Biobehavioural Regulation of Negative Emotion as a Transdiagnostic Mechanism of Children's Psychotherapy
Phase: NA
Conditions: Anxiety Disorders, Depressive Disorder, Mood Disorders, Conduct Disorder, Oppositional Defiant Disorder, Regulation, Emotion, Child Behavior Disorders, Trauma and Stressor Related Disorders
Sponsor: University of Guelph

 
1 
Protocol Version 4.2 Oct 10/24 
 
Protocol 
 
Study Title: Testing the Biobehavioural Regulation of Negative Emotion as a Transdiagnostic 
Mechanism of Change in Child Psychotherapy 
 
Lay Title: Big Feelings: A Study on Children’s Emotions in Therapy 
 
PRINCIPAL INVESTIGATOR: 
 
Dr. Brendan Andrade, Ph.D., C. Psych  
 
INVESTIGATOR CONTACT:  
 
Brendan.Andrade@camh.ca 
 
 
 
 
 
416-535-8501 ext. 33642 
 
 
 
 
 
Fax: 416-979-4685 
 
Centre for Addiction and Mental Health  
 
 
 
 
 
Child, Youth, and Emerging Adult Program 
 
 
 
 
 
Intergenerational Wellness Building 
 
 
 
 
 
80 Workman Way, Room 1109 
 
 
 
 
 
Toronto, Ontario M6J 1H4 
 
 
CO-INVESTIGATOR: 
 
 
Dr. Madison Aitken, Ph.D., C. Psych 
 
INVESTIGATOR CONTACT: 
 
Madison.Aitken@camh.ca 
 
 
 
 
 
416-535-8501 ext. 34091 
 
 
 
 
 
Fax: 416-979-4996 
 
Centre for Addiction and Mental Health  
 
 
 
 
 
Child, Youth, and Emerging Adult Program 
 
 
 
 
 
Intergenerational Wellness Building 
 
 
 
 
 
80 Workman Way, Room 5124 
 
 
 
 
 
Toronto, Ontario M6J 1H4 
 
 
 
 
CO-INVESTIGATORS: Drs. Kristel Thomassin, Andrew Hamilton-Wright, John Weisz, Joanna Henderson, 
Wei Wang.  
 
SOURCE OF SUPPORT:   
Canadian Institute of Health Research (CIHR)  
 
 
 
 
 
 
 
 
 
 
 
 
 

 
2 
Protocol Version 4.2 Oct 10/24 
 
Introduction and Background 
Mental health problems are a pressing concern facing children today. Approximately 1 in 5 children 
have experienced mental health difficulties that impact their emotional and behavioural functioning, 
which increases their risk of dropping out of school, adulthood mental illness, substance use disorders, 
and suicide1-2. Anxiety, depression and disruptive behaviour disorders are amongst the most prevalent 
childhood disorders, comprising approximately 75% of clinicians’ caseloads3. While effective 
treatment can reduce short term and long term morbidity, meta-analyses show that evidence-based 
psychotherapies are only moderately effective4. Up to 50% of children experience no improvement or 
will drop out of treatment5. Thus, there is significant room for improvement in our mental health 
treatment. One method of improving treatment outcomes is to understand the underlying 
mechanisms that determine treatment success, failure, and non-response.  
 
Empirical research has established that emotion regulation operates at physiological, behavioural, 
cognitive, and experimental levels6. Emotional experience and regulation engage biological systems, 
particularly the parasympathetic and sympathetic branches of the autonomic nervous system, which 
regulate bodily processes and respond to environmental demands7. Two widely used biobehavioural 
indicators of emotion regulation are vagal tone and skin conductance. Vagal tone is indicative of the 
parasympathetic nervous system’s control over the heart rate, with increased variability 
corresponding to enhanced capacity for emotional regulation. In the same manner, skin conductance 
corresponds with activity from the sympathetic nervous system. Previous research has found an 
association between low heart rate variability and high skin conductance with adverse childhood 
experiences, stress, and psychopathology8-10. 
 
Rationale and Study Objectives 
Extensive research has supported emotion dysregulation as a significant risk factor for childhood 
emotional and behavioural disorders. The propensity to experience dysregulated negative emotions is 
considered a general, non-specific etiologic factor for a broad range of psychopathologies11-12. This is 
consistent with our own work outlining emotional and behavioural dysregulation as a general factor in 
clinical samples of children and adolescents and also as a potential clinical measure to assess severity 
of behaviours13-14. 
 
Helping children regulate negative emotion through cognitive, behavioural, and emotion management 
is a common component of evidence-based psychotherapy15. For example, the strategy of cognitive 
restructuring involves challenging unhelpful and negative thinking (e.g. I am a worse person than most 
people), which often contribute to negative emotions, and developing realistic thoughts (e.g. most 
people have good and bad qualities). Behavioural strategies often involve reducing physiological 
arousal associated with emotional dysregulation, such as mindfulness and body awareness.  
 
While emotion regulation has been established as a primary component of child psychotherapy, 
biobehavioural domains have not been systematically integrated into treatment models. Studies have 
shown that treatment for adult disorders results in decreased emotion dysregulation, yet very few 
studies evaluate emotion regulation as a mechanism of change at the biobehavioural level16. To our 
knowledge, there have been no studies to date, examining emotion regulation as a mechanism of 
change in child and adolescent psychotherapy. 
 
The primary objective of this study is to test biobehavioural regulation of negative emotion as a 
transdiagnostic mechanism of change in child psychotherapy. We hypothesize that psychotherapy will 

 
3 
Protocol Version 4.2 Oct 10/24 
improve emotion regulation of negative emotion in children, as compared to waitlisted controls. 
Additionally, we hypothesize that these anticipated changes in emotion regulation will be observed in 
biobehavioural markers, such as heart rate variance and performance on cognitive tasks. 
 
The study will use an evidence-based transdiagnostic psychotherapy and machine learning models to 
characterize treatment response variations based on biobehavioural regulation. Within this objective, 
we have three specific aims of this study.  
 
1) The first aim is to test biobehavioural regulation as a transdiagnostic mechanism of treatment 
response in psychotherapy for children with anxiety, depression and/or disruptive behaviour.  
Treatment response will be evaluated as pre-to-post change in diagnosis, symptoms, and the 
rate of symptom change. Biobehavioural regulation will be measured using a multimodal 
approach comprising validated parent- and child-report questionnaires, performance on 
behavioural and cognitive regulation tasks, and physiological reactivity.  
2) The second aim is to apply association rule mining, a machine learning technique, to uncover 
patterns governing variations in the regulation components throughout the course of 
treatment. Patterns will be expressed in the form of data-driven and rule-based algorithms 
reflecting the relation between emotion regulation and treatment response.  
3) The third aim is to engage our knowledge translation partners and stakeholders to incorporate 
the algorithms into a broader clinical decision-making framework and develop methods to 
pilot this framework in practice, to improve treatment response.  
4) Finally, other research questions may focus on moderators of treatment course and treatment 
response. 
 
