PONE-D-24-35309The impact of extended reality cognitive behavioral therapy on mental health outcomes among children and youth: a systematic review protocolPLOS ONE

Dear Dr. Katapally,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Oct 25 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Jamil Rababa

Academic Editor

PLOS ONE

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“Canada Research Chairs”

Please state what role the funders took in the study.  If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

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2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: No

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3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for submitting your systematic review protocol titled "The Impact of Extended Reality Cognitive Behavioral Therapy on mental health outcomes among children and youth." This protocol addresses an important and timely topic, exploring the innovative use of extended reality (XR) technologies in cognitive behavioral therapy (CBT) for children and youth, a demographic experiencing significant mental health challenges.

Below are specific comments and suggestions to address before this protocol can be accepted for publication:

(1) Rationale and Research Questions: The manuscript provides a strong rationale for exploring XR-CBT and clearly outlines the research questions. However, further elaboration on how XR-CBT uniquely addresses the mental health needs of children and youth compared to traditional CBT would strengthen the justification for the study.

(2) Technical Soundness and Methodology: The methodology is robust and follows PRISMA-P guidelines, ensuring a structured approach to the systematic review. However, providing additional details on the data synthesis method (e.g., narrative synthesis or meta-analysis) would enhance the transparency of the planned analyses.

The current inclusion and exclusion criteria are clear and appropriate. Consider including a brief discussion on any exploratory analyses planned or how potential methodological challenges will be managed.

(3) Feasibility and Replicability: The protocol describes the methodology sufficiently to allow replication by other researchers. The use of Covidence software, independent reviewers, and a detailed search strategy are all strengths that support the feasibility of the review. No major changes are required in this regard.

(4) Data Availability: The protocol currently does not specify where the data underlying the findings will be made available upon completion of the review. Please include a statement detailing the data-sharing plan, such as depositing the data in a public repository, to comply with PLOS ONE’s data policy. This will ensure transparency and accessibility of the review's findings.

(5) Presentation and Language: The manuscript is well-written and presented, with minimal language errors. The writing is clear, coherent, and professional, making the manuscript easy to understand. Only minor language polishing is needed to improve readability and flow.

(6) Additional Suggestions: Consider adding a brief theoretical framework that connects XR technologies with CBT principles to strengthen the conceptual basis of the review.

Expanding on the future implications and potential challenges of XR-CBT (e.g., ethical considerations, cost, and accessibility issues) would provide a more comprehensive outlook on its practical application.

Overall, the protocol is well-constructed and addresses a critical gap in the literature. Minor revisions, as outlined above, will enhance the quality and transparency of the manuscript, making it suitable for publication. We look forward to seeing the final version of this important work.

Thank you for your contributions to this emerging area of mental health research.

Reviewer #2: The paper titled "The impact of extended reality cognitive behavioral therapy on mental health outcomes among children and youth: a systematic review protocol" addresses the growing concern of mental health issues in children and youth, particularly the increasing rates of anxiety, depression, and other psychological disorders. The authors highlight the limitations of traditional cognitive behavioral therapy (CBT), which often struggles with patient engagement and stigma, especially among younger populations. In response to these challenges, they propose investigating extended reality (XR) technologies—encompassing virtual reality, augmented reality, and mixed reality—as innovative therapeutic tools that may enhance the effectiveness of CBT by providing immersive and engaging environments.

The systematic review aims to evaluate the efficacy of XR-CBT interventions specifically for children and youth, an area that has not been systematically reviewed before. The authors outline a comprehensive literature search strategy utilizing five electronic databases to gather relevant studies. They will assess the impact of XR-CBT on mental health outcomes, explore the customization of these interventions, and consider their integration into digital mental health platforms. The findings from this review are expected to contribute valuable insights into the potential of XR-CBT to address the escalating mental health crisis among younger populations, ultimately informing future therapeutic practices and research in this emerging field.

In my opinion, the idea of this Research article is really interesting and the authors’ fascinating observations on this timely topic may be of interest to the readers of Plos One. However, some comments, as well as some crucial evidence that should be included to support the authors’ argumentation, need to be addressed to improve the quality of the article, its adequacy, and its readability prior to the publication in the present form.

Strengths:

• The paper addresses a critical and timely issue, given the rising prevalence of mental health disorders among children and youth. The integration of XR technologies into therapeutic practices is an innovative approach that could potentially enhance engagement and treatment efficacy.

