Digital Gamified Interventions Targeting Internalizing Mental Health Outcomes in Children and Adolescents: Systematic Review and Meta-Analysis
Journal of Medical Internet Research ·
Background: Gamified digital mental health interventions have been proposed as a scalable and engaging approach to addressing the substantial treatment gap in child and adolescent mental health, including limited access to evidence-based care and difficulties with treatment engagement. However, the evidence remains fragmented, and it is unclear which specific gamification elements contribute to clinical effectiveness and sustained engagement. Objective: This review aimed to (1) characterize the gamification elements implemented in digital mental health interventions for children and adolescents; (2) evaluate their effects on internalizing mental health outcomes; (3) assess engagement, adherence, and user experience outcomes; and (4) descriptively explore whether specific gamification elements are associated with differences in clinical or engagement outcomes. Methods: A systematic review and meta-analysis was conducted following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines. Six electronic databases were searched for studies published between January 2018 and March 2026. Eligible studies examined gamified digital interventions targeting internalizing symptoms in children and adolescents. Gamification elements were systematically coded across 10 categories using a predefined coding framework. A 3-level random-effects meta-analysis was conducted for controlled studies reporting validated mental health outcomes. Results: A total of 27 studies (N=28,777; mean age range 5.05-18.78 years) were included. Feedback, challenges, and progress tracking were the most frequently implemented gamification elements; social interaction and competition were rare. The meta-analysis of 5 eligible controlled studies yielded a small effect in favor of gamified interventions ( g =–0.28, 95% CI –0.54 to –0.02; P =.04). However, the 95% prediction interval (–0.79 to 0.24) included zero, indicating substantial uncertainty regarding the effect expected in future comparable settings. Narrative synthesis suggested potentially more favorable effects for depression and anxiety outcomes in some clinical or at-risk samples and in interventions incorporating structured therapeutic content, although these patterns could not be formally examined as moderators. Engagement and adherence limitations were frequently reported across studies. Conclusions: Gamified digital interventions may be associated with small improvements in internalizing outcomes in children and adolescents, although the conditions under which these interventions are most effective remain unclear. The limited evidence base and uncertainty across settings preclude firm conclusions regarding efficacy. Future research should determine which gamification elements enhance clinical outcomes and engagement, for whom they are most effective, and under which conditions.