Study Design 
This project will have several components, which we anticipate will unfold over the course of 5 years. 
The first step of the process will be training research and clinical staff; practicum students, psychology 
residents, and staff clinicians at CAMH on administering the Modular Approach to Therapy for 
Children with Anxiety, Depression, Trauma, and Conduct Problems (MATCH-ADTC) treatment. The 
study investigators will be primarily involved in training clinical staff on MATCH-ADTC treatment. They 
will not be directly involved in administering care, but they will be responsible for supervising 
practicum students and residents administering care. These students are clinical trainees in a doctoral 
program for clinical psychology, supervised by registered psychologists at CAMH (e.g.,  Dr. Andrade,  
Dr. Aitken). These students have previously completed coursework and training in therapeutic 
methods. When matching clients to students, we will consider the expected length of treatment in 
relation to the length of their practicum or residency. Most practicums and residencies range from 9 
months to 12 months, which will provide ample time to complete most courses of treatment. In the 
case that a student is unable to complete a course of treatment for a client, we will ensure continuity 
of care as is standard within our clinical services. There would be a plan for a warm transfer, where 
another trainee or clinician would continue treatment.  
 
Children and their parent(s)/caregiver(s) will be recruited on an ongoing basis from two outpatient 
children’s mental health clinics (CAMH and University of Guelph). Senior research staff will screen 
families, enroll them in the study, and conduct pre-treatment assessments. After enrolment and 
collection of initial measures, participants will be randomly assigned to the intervention arm or the 
waitlist control arm. We anticipate that the duration of both MATCH-ADTC treatment and the waitlist 
will range between 4 – 6 months, which is similar to the usual wait times for services at both clinics.  
 

 
4 
Protocol Version 4.2 Oct 10/24 
During this period, participants in both arms will complete brief weekly measures, which consist of 
very brief symptom scales. Participants will be required to complete quarterly assessments 
(approximately 3 months following their initial assessment), which will consist of symptom scales, 
medication tracking, clinical interviews, experimental tasks and physiological measures.  
 
Following the intervention or waitlist period, our team will conduct post- assessments. The post- 
assessments will allow us to analyze any changes in biobehavioural regulation and compare the 
differences between the intervention and control arms. Participants in the control arm will complete 
the post assessment approximately 4-6 months after their initial assessment, or prior to them being 
picked up off the waitlist for treatment in the clinic.  . As screening and enrolment are ongoing, we will 
consistently clean data and engage in quality assurance procedures to ensure our methods are 
rigorous and meet scientific standards.  
 
Participant Recruitment 
Children will be recruited from the Child, Youth, and Emerging Adult Program (CYEAP) at CAMH and at 
the Maplewoods Centre for Family Therapy and Child Psychology at the University of Guelph. 
Approximately 250 families (children aged 8 – 15, and their parent(s)/caregiver(s)), seeking 
psychotherapy for child anxiety, depression or disruptive behaviour will be recruited for this study. 
Families recruited from CAMH will have been referred to the Better Behaviours Service or Mood & 
Anxiety Clinic, or will be on the psychiatric assessment waitlist. Many families on the waitlist wait over 
a year for psychiatric evaluation, and many do not need or benefit from an assessment because they 
have been referred specifically for psychosocial treatment, and may already have a diagnosis and 
prescribed medication. To reduce the wait times for families and reduce the assessment burden, 
clinicians will screen families before their psychiatric assessment to identify children who may benefit 
from directly receiving psychosocial treatment without needing a psychiatric assessment first. These 
families will be contacted and asked to complete a short clinical screening (i.e. reason for referral) and 
approached to participate in research if the clinical team thinks the family would be a good fit. This 
process follows a similar procedure previously approved for use in our clinic (REB #018/2022).  
 
Initial Research Contact  
Initial contact will be made via email by an administrative staff to confirm the referral and advise 
clients about contact by the research team. This process ensures that clients receive detailed 
information about treatment options and opportunities, that they would otherwise be unaware of. 
We aim to provide all information to clients upfront, reducing the complexity and confusion that 
comes with receiving various pieces of information at different time points and from multiple 
contacts. Our priority is to inform clients and empower them to make their own decisions for relevant 
treatment services. This includes being introduced to treatment involved clinical studies that may be 
of interest and accelerate their access to evidence-based treatment services. In order to ensure that 
potential participants have the opportunity to understand their options fully and ask any questions 
they may have, the project coordinator is the best point of contact. This individual is most 
knowledgeable on processes within the BBS and MAC and is a member of both the clinical and 
research team. They are trained in the clinical and study procedures and are most knowledgeable to 
answer the client’s questions about the study and other usual care options.  
 
 
Due to this, our pathway will involve a confirmation of referral by a clinical team member or 
Information Specialist, an explanation of the process at the BBS and MAC and an opt out option for 
those that do not want to be approached by a clinical-research staff member. The clinical team 

 
5 
Protocol Version 4.2 Oct 10/24 
member or information Specialist is not positioned to have thorough discussions about pathways and 
treatment options, which involve clinical-research studies, with clients like the project coordinator is. 
Thus a generic “Would you be interested in research” would mean that families would not learn of 
opportunities to participate in a novel and evidence-based treatment, and would remain on the 
waitlist for usual care. At this point, families do not have enough information to make an informed 
decision (i.e. they do not know the potential benefits of participating in a research project, along with 
alternatives, and the nuances of a clinical trial).  
 
If the clinical-research team member is the first point of contact discussing research in detail, clients 
are given the opportunity to participate in a clinical trial, learn about the potential benefits of 
treatment, as well as the risks and alternatives. This process follows a core GCP principle of respect for 
persons and beneficence in that all clients are given the opportunity to choose if they want to 
participate in a clinical trial or not after receiving detailed information about the potential risks, 
benefits, and alternatives to participation. Efforts are taken to provide all possible options and 
alternatives to reduce any perceived or actual pressure on clients. Additionally, our consent form is 
structured in a way that participants can decline aspects of the study and still participate in others and 
receive treatment. If families choose not to participate in research, they are provided with the 
standard of care at the BBS and MAC, which includes assessment and treatment services as usual.  
 
