Emotion Regulation Training for Adolescents With ADHD
Phase: NA
Conditions: Attention Deficit Disorder With Hyperactivity, Emotion Regulation, ADHD
Sponsor: Uppsala University

2022-11-23 
Emotion regulation training for adolescents with ADHD 
 
Study Protocol (including analysis plan) 
 
This is a brief protocol and proposed plan for data analyses corresponding to the pre-registered 
research aim: To evaluate feasibility and potential effectiveness of a psychological intervention 
(SKILLS-ER) designed to strengthen adaptive regulation skills for adolescents with ADHD. Due to un-
foreseen conditions related to data or other unexpected circumstances, this plan may have to be 
revised. 
 
Intervention 
The intervention (SKILLS-ER) has been developed by the authors, and aims to increase a participant's 
emotion regulation capacity by targeting different stages of the emotion regulation process 
proposed by the extended process model of emotion, i.e., identification, selection, implementation 
and monitoring (Sheppes et al., 2015). SKILLS-ER will comprise of eight sessions and include 
identification and differentiation of emotions, tolerance/acceptance of emotions, education of 
different regulatory skills, as well as on how to select, implement and monitor strategies. Sessions 
will take place at the Uppsala child- and adolescent psychiatry unit and consist of activating and 
experiential exercises administered by a clinical psychologist. Participants will gain access to internet-
delivered material, such as homework assignments in-between sessions. SKILLS-ER will be delivered 
individually to the participants, where their parents will be involved in some sessions. 
 
Participants 
Adolescents (n=9; 13-18 years of age) with ADHD and emotion dysregulation will participate in 
SKILLS-ER in order to evaluate feasibility, potential effectiveness and to detect mechanisms that 
could strengthen adaptive regulation skills. The participants will be recruited from Uppsala child and 
adolescent psychiatric outpatient unit. Inclusion criteria is an ADHD diagnosis and self- and/or 
parent-rated emotion regulation difficulties, as indicated by the Emotion Questionnaire, on which 
the adolescent and parent rate either “strongly disagree” or “disagree” on the specific item: “when I 
(he/she) am (is) angry/sad/afraid/happy I (he/she) can change my (his/her) mood” (note: this item 
encompasses four separate questions related to being i) angry, ii) sad, iii) afraid or iv) happy). 
Further, emotion regulation difficulties should be identified as a problem for the adolescent. 
Exclusion criteria includes intellectual disability, autism, psychosis, bipolar disorder, severe 
depression, non-stabilized medication for ADHD at intake (if on medication for ADHD), and other 
ongoing psychological treatment. 
 
Study design 
A single-case multiple baseline design will be used, where the participants will be randomized to pre-
intervention concurrent baselines at different lengths (5, 6 and 7 weeks). 
 

2022-11-23 
Primary outcome measures: Rated emotion regulation  
The participants and their parents will rate emotion regulation weekly using the Difficulties in 
Emotion Regulation Scale Short Form (DERS-SF; Kaufman et al., 2016). In addition, the parents will 
rate two daily measures of individually defined target behaviors associated with emotion regulation 
of their child (e.g., number of tantrums), collected during all phases (baseline [5-7 weeks], 
intervention [8 weeks] and post-intervention [2 weeks]). We will analyze the data with a combination 
of visual and quantitative analyses. For the visual analyses, we will follow the steps outlined by 
Kratochwill and colleagues (2013), investigating level, trend, variability, immediacy of effect, overlap 
and consistency of data patterns. To complement the visual analyses, we intend to use Tau-U as an 
effect size measure. We will follow the recommendations by Fingerhut and colleagues (2021) to 
decide which specific index of Tau-U is most appropriate in relation to the data as indicated by visual 
inspection.  
 
Hypotheses 
We hypothesize that emotion dysregulation (operationalized as the total summed score of DERS-SF) 
will decrease and that the individually defined target behaviors will change in frequency (with a 
decrease of emotion dysregulation or increase in emotion regulatory behaviors) during the 
intervention, comparing baseline with the intervention phase, and that any effect will remain up to 
two weeks after the intervention. In addition, we expect to see changes in the DERS-SF subscale 
scores during the intervention in a manner that corresponds to specific sessions dealing with content 
relevant to certain subscales. We hypothesize that ratings of the emotional awareness and clarity 
subscales will change first in the treatment, followed by the subscales nonacceptance, engaging in 
goal-directed behavior and emotion regulation strategies. Further, we hypothesize that time to 
change will be related to start of intervention, not start of baseline. An exploratory hypothesis will be 
adopted for the impulse subscale since it may correlate more with ADHD core symptomatology than 
other subscales and may not be as sensitive to the effects of the emotion regulation training. 
 
Secondary outcome measures: Rated emotion regulation, functional impairment, client 
satisfaction, adverse events, ADHD symptoms and comorbidity 
The participants will rate emotion regulation with the Cognitive Emotion Regulation Questionnaire 
(CERQ) pre- and post-intervention. Both participants and parents will (pre- and post-intervention) 
rate functional impairment in every-day life, ADHD symptoms with total score on the Adult ADHD 
Self-Report Scale Adolescent version (ASRS-A) and anxiety with total score on the Spence Children’s 
Anxiety Scale (SCAS). Parents will also rate symptoms of oppositional defiant disorder with eight 
items from the SNAP-IV scale. Post-intervention, participants and their parents will rate adverse 
events using the Negative Effects Questionnaire (NEQ), and some items targeting client satisfaction 
(e.g., would recommend the treatment, can better handle emotions and ADHD, has benefitted from 
the treatment, impressions of the treatment). Difference in ratings between pre- and post-
intervention will be calculated using Wilcoxon (paired) signed-rank test. We have no hypotheses in 
relation to these secondary outcomes, given the small sample size, but expect that these analyses 
will generate an effect size and enable calculations of appropriate sample size for a future 
randomized controlled (RCT) study. Post-intervention rating on NEQ and client satisfaction will be 
presented using descriptive statistics.  

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Feasibility 
The overall aim to assess feasibility will include the outcome measures, as well as information on 
participants attendance to sessions, completed homework assignments, and the therapist adherence 
to the intervention measured with self-ratings after each session (rated for different elements of the 
intervention: “not completed”, “partly completed”, “completed”). We will focus on sample 
characteristics, data collection procedures and outcome measures, acceptability and suitability of the 
intervention and study procedures, and preliminary evaluation of participant responses to the 
intervention.  
 
References 
Fingerhut, J., Xu, X., & Moeyaert, M. (2021). Selecting the proper Tau-U measure for single-case 
experimental designs: Development and application of a decision flowchart. Evidence-Based 
Communication Assessment and Intervention, 15(3), 99–114. 
https://doi.org/10.1080/17489539.2021.1937851 
 
Kaufman, E. A., Xia, M., Fosco, G., Yaptangco, M., Skidmore, C. R., & Crowell, S. E. (2016). The 
Difficulties in Emotion Regulation Scale Short Form (DERS-SF): Validation and Replication in 
Adolescent and Adult Samples. Journal of Psychopathology and Behavioral Assessment, 38(3), 443–
455. https://doi.org/10.1007/s10862-015-9529-3  
 
Kratochwill, T. R., Hitchcock, J. H., Horner, R. H., Levin, J. R., Odom, S. L., Rindskopf, D. M., & Shadish, 
W. R. (2013). Single-Case Intervention Research Design Standards. Remedial and Special Education, 
34(1), 26–38. https://doi.org/10.1177/0741932512452794 
 
Sheppes, G., Suri, G., Gross, J. J. (2015). Emotion regulation and psychopathology. A Annual Review of 
Clinical Psychology, 11, 379-405. doi: 10.1146/annurev-clinpsy-032814-112739.