associated with depressive symptoms in children, adolescents, and adults [65, 66, 67]. Early difficulties with EFs are a prominent feature of several clinical conditions with childhood or adolescent onset, including internalizing disorders such as anxiety and depression [67, 68]. Thus,  
Figure 3: Global T-scores computed for each subgroup of cognitive function assessed, including cognitive flexibility, with global mean T-scores of all Wisconsin Card Sorting Test (WCST) subtests; working memory, with a global mean T-scores of Trail Making Test (TMT-B) and Stroop Color and Word Test (SCWT) color (C) and word (W) individual subtests; auditory attention, with the mean total Scores of the Digits test, and Simple attention, with global mean T-scores TMT-A and SCWT color and word (C&W) subtest. Standard error of the mean reported. this study provides further evidence that interventions targeting EFs may also alleviate associated depressive symptoms, as other review studies have shown [69; 70]. On the other hand, although our results did not show significant group differences in the improvement of anxiety symptoms after the interventions, the experimental group still showed a more pronounced reduction in these symptoms compared to the control group. This positive trend in the experimental group is consistent with previous meta-analyses and systematic review studies reporting that cognitive training targeting EFs, including working memory training, can reduce anxiety symptoms [12; 22]. Our results also indicated significant improvements in emotional control and reductions in ruminative symptoms, with no significant changes in emotional suppression and cognitive reappraisal skills. These improvements were particularly pronounced in the experimental group, while the control group did not show significant improvements. Training EFs improves cognitive processes essential for ER, such as inhibitory control, goal-directed focus, and behavioral flexibility. This is consistent with previous theoretical models that emphasize the role of conscious and voluntary strategies in achieving goals and managing emotional responses [31]. These findings also support previous studies highlighting that EFs training can lead to improvements in explicit ER skills in both clinical [71] and healthy population [19; 22]. Internalizing symptoms often result from maladaptive ER strategies that amplify or suppress emotional expression, leading to emotional dysregulation [72; 73]. Stimulating EFs across sessions may strengthen connections between fronto-parietal brain areas involved in the development of ER skills [74; 75; 73] and promote more effective and cognitively integrated ER strategies [76; 77]. In this sense, previous studies have shown that EFs training programs, such as working memory training, could improve ER ability in children, adolescents, and adults [78; 79].