Sample Size 
A Monte-Carlo simulation study with 1000 replications, moderate treatment effect (d = 0.5) 𝛼 of 0.05 
and 𝛽 of 0.2, and 25% as the proportion mediated resulted in a required sample size of N = 168. We 
anticipate an attrition rate for both the intervention arm and the waitlist arm to be 20%, so we 
increased our sample size to 202. The Child, Youth and Family Services at CAMH and Maplewoods 
Centre at Guelph receive approximately 400 new child referrals per year within the age range and 
diagnostic criteria, so this target is quite feasible.  
 
Clinical Records 
If a family is eligible and interested in study participation, the research staff will document this in their 
clinical chart after the initial screening. All referrals to the Better Behaviours Service are maintained on 
a clinic waitlist, and referrals to the Mood & Anxiety Clinic are maintained on two waitlists: 
individualized treatment and group treatment. After participants provide informed consent, they will 
be enrolled into the study. Research notes will be generated and added to their clinical charts 
identifying their participation in the study as well as which condition they have been assigned to. 
Additionally, their status in the study (e.g. waitlisted for MATCH-ADTC, waitlisted for treatment, 
currently in treatment), will be identified on the clinic waitlists at the Better Behaviours Service and 
Mood and Anxiety Clinic. The study investigators are clinicians at both clinics so they have oversight of 
the clinic waitlists. Clinicians at the Better Behaviours Service and the Mood and Anxiety Clinic will also 
be involved with administering MATCH-ADTC treatment and treatment as usual, so they will also 
generate notes for the patient’s clinical charts.  
 
Study Inclusion/Exclusion 
Children aged 8 – 15 will be screened for a primary diagnosis of anxiety, depression, or disruptive 
behaviour prior to study enrollment. Parent(s)/caregiver(s) will report on their child’s symptoms, 
behaviours and functioning using the Child Behavior Checklist (CBCL). Children aged 11 – 15 will 
complete the CBCL and the Youth Self Report (YSR). A diagnostic profile will be generated and 
reviewed to determine if the child meets the criteria for a primary diagnosis of anxiety, depression, or 
disruptive behaviour. Comorbidity is expected, and children with comorbid diagnoses will be included 

 
6 
Protocol Version 4.2 Oct 10/24 
in the study. Children who meet the criteria for psychosis, schizophrenia spectrum disorders, eating 
disorders, or autism spectrum disorders will be excluded. Children with low cognitive functioning or 
lack of English proficiency that would prevent active participation in research tasks will be excluded 
from this study. Finally, children who report current suicidality and require immediate hospitalization 
for suicide risk will also be excluded. If a child does not assent to participation, we will not include the 
family in the study.  
 
Parents must be over the age of 18 and have English proficiency (e.g. reading, writing) to be able to 
participate in the study. Parents that do not consent to participation, or withdraw their consent during 
the study will be excluded. PIs may choose to withdraw participants from the study if participants 
express active suicidal ideation requiring acute care or immediate hospitalization. If this does happen, 
participants would not receive the study intervention for the full duration as described in the consent 
form and would be offered alternative care within CAMH/Maplewoods Centre (based on which clinic 
they were recruited from) and/or directed to crisis or emergency services. 
 
Consent and Assent 
Parent(s)/caregiver(s) invited to participate in this research study will be asked to provide informed 
consent before the initial assessment. They will be provided a copy of the informed consent form via 
REDCap, and trained senior lab members will review the consent form with them. Upon clicking the 
link, participants will review the landing page and continue on to the text. The contents of the 
informed consent form will be displayed according to the submitted consent form, minus the 
signature/attestation page. The lab member will explain the purpose of the study, treatment 
intervention, risks, benefits, expected duration, participants’ responsibilities, compensation, 
confidentiality, privacy, and that participation is voluntary. Due to clinician availability, participants 
randomized to MATCH-ADTC will not receive treatment immediately, and will be added to a waitlist 
that will be separately maintained from the clinic’s waitlist. Participants will be informed of the 
estimated duration of the waitlist for both MATCH-ADTC and usual care prior to enrollment in the 
study. Additionally, they will be informed of the benefits and drawbacks of both MATCH-ADTC and 
usual care waitlist. The benefits of MATCH-ADTC are that they will be provided with individualized, 
flexible and tailored treatment. However, MATCH-ADTC is not offered in a group format, which can be 
beneficial for children and parent(s)/caregiver(s). Parent’s and children who choose not to participate 
in the study or who are waiting for usual care (control arm) will be informed of the potential benefits 
of  usual care and that the treatments are typically evidence-based, well-established and structured, 
and can be offered in group or individual formats. Group treatment can be beneficial for children with 
peer difficulties and can benefit parents by having the support of other parent(s)/caregiver(s) with 
similar experiences. If at any point during the study, a participant decides to withdraw from the study, 
additional research visits will not be scheduled, and measures will not be sent. If a participant decides 
to withdraw after having already begun MATCH-ADTC treatment or treatment as usual, they will 
continue to receive treatment. The participant will be given time to ask any questions and review the 
consent form on their own. 
 
Parent(s)/caregiver(s) will be asked to provide consent for themselves and their child:  
• 
Consent to participation in the study  
• 
Consent for their data obtained from previous studies or clinical appointments to be used for 
this study 
• 
Consent to be contacted for future research  

 
7 
Protocol Version 4.2 Oct 10/24 
• 
Consent for their de-identified data to be used for future research 
 
The intention of obtaining data from previous studies or clinical appointments is to reduce the burden 
on participants. It is possible for patients to receive multiple referrals to CAMH at different time 
points. It is also possible for parent(s)/caregiver(s) to have previously participated in research at 
CAMH, but for their children to be new participants. Participants may find it tedious and repetitive to 
complete the same measures at several time points, and certain data collected previously may not 
have to be collected again. At a participants’ initial referral to CAMH, they are asked to complete the 
Child Behavior Checklist and Youth Self Report, which are collected at several time points in this study. 
Obtaining data from their intake assessment could reduce the measurement burden at their initial 
study visit.  
 
Children will be asked to provide assent during the initial assessment. This assent will be obtained by 
trained senior research members. The assent form will be read to the children in the presence of their 
parent(s)/caregiver(s). Children will be given the opportunity to ask questions and to provide assent by 
writing their name on the form. If not able to write or sign, the research member will obtain assent 
orally. Many of the same components of the consent form are captured on the assent form, but the 
language has been altered to use child-friendly vocabulary.  
 