• The objectives of the systematic review are clearly outlined, focusing on the efficacy, customization, integration into digital platforms, and future recommendations for XR-CBT. This provides a comprehensive framework for the review.

Please consider the following comments:

• The introduction could benefit from a more extensive literature review that discusses existing studies on XR-CBT, particularly those involving children and youth. This would help establish a stronger foundation for the need for this systematic review.

• While the paper mentions the databases to be used for the literature search, it lacks specific details about the search strategy (e.g., keywords, inclusion/exclusion criteria). I would ask the authors to provide this information to enhance the reproducibility of the review.

• The paper should address potential biases in the selection of studies, such as publication bias or language bias. Including a plan for assessing the risk of bias in the included studies would strengthen the review's credibility.

• Although the paper mentions the need for an ethics statement, it does not elaborate on how ethical considerations will be handled, particularly given the vulnerable population involved (children and youth).

• The authors state that no datasets will be generated or analyzed during the current study. However, they should clarify how they plan to share any findings or insights from the review, as transparency in data availability is increasingly important in research.

• The review should specify how the impact of XR-CBT will be measured. Authors should better define clear metrics or outcomes for evaluating mental health outcomes will enhance the study's applicability and relevance.

Reviewer #3: Recommendations for Manuscript ID PONE-D-24-35309 Title: “ The impact of extended reality cognitive behavioral therapy on mental health outcomes among children and youth: a systematic review protocol” for the Plos One.

General Comments

From my point of view, it is a very interesting topic and simultaneously it seems that to the best of my knowledge is an empirical study aims to evaluate the impact of XR-CBT on mental health outcomes among children and youth. A comprehensive literature search was conducted using five electronic databases: PsycINFO, PubMed, EMBASE, Scopus, and Web of Science. The search strategy will include terms related to virtual reality, augmented reality, mixed reality, cognitive behavioral therapy, exposure therapy, youth, children, and mental health. Two independent reviewers will evaluate the search results from the five selected databases based on the pre-determined search strategy. Findings from this study will provide insights regarding the potential of XR-CBT to enhance mental health outcomes, which can contribute to addressing the escalating mental health crisis among children and youth.

The paper contains the following sections: Introduction, Methods, Limitations, Conclusion.

However, I find some recommendations:

1. The Manuscript needs careful English proofreading because there are some shortcomings. For instance, the article “the” is sometimes missing in front of nouns, the message in some paragraphs is not clear enough. It looks like the first part was written by one author with a greater command of the English language, and the rest of the paper was written by someone else. The numerous grammar errors made this a difficult paper to read. It was strange to see the authors refer to tables that were not submitted. I was unable to find any supplementary material to the submission, so I think this was truly omitted by the authors. Please read the manuscript carefully.

2. The abstract must contain the main purpose of the paper, the research method used in the research and the main contributions.

3. The last section must contains Conclusions and Policy Implications.

4. It would be very useful to add the "Introduction" section and the purpose, objectives and hypothesis of the research. I consider that a weak point of the paper is that the authors did not show the novelty of the paper compared to other works. That is why, I consider that the introduction should specify the novelty of the paper compared to other papers published in this area.

5. The research is well based on science and the results are in agreement with the theoretical part. The paper is well written and easy to read.

6. The Literature Review section cannot be missing from the paper.

7. The model applied to the analyzed data is correctly used in the analysis undertaken, it is a strength point of this paper.

8. The research is well based on science and the results are in agreement with the theoretical part. The model applied to the analyzed data is correctly used in the analysis undertaken, it is a strength point of this paper.

9. Authors must present the software used in data processing (STATA, Eviews, etc)

10. In the same time, the authors must present a minimum an empiric model.

11. I recommend the authors to refer to other recent works indexed in Web of Science, because the papers cited works is not enough for a scientific paper. In my opinion, the authors must cite other papers regarding this subject.

1.

12. The conclusions at the end of the paper should be expanded showing the economic policy implications of the research results.

In conclusion, the article should be improve. It should also be enhanced with a review of the literature adequate to the subject and a broader interpretation and commentary of the research results.

Reviewer #4: Dear colleagues,

This review’s topic is fascinating, and will surely be of interest to the wider scientific community. The quality of writing is of a high standard, and the introduction and study context is generally clear and well-supported. However, I recommend a major re-conceptualisation and rewrite regarding the specifics of the review. In particular, I am concerned how particular constructs are defined (or lack thereof), and what outcome measurements are of interest for analysis. I recommend the authors follow pre-registration guidance at Prospero and/or OSF to tightly define the review's scope before proceeding any further. Currently, the protocol is close to being broad enough to perform a scoping review; however as a systematic review and meta-analysis the study design needs major revisions before being accepted as a published report. I have provided comments within the text for areas of revision.

Kind regards

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes:  Andrew Danso

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Attachments

Attachment

Submitted filename: PONE-D-24-35309_updated.pdf

PONE-D-24-35309R1The impact of extended reality cognitive behavioral therapy on mental disorders among children and youth: a systematic review and meta-analysis protocolPLOS ONE

Dear Dr. Katapally,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Nov 23 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Jamil Rababa

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Partly

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (1) The manuscript requires further proofreading. Minor grammatical and typographical errors affect readability. These need to be corrected to ensure the manuscript is clear and correct and meets PLOS ONE's standards for intelligibility. Ensure smooth transitions between sections and improve the overall flow.

(2) Clearly distinguish any exploratory aspects of the analysis. While the protocol outlines the methodology well, it would benefit from explicitly marking which parts of the analysis are exploratory to prevent potential flexibility in interpretation after the study is conducted.

(3) Double-check that all supplementary materials are fully included and correctly uploaded. This includes ensuring the full search strategy and supplementary data files are accessible and meet the journal’s requirements.

So, please Conduct a thorough language revision, clarify exploratory analysis aspects, and ensure proper inclusion and access to all supplementary files.

Reviewer #2: Dear Authors,

Thank you for the thorough revisions and for addressing the key points raised in the previous review. The manuscript has improved significantly, particularly with the expanded literature review and detailed methodology. I appreciate the inclusion of additional references and the clarification of the search strategy, which strengthens the overall rigor of the paper.

However, there are a few additional minor points that I would like to bring to your attention for further refinement of the manuscript:

• The addition to the introduction on XR therapies (lines 106-112) is strong. However, the authors might further highlight how this systematic review addresses gaps in previous research (perhaps adding a sentence or two) to emphasize its unique contribution.

• In the section discussing the use of a random-effects model for the meta-analysis (lines 213 to 220), it could be helpful to briefly explain why a random-effects model is chosen over a fixed-effects model.

• While the ethics statement mentions that the study does not involve primary data collection and will assess ethical considerations of included studies (lines 209-211), authors might want to elaborate slightly on how this assessment will be done—whether specific frameworks will be used or if it will be handled case by case.

• While the manuscript mentions subgroup analyses to explore potential sources of heterogeneity (lines 219-220), consider indicating whether any visual representations of these subgroup analyses (e.g., stratified forest plots) will be included in the results.

• Authors mentioned that sensitivity analyses will exclude studies with small sample sizes (lines 220-221), but it could help to briefly define what constitutes a "small" sample size in this context, or explain how you will determine the threshold.

• While authors do mention subgroup analyses by study design (lines 219-220), it might be helpful to expand slightly on why different designs (e.g., RCTs vs. quasi-experimental) could affect the results or introduce biases, just to emphasize the rationale for this analysis.

I believe that addressing these minor points will further enhance the clarity and rigor of your manuscript. Thank you once again for your hard work and thoughtful revisions. I look forward to seeing the final version of this important contribution to the field.

Best regards,

Reviewer

Reviewer #3: Accept the paper for publication. I carefully examined the changes made to the paper and found that the authors took into account the reviewer's observations.

Reviewer #4: Dear colleagues, this is an excellent revision which has addressed many previous weaknesses. As this has substantially improved I will provide recommendations for a more detailed analysis plan:

Can you explicitly state what your reported measures of effect will be (e.g., Cohen's d, Hedges' g etc) as to your primary research question?

It is important to specify timepoints for the outcomes of interest from the DSM-5 outcome measures. For example, are you interested in measurements taken immediately, to 10-minutes post-intervention? And why? Please explicitly state this.

As part of your synthesis plan, I recommend including a plan to perform an apriori meta-regression analysis on specific outcomes from the DSM-5 outcome measures relevant to mental health symptoms, especially if the number of studies is at minimum 10, included in the meta-analysis. I would also recommend you do a post-hoc exploratory meta-regression analysis on factors such as age, gender, and time since diagnosis (as these factors may be associated with symptoms associated with mental disorders).

The hypothesis needs a minor revision to, "XR-CBT shows a greater effect on symptoms associated with mental disorders in children and youth compared to traditional therapies and the control condition (e.g., no treatment) at post-intervention".

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step.

PONE-D-24-35309R2The impact of extended reality cognitive behavioral therapy on mental disorders among children and youth: a systematic review and meta-analysis protocolPLOS ONE

Dear Dr. Katapally,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Dec 26 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Mohammad Jamil Rababa

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:  Thank you for the comprehensive revisions, which have made the protocol clear and robust, effectively addressing prior reviewer comments. You have provided an excellent justification for the research question, highlighting the significance of this study in filling an important gap in digital mental health.

The methodology is well-detailed and thoughtfully planned, with clear inclusion criteria, controls, and justified model choices. The manuscript is well-written, and the data availability plan aligns with journal standards.

No further revisions are necessary, and the protocol is ready for acceptance.

Reviewer #2:  Dear Authors,

I want to express my gratitude for the detailed and thoughtful responses provided to the comments I raised in the second review of this manuscript.

Authors have addressed my concerns and queries in a clear and comprehensive manner, and the revised manuscript aligns more closely with the scientific rigor expected for publication in PLOS ONE.

Having reviewed the revised manuscript, I am largely satisfied with the changes that have been implemented. I have just a couple of additional comments that I believe could further refine the manuscript:

- While you provided valuable information on the adapted framework based on Hawker’s quality assessment, it may be beneficial to briefly explain why this framework is especially suitable for assessing studies on XR-CBT in children and youth, enhancing clarity for readers.

- The addition explaining the rationale for analyzing different study designs is helpful; still, I believe that a brief note on specific biases that quasi-experimental studies might introduce (such as selection or performance bias) could further reinforce your rationale for prioritizing RCTs.

With these minor additions, I believe the manuscript will be ready for publication.

Thank you again for your diligent work on this revision.

Best regards,

Reviewer

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: No

**********

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The impact of extended reality cognitive behavioral therapy on mental disorders among children and youth: a systematic review and meta-analysis protocol

PONE-D-24-35309R3

Dear Dr. Katapally,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Mohammad Jamil Rababa

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Does the manuscript provide a valid rationale for the proposed study, with clearly identified and justified research questions?

The research question outlined is expected to address a valid academic problem or topic and contribute to the base of knowledge in the field.

Reviewer #2: Yes

**********

2. Is the protocol technically sound and planned in a manner that will lead to a meaningful outcome and allow testing the stated hypotheses?

The manuscript should describe the methods in sufficient detail to prevent undisclosed flexibility in the experimental procedure or analysis pipeline, including sufficient outcome-neutral conditions (e.g. necessary controls, absence of floor or ceiling effects) to test the proposed hypotheses and a statistical power analysis where applicable. As there may be aspects of the methodology and analysis which can only be refined once the work is undertaken, authors should outline potential assumptions and explicitly describe what aspects of the proposed analyses, if any, are exploratory.

Reviewer #2: Yes

**********

3. Is the methodology feasible and described in sufficient detail to allow the work to be replicable?

Descriptions of methods and materials in the protocol should be reported in sufficient detail for another researcher to reproduce all experiments and analyses. The protocol should describe the appropriate controls, sample size calculations, and replication needed to ensure that the data are robust and reproducible.

Reviewer #2: Yes

**********

4. Have the authors described where all data underlying the findings will be made available when the study is complete?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception, at the time of publication. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above and, if applicable, provide comments about issues authors must address before this protocol can be accepted for publication. You may also include additional comments for the author, including concerns about research or publication ethics.

You may also provide optional suggestions and comments to authors that they might find helpful in planning their study.

(Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Dear Authors,

Thank you for your thoughtful responses to the comments I provided on the revised manuscript.

After careful consideration, I am satisfied with the revisions you have made and your responses to my concerns. Therefore, I am confirming my acceptance of the manuscript for publication. I believe your efforts have improved the quality of the paper, and I look forward to seeing it contribute to the scientific community.

Best regards,

Reviewer

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #2: No

**********