Parent(s)/caregiver(s) will be provided with a complete, signed copy of their informed consent and 
assent form for their reference. The PIs may withdraw participants from the study without their 
consent if they feel that the study is no longer in the participant’s best interest.  
 
Videos will be recorded using an ipadaudio will be recorded via a digital recorder for the purpose of 
transcription, qualitative coding and fidelity checks. Recordings will be transferred via secure file 
transfer to the research team at the University of Guelph for transcription and coding. Once 
transferred, the video and audio recordings on the devices will be deleted from the recording devices 
and will be stored on encrypted hard drives at CAMH and secure servers at Guelph. The folder 
containing all video/audio recordings will be accessible only to members of the research team who 
have received appropriate training. Video and audio recording files will be retained at both sites for 10 
years.  
 
Once a participant agrees to participate in this study and signs the consent form, a research note will 
be generated on their medical record. 
 
Participant Randomization 
Stratified randomization by gender (boy, girl and non-binary) and age group (ages 8 – 10, 11 – 13, 14 - 
15) will be employed to ensure balance in sample size between treatment and control groups with 
regard to gender and age randomization. REDCap will be employed and will allocate the participants 
based on a computer-generated randomization list using random block sizes. Allocation concealment 
will be achieved since the person making this assignment will have no awareness or control over the 
randomization schedule.  
 
Data Collection  
Measurement for this study will be multi-modal and will consist of questionnaires for the 
parent(s)/caregiver(s) and child, behavioural/cognitive tasks, a parent-child interaction task, and 
physiological measures. Data collection will be conducted by trained research staff with the 
supervision of the study investigators. The study investigators will conduct regular meetings with the 

 
8 
Protocol Version 4.2 Oct 10/24 
research staff to review ongoing data collection and ensure that data is collected in a reliable manner.  
 
Parent and child questionnaires will be administered electronically via REDCap In order to ensure 
consistency between the two sites (CAMH and Guelph), we will use a shared REDCap Project to 
administer questionnaires to participants. REDCap questionnaires, behavioural/cognitive tasks, 
parent-child interaction task, and physiological measures will be completed at each study visit. 
Additionally, parents and children  will complete brief weekly questionnaires via secure, encrypted 
links from REDCap.  
 
Parents and children can opt to have their weekly measures sent to them via email or texted to their 
mobile devices via Twilio. Twilio is a widely used third-party SMS provider integrated with the REDCap 
platform. Once the participant clicks on a link to the survey, they will fill out the REDCap survey on 
their mobile device. Participants’ SMS records do not stay on Twilio’s logs, but are removed shortly 
after being completed, for security and privacy purposes. 
 
There will be several in-person study visits throughout the course of this study. All in-person visits are 
dependent on COVID-19 protocols as determined by provincial and CAMH guidelines. All visitors to 
CAMH (during pandemic periods) are required to show proof of vaccination, complete a COVID 
screening and masks are worn at all times. If the situation arises in which in-person visits became 
unfeasible, we would adjust our assessment procedures as necessary.  
 
The initial pre-randomization study visit will be completed shortly after enrollment in the study and 
prior to starting MATCH-ADTC treatment (for those assigned to that condition). Quarterly study visits 
will be conducted at 3-month intervals while the participant is in n the waitlist control arm or in 
MATCH-ADTC treatment. The post-study visit, for those in the waitlist control arm will be conducted 4-
6 months after the initial study visit or prior to them being picked up off the waitlist to be seen for 
usual care (i.e., whichever is sooner). A participant in the treatment condition will be seen for a post-
assessment after  completion of MATCH-ADTC treatment (i.e., usually about 3-6 months).  
 
If a participant becomes uncomfortable or distressed during a study visit, they will be able to take 
breaks as needed or reschedule the study visit to a later date. If a participant becomes significantly 
distressed during an assessment, they will be provided with additional resources for support (e.g. Kids 
Help Phone, What’s Up Walk-In Clinics). A clinician will be available in an on-call capacity to conduct 
risk assessments and provide support (e.g. de-escalation) for participants.  
 
Measures of symptoms, such as the Child Behaviour Checklist, list items that may be indicative of 
imminent risk, such as suicide ideation. If high scores are reported on these items, research staff will 
flag it and discuss the next steps with the principal investigator. If appropriate, the research staff and 
principal investigator will contact the participant, provide them with additional resources, and direct 
them to emergency services.  
 
Overview of Measurement Model 
Primary Construct 
Measurement 
Reporter 
P = Parent;  
C = Child;  
R = Researcher 
Pre/Post 
Weekly/Quarterly 
Child Diagnosis and Symptoms 
Impairment 
Brief Impairment Scale 
P 
x 
 

 
9 
Protocol Version 4.2 Oct 10/24 
(modified)  
 
 
 
Symptoms 
 
Child Behavior Checklist 
(CBCL)  
P 
x 
Quarterly 
Youth Self-Report (YSR)  
C (11 – 15) 
x 
Quarterly 
Top Problems 
Assessment (TPA)  
P, C, R 
x 
Quarterly 
Behavior and Feelings 
Survey (BFS)  
P, C 
x 
Weekly 
 
Trauma 
 
Child and Adolescent 
Trauma Screener (CATS) 
P, C 
Pre-only 
 
Child Biobehavioural Regulation of Negative Emotion 
 
 
Questionnaires 
Child and Adolescent 
Dispositions Scale – 
Negative Emotionality 
(CADS)  
P, C 
x 
Weekly 
Positive and Negative 
Affect Scale (PANAS) 
C 
x 
Quarterly 
 
Physiology 
Heart Rate Variability 
(HRV) 
C 
x 
Quarterly 
Skin Conductance Level 
(SCL)  
C 
x 
Quarterly 
 
 
Behavioural/ 
Cognitive Tasks 
Modified Trier Social 
Stress Test for Children 
(TSST-C)  
C, R 
x 
Quarterly 
Piñata Task 
C, R 
x 
Quarterly 
Cognitive Reappraisal 
Task (CRT)  
C, R 
x 
Quarterly 
Observational Coding of 
Parent-Child Interaction 
P, C, R 
x 
Quarterly 
Parent Functioning, Family Functioning, and Parenting 
 
 
 
 
Parent Functioning 
Brief Symptom Inventory 
(BSI-18)  
P 
x 
 
Parenting Stress Index-
Short Form (PSI-SF) 
P 
x 
 
Difficulties in Emotion 
Regulation Scale Short 
Form (DERS-SF)  
P 
x 
 
Family Functioning 
Family Functioning Style 
Scale (FFSS) 
P 
x 
 
Confusion, Hubbub, and 
Order Scale (CHAOS) 
P 
Pre-only 
 
 
Parenting 
Coping with Children’s 
Negative Emotions Scale 
(CCNES)  
P 
x 
 
Covariates 
Demographics 
Demographics 
P 
Pre-only 
 

 
10 
Protocol Version 4.2 Oct 10/24 
Questionnaire 
Puberty 
Tanner Stages 
Assessment 
P, C 
Pre-only 
 
Medication 
Medication 
Questionnaire 
P 
x 
Quarterly 
Additional Services 
Service Access Form 
P 
x 
 
 
 
Impairment 
BIS18: The Brief Impairment Scale is a global measure of impairment that is completed by the 
parent(s)/caregiver(s) of the child. It consists of 23 items that are not specific to any disorders, but 
measure impairment across 3 domains: interpersonal (parents, siblings, peers), school/work 
(attendance, performance, responsibility), and self-fulfillment (hobbies, enjoyment, self-care). The 
original BIS was intended to be administered by a clinician and referred to the child and 
parent(s)/caregiver(s) using gendered pronouns. For the purposes of this study, we created a modified 
version of the BIS) with gender-neutral language and reduced redundant answer options (e.g. prefer 
not to answer, do not know, is not applicable). The modified BIS will be completed at pre-test, post-
test and at follow up.  
 
Symptoms 
CBCL19: The Child Behavior Checklist (CBCL) will be completed by all parent(s)/caregiver(s) at pre- and 
post-test, quarterly during the intervention/waitlist period, and at follow up. The CBCL collects 
information from adults involved in a child’s life and measures a range of behavioural and emotional 
issues using six scales: affective problems, attention deficit/hyperactivity, anxiety, oppositional-
defiance, somatic problems, and conduct problems20. The items assess syndromes scales 
(anxious/depressed, withdrawn/depressed, somatic problems, social problems, thought problems, 
rule-breaking behaviour, and aggressive behaviours) and DSM-oriented scales (affective problems, 
anxiety problems, somatic problems, attention-deficit/hyperactivity problems, oppositional defiant 
problems, and conduct problems). Additionally, it measures competency in hobbies, social functioning 
and school performance. 
 
YSR21: The Youth Self-Report Form (YSR) will be completed by children aged 11 – 15 at pre- and post-
test, quarterly during the intervention/waitlist period, and at follow up. The YSR consists of 112 items 
and is designed for self-report from children aged 11 – 18. The YSR measures similar constructs as the 
CBCL.  
 
TPA22: The Top Problems Assessment (TPA) is a brief, idiographic procedure that aims to identify the 
most important problems from the perspective of the child and their parent(s)/caregiver(s). The 
assessment will be conducted at pre- and post-test, quarterly during the intervention/waitlist period, 
and at  follow up. At each assessment, the parent(s)/caregiver(s) and child will be asked to identify 
one to three primary issues that they would like to work on in treatment and will rate the severity of 
each problem.  
 
BFS23: The Behavior and Feelings Survey (BFS) is a 12-item scale with parallel versions for the child and 
the parent. The items assess internalizing problems, externalizing problems, and total problems. It 
takes less than 5 minutes to complete and will be completed by the child and parent(s)/caregiver(s) 
each week over the course of the intervention/waitlist period.  
 

 
11 
Protocol Version 4.2 Oct 10/24 
Trauma 
CATS24: The Child and Adolescent Trauma Screener (CATS) is a brief screener of traumatic events and 
symptoms of PTSD. It consists of possible traumatic events (e.g. natural disaster, physical abuse), and 
if one or more are reported to be present, it screens for symptoms of traumatic stress (e.g. 
hyperarousal, nightmares). It has been validated for children aged 7 – 17, and will be completed by 
parent(s)/caregiver(s) at pre-test, post-test, and at follow up.  
 
Biobehavioural Regulation of Negative Emotion Questionnaire 
CADS25: The Child and Adolescent Dispositions Scale (CADS) is a valid and reliable measure that was 
developed to assess the developmental propensity of conduct disorder. The negative emotionality 
subscale consists of 7 items and is reported by the child. The original CADS scale refers to the child as 
he/she. For the purposes of this study, we created a modified version of the CADS with gender-neutral 
language. Children who score highly on negative emotionality items are more likely to be easily upset 
by frustrations and setbacks, to which they respond to with intense anger. It will be completed weekly 
by parent(s)/caregiver(s), and by children who are 9 years or older.  
 
PANAS26: The Positive and Negative Affect Scale (PANAS) is a valid and reliable measure that is 
intended to assess an individual’s moods. It consists of 20 single-word items that are a positive (e.g. 
excited) or negative (e.g. scared) affect. The PANAS will be complete by children at the pre-test, post-
test, quarterly, and follow up assessments. 
 
Behavioural/Cognitive Tasks 
There are four experimental tasks that will be used to assess the child’s behaviour, cognitive processes 
and physiological responses. For the duration of these experimental tasks, the child will be asked to 
wear a BIOPAC compact mobile testing unit, which will collect their heart rate information and skin 
conductance level. Prior to these tasks, the child will sit quietly for 5 minutes to establish their 
baseline physiological responses. 
 
TSST-C27: The Modified Trier Social Stress Test for Children (TSST-C) is a validated behavioural task that 
uses social evaluation, uncontrollability, and unpredictability to induce stress and anxiety28. This task 
will involve the researcher and the child, and will be conducted at pre- and post-test, quarterly during 
the course of treatment and at  follow up. The child will be given 2 minutes to prepare a 5-minute 
speech on a topic given by the researcher (e.g. friendship). The child will then be asked to deliver their 
speech facing a camera. The researcher will record the observed speech performance and the child’s 
self-reported anxiety. Audio and video recordings of the speech will be coded using the Evaluated 
Speech Performance Measure and 25% will be double-coded for inter-rater reliability. Data collected 
from this task will be observed speech performance, self-reported anxiety, and change in heart rate 
and skin conductance.  
 
Piñata Task29: The piñata task is a computerized cognitive task that measures a child’s sensitivity to 
reward. This task will be administered using Inquisit software by Millisecond. It involves the researcher 
and the child, and will be conducted at pre- and post-test, quarterly during the intervention/waitlist 
period and at  follow up. The child will be seated in front of a computer screen and piñatas will appear 
in succession. Each piñata carries a number of stars ranging from 0 – 4, and hitting a key will allow the 
child to collect those stars. The piñata task measures sensitivity to reward through reaction time. A 
child who is slower to hit piñatas with few stars but quick to hit piñatas with several stars is highly 
sensitive to reward. Low sensitivity to reward is related to depression30, whereas high sensitivity can 
be related to behaviour problems, such as risk-tasking behaviours31.  

 
12 
Protocol Version 4.2 Oct 10/24 
 
CRT32: The Cognitive Reappraisal Task is a widely used task for assessing markers of emotional 
reactivity and regulation. This task will involve the researcher and the child, and will be conducted at 
pre- and post-test, quarterly during the intervention/waitlist period and at follow up. Cognitive 
reappraisal involves reinterpreting an emotionally arousing stimulus to alter the intensity of the affect. 
Children will be presented with a series of emotionally arousing images, and for each image they will 
be instructed to “look” or “far”. The instruction to “look” indicates that they should attend to the 
image and allow their emotions to unfold. A child may look at an image of ice cream and feel happy 
and excited at the thought of delicious ice cream. The instruction of “far” for the same image would 
require the child to utilize cognitive strategies to reduce the intensity of their affect. With the example 
of ice cream, a child may think about their least favourite flavours of ice cream to reduce the positive 
affect. Children who are better able to cognitively reappraise negative situations are likely to be better 
at regulating their negative emotions. The CRT task will only be administered for 15 minutes.  
 
Observational Coding of Parent-Child Interaction33: The child and their parent(s)/caregiver(s) will 
participate in a 5-minute conflict discussion task, which will be video-recorded and coded for verbal 
content, and behavioural and facial expressions of emotions. This task will be conducted at pre- and 
post-test, quarterly during the intervention/waitlist period, and at follow up. Behavioural observations 
are the most effective way to assess parent-child interactions. The child and their 
parent(s)/caregiver(s) will be independently asked to list  topics that create conflict in their 
relationship (e.g. homework, chores) and the researcher will select a topic that is relevant to both 
members . The conflict topics will be varied at each assessment to prevent practice effects.  
 
Parent Functioning 
 
BSI34: The Brief Symptom Inventory-18 (BSI-18) is a concise test that measures 3 dimensions: 
somatization (distress caused by bodily dysfunction), depression (anhedonia, suicidal ideation), and 
anxiety (tension, panic). It is very short and easy to administer and has been widely used in both 
clinical and research domains35. It will be completed by the parent(s) of the child at pre- and post-
treatment, and at 1-year follow up.  
 
 
PSI-SF35: The Parenting Stress Index – Short Form (PSI-SF) is a self-report measure of stress in a parent-
child relationship. It consists of 36 items that pertain to the child’s feelings and behaviours, the 
parent’s feelings and behaviours, and their parent-child interactions. The items are categorized in 
subscales: Parental Distress, Parent-Child Dysfunctional Interaction, and Difficult Child. It will be 
completed by parent(s)/caregiver(s). at pre-test, post-test, and at follow up.  
 
DERS36: The Difficulties in Emotion Regulation Scale Short Form (DERS-SF) is a widely used self-report 
measure of emotion regulation ability. Higher scores on the scale reflect greater emotion 
dysregulation. It consists of 36 items that measure 4 facets of emotion regulation: 1) Awareness and 
understanding of one’s emotions (e.g. I am clear about my feelings), 2) Acceptance of one’s emotions 
(e.g. When I’m upset, I believe that my feelings are valid and important), 3) Ability to control impulses 
and behave in accordance with goals in the presence of negative affect (e.g. When I’m upset, I have 
difficulty concentrating), 4) Access to emotion regulation strategies that are effective for feeling better 
(e.g. When I’m upset, I believe that wallowing in it is all I can do). It will be completed by the 
parent(s)/caregiver(s) of the child at pre- and post-test, and at follow up.  
 

 
13 
Protocol Version 4.2 Oct 10/24 
Family Functioning 
FFSS37: The Family Functioning Style Scale is a widely used scale that intends to assess a family’s 
strengths and capabilities when dealing with stress. It is a self-report measure consisting of 26-items 
that measure a family’s unique style of dealing with life events (e.g., In our family we are always 
willing to “pitch in” and help one another). It will be completed by the parent(s)/caregiver(s) of the 
child at pre- and post-test, and at follow up.  
 
Confusion, Hubbub, and Order Scale (CHAOS)38: The CHAOS scale is a 15-item, true or false 
questionnaire that assesses the degree of disorganization and confusion within the home. 7 items 
reflect routine and organization (e.g. At home we can talk to each other without being interrupted), 
and 8 items reflect disorganization and commotion within the home (e.g. It’s a real zoo in our home). 
It will be complete by the parent(s)/caregiver(s) of the child at the pre-test assessment.   
 
Parenting 
CCNES39: The Coping with Children’s Negative Emotions Scale is a self-report assessment which 
presents parent(s)/caregiver(s) with hypothetical scenarios in which their child is upset or angry (e.g. 
My child falls off their bike and breaks it, then gets upset and cries). Each scenario provides 6 possible 
responses to the child’s distress and the parent(s)/caregiver(s) are asked to rate their likelihood of 
utilizing that response. Each response represents a different way of responding to a child’s distress. It 
will be completed by the parent(s)/caregiver(s) of the child at pre- and post-test, and follow up.   
 
Covariates 
Prior to treatment, demographic information (e.g. child’s age, sex, gender identity, ethnicity, 
language) will be provided by the child’s parent(s)/caregiver(s). Demographic information is important 
for data analysis purposes and will allow us to identify any different patterns of treatment responses 
in different groups (e.g. treatment response in male children compared to treatment response in 
female children). Parents will report on their country of birth and their child’s country of birth, as 
parents and children born outside of Canada often face immigration difficulties, cultural adjustment 
issues, and language barriers. Additionally, this allows us to evaluate the representativeness of our 
sample compared to the Canadian population. Information will be collected from the participants’ 
health record on the number of sessions attended, and will be included as a control variable.  
 
The parent(s)/caregiver(s) and child will report on the child’s pubertal development, as indicated by 
the Tanner Stages Assessment40. Information on pubertal development is needed because puberty can 
influence the physiological measures of emotion regulation being used in this study (e.g., heart rate 
variability). Parent(s)/caregiver(s) will report on their child’s medication status pre- and post-test, at 
follow up, and quarterly during the course of treatment. To assess for satisfaction with treatment, 
parent(s)/caregiver(s) will complete the Youth Services Satisfaction Survey for Families410. 
 
At the post-test assessment, families in to the usual care condition will complete the Service Access 
Form to report any external services (e.g. couples therapy, psychoeducational assessment) they 
accessed while on the waitlist for usual care, or participating in usual care. It is common for families to 
be waiting for treatment from multiple services, or to seek private therapy while they are on our 
clinic’s waitlist. This which will allow us to evaluate any pre-post change that may be due to those 
services. Families in the intervention condition will report on their access and use of external services 
at their 1-year follow up assessment.  
 
Physiological Measures 

 
14 
Protocol Version 4.2 Oct 10/24 
Heart rate variability (HRV) and skin conductance level (SCL) will be measured using the widely used, 
non-invasive, compact mobile testing unit from BIOPAC. This unit consists of two transmitter modules 
and a transducer (attached to two nylon belts and electrods) that transmits physiological data to the 
BioNomadix Logger (BN-Logger), which is a battery-operated, wearable physiological recording 
platform capable of digitally storing signals for long periods of time. The comfortable system will be 
worn by the child as a bracelet and two belts for duration of the Trier Social Stress Test, the Pinata 
Task, Cognitive Reappraisal Task and Parent-Child Interaction.  
 
 
MATCH Treatment  
The intervention arm of this project will consist of a transdiagnostic psychotherapy treatment: The 
Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems 
(MATCH-ADTC42).  
 
Two randomized effectiveness trials have demonstrated MATCH’s effectiveness against usual care and 
standard treatment protocols (Cohen’s ds from .47 to .55)43-44. MATCH draws from various domains of 
evidence-based treatment and consists of 33 treatment modules. There are several core module 
sequences for problem areas such as depression, anxiety, trauma, or disruptive behaviour and a 
clinician can utilize these sequences based on the primary concern for the individual. MATCH 
treatment usually ranges from 4 – 6 months, but the duration is flexible and dependent on the 
individual’s needs. If an individual reports additional stressors or comorbid conditions, the clinician 
can modify the sequence of the modules to address these comorbidities. For example, if a child has 
been referred for the treatment of conduct problems, the clinician may utilize behavioural parent 
training, rewards, and time outs. If the child were to further report depressive symptoms, the clinician 
could incorporate modules from the depression pathway, such as problem solving and cognitive 
restructuring. MATCH treatment is flexible and can be tailored for each individual, so it is highly 
effective45.  
 
Clinicians administering MATCH-ADTC treatment will be asked to complete a Therapist Background 
Questionnaire46, which asks about their training, educational background, and experience with child 
psychotherapy. They will have regular team meetings with the principal investigators (Andrade, 
Aitken, Thomassin) to discuss the implementation of the MATCH treatment program. These 
consultation meetings – which will not entail clinical supervision – are to support the implementation 
of MATCH with high fidelity. Brief consultation notes will be documented. All information shared at 
these meetings will be de-identified and personal health information will only be discussed on an as 
needed basis (e.g. age, sex, mental health concerns). To establish treatment alliance, adherence, and 
fidelity, therapy sessions will be audio recorded. A randomly selected 20% of the sessions will be 
coded for fidelity using the Therapist Integrity in Evidence Based Interventions and Therapy Process 
Observational Coding System – Alliance Scale 47. Clinicians will complete weekly session notes and 
fidelity checks, and at discharge of each MATCH-ADTC client, clinicians will complete the Therapist 
Satisfaction Index48.  
 
Control Group 
Previous studies involving randomized waitlist controlled studies have established that MATCH-ADTC 
treatment is more effective than usual care. The justification of the control arm in this study is to allow 
us to evaluate the changes in biobehavioural regulation as a consequence of MATCH-ADTC treatment. 
The waitlist control exists to support our hypothesis that changes in emotion regulation are not 
merely due to the passage of time or normal emotional/psychological development in children.  

 
15 
Protocol Version 4.2 Oct 10/24 
The control arm of this project will consist of a no-treatment, waitlisted group. Participants in the 
waitlist condition will remain on the waitlist for standard usual care, and the estimated wait time is 
approximately 4-9 months. While in the waitlist control arm, participants are required to complete 
75% of the weekly measures and attend both the quarterly (3-month) and the post-test study visit. If 
participants decide not to continue with the study, or they are lost to follow-up, they will be 
considered a drop-out in the Big Feelings Study, but their referral will remain open for usual care and 
they will remain on the clinic waitlist. Upon completion of the post-assessment, participants in the 
waitlist condition will be offered a bridging treatment (usually  MATCH-ADTC treatment) until their 
usual care standard treatment spot becomes available, at which point they can decide whether they 
would like to continue with the bridging treatment or move to the standard care. Therefore, 
participants assigned to the control arm will also receive high quality, evidence-based treatment.  
 
 
Compensation 
Children and their parent(s)/caregiver(s) will be compensated for their participation. They will be 
provided with gift cards at each study visit and for completion of the weekly surveys. If participants 
are only able to complete the questionnaires, they still receive a portion of honorarium (see table, 
where the amount for “questionnaires” indicate how much participants can receive as honorarium for 
partial completion). 
 
 
Pre-Test Visit 
Weekly 
Surveys 
Quarterly 
Visit(s)  
Post-Test Visit 
 
Parent 
$30 
questionnaires 
only  
 
$40 both 
questionnaires 
and in person 
visits 
$2 per survey 
 
$5 bonus for 
every 5 
completed 
$30 
questionnaires 
only  
 
$40 both 
questionnaires 
and in person 
visits 
$30 
questionnaires 
only  
 
$60 both 
questionnaires 
and in person 
visits 
 
Child 
$10 
questionnaires 
only  
 
$15 both 
questionnaires 
and in person 
visits 
$2 per survey 
 
$5 bonus for 
every 5 
completed 
$10 
questionnaires 
only  
 
$15 both 
questionnaires 
and in person 
visits 
$10 
questionnaires 
only  
 
$25 both 
questionnaires 
and in person 
visits 
 
 
Risks 
There are minimal risks for participation in this study. The physiological measures (heart rate and skin 
conductance) are collected using a widely used, non-invasive, compact mobile testing unit that is worn 
like a bracelet and two belts attached to electrodes. Children may feel mild discomfort from the 
electrodes attached to the skin, and taking the electrodes off may feel like taking a “Band-Aid” which 
might be uncomfortable for some children.  
 
However, parent(s)/caregiver(s) and children are shown all equipment and are encouraged to try 
putting on and peeling off the electrodes from the back of their hand prior to outfitting the child with 

 
16 
Protocol Version 4.2 Oct 10/24 
the equipment. If either the parent(s)/caregiver(s) or the child are not comfortable with the 
equipment and electrodes, they can choose to remove it at any time (as addressed in both the 
consent and assent process).  
 
The assessment measures are validated and reliable, and have previously been used in large-scale 
studies. The only identifiable risk is that participants may find some of the questions to be difficult to 
discuss and stress inducing, such as questions about trauma. Participants can decline specific 
questions or questionnaires if they would prefer not to answer.  
 
Benefits 
Participation in this study has several potential benefits for the participants. If they are assigned to the 
MATCH-ADTC condition, they will receive an evidence-based treatment that has been shown to be 
highly effective. Additionally, there will be weekly check-ins and regular assessments with the 
waitlisted participants, which is not usually provided for clients on the waitlist. 
 
Data Analysis 
Preliminary analyses will test for significant differences in demographic factors between the MATCH 
and waitlist groups; significant factors will be covaried in our models. In the unlikely event that 
medication discrepancies are discovered between the two treatment groups, we will equate the 
groups by imposing propensity scores-based weighting in the analysis. An exploratory factor analysis 
(EFA) will examine whether the emotion regulation variables load onto a broad latent construct. 
Variables that do not load on the same factor will be examined independently within our mediation 
models. Latent Growth Curve (LGC) mediation modeling, which will account for the nested structure 
of the data as well as potentially unequally spaced time points, will test whether improvements in 
emotion regulation mediate improvements in symptoms as a result of MATCH treatment. We will 
conduct two types of mediation analyses corresponding to our operationalization of treatment 
response – pre-post change and trajectory of change. First, emotion regulation (latent biobehavioural 
regulation factor(s) from the EFA) will be modeled as a latent change from baseline to the 3-month 
quarterly assessment, and symptom change (CBCL/YSR internalizing and externalizing scores) will be 
modeled as a latent change from baseline to the post assessment. Our predictor will be specified as 
MATCH vs. Waitlist to ensure we can derive conclusions about the impact of MATCH on emotion 
regulation and symptoms. To test the mediated effect, we will apply the recommended bootstrap-
based product of coefficients, which will yield bias-corrected 95% CIs based on the recommended 
asymmetric CI method. Second, to understand trajectories of change during MATCH treatment, we 
will apply LGC modeling to examine latent slopes of change in emotion regulation (weekly CADS) and 
symptoms (weekly BFS) and explore the temporal relations between the two trajectories. This will 
allow us to understand the temporal order and bi-directionality of changes in regulation and 
symptoms. In both modeling approaches, we will co-vary child age, gender/sex, medication use, 
puberty status, ethnicity, and treatment fidelity. We will apply an intent-to-treat approach and full 
information maximum likelihood estimation to account for potential bias caused by missing data.  
 
In Aim 2, we will use machine learning techniques to uncover associations between biobehavioural 
indicators of emotion regulation (i.e., parent- and child-report questionnaires, performance on 
behavioural and cognitive tasks, physiological reactivity, and family factors) and treatment response 
(i.e., trajectory of symptom change). Association rule mining will identify patterns of observed values 
in our emotion regulation indicators that are significantly related to treatment response by looking for 
frequencies of co-occurrence of the specific indicator and response values that are significantly 
different than that expected under random chance. This is calculated by the Haberman residual and 

 
17 
Protocol Version 4.2 Oct 10/24 
provides a z-score indicating the likelihood of random occurrence of an observation. Together, these 
significant co-occurrences, or “patterns”, (i.e., those not occurring due to chance or noise) will provide 
a model of the data that can be used to predict treatment response trajectories. We will follow 
recommended nested cross-validation which validates patterns by examining the pattern discovery 
across a set of cross-validation trials. Participant data will be allocated in round-robin fashion into N 
sets. We will use 10-fold cross-validation such that a “fold” is created by using one set only for testing, 
and dividing the remaining between training and parameter validation. This allows unseen validation 
data to determine the efficacy of the discovered patterns obtained from the “training” sets and allows 
detection of overfitting using the validation sets. This process is then repeated whereby each fold is 
used only once for model testing, which will also allow us to assess the stability of the patterns 
discovered across the collection of training and validation exercises. Overfitting of the process is 
properly managed through this cross-validation strategy. In addition, we have addressed overfitting by 
employing association mining (versus, for example, convolutional neural networks) because it is 
associated with a much lower risk of overfitting (Hamilton-Wright & Stashuk, 2009) and provides a 
simple statistical measure of rule significance. To establish the power of these patterns, we will use 
information theory to score each one, describing how much support each pattern has within the 
overall distribution of the data. This allows us to distinguish patterns based on richly described regions 
of the data distribution from those with sparse support. The result is a confidence value associated 
with assertions made about treatment response using the patterns, indicating whether there is high 
confidence (based on well characterized regions of the data) or poor confidence (based on rare or 
conflicting regions of the data). Altogether, significant and meaningful rules and associated 
confidences are assembled into a rule-based framework that will allow characterizations (i.e., 
predictions) to be made, in new cases, describing the likely treatment response trajectory based on 
emotion regulation indicators. As one example, the algorithm could reveal that when child arousal 
(i.e., skin conductance level) is above a certain threshold, treatment response is slow, and that the 
framework’s confidence in this characterization is 90%. Such a result would suggest that child arousal, 
when above a certain threshold, is a key regulation component in treatment response, that there is a 
high amount of evidence within the system for this characterization, and that it would be worthwhile 
to consider when tailoring psychotherapy. The resulting set of significant and meaningful association 
rules, or algorithms, will be applied to a predictor system,80 which will form the basis of bidirectional 
and iterative conversations with KT users and partners about applying the algorithms to a clinical 
decision-making framework.  
 
Knowledge Translation 
In Aim 3, we will translate findings from Aim 2 by engaging clinical leaders in the CAMH CYEAP. Once 
data have been collected, discussions will involve reviewing and refining the rule-based algorithms 
from our machine learning analyses. Through a bidirectional and iterative process, we will develop a 
clinical decision-making framework that applies these rules to predict treatment trajectories. We will 
also engage with community stakeholders, particularly families with lived experience as caregivers for 
children with mental health difficulties. We will also engage in broader information dissemination and 
KT uptake of our findings to academic (e.g., international conferences, peer-reviewed publications) as 
well as clinical (e.g., clinicians, trainees) and community audiences (e.g., family partners). One 
expected outcome of our research will be knowledge gained about transdiagnostic mechanisms of 
change in child psychotherapy for emotional and behavioural problems. This knowledge will be 
disseminated to clinicians and trainees at CYEAP and CPS through invited talks, trainings, newsletters, 
and web platforms. We will also leverage existing knowledge dissemination activities and outlets such 
as monthly rounds that are well-attended by both clinicians and researchers, newsletters, and the 

 
18 
Protocol Version 4.2 Oct 10/24 
Portico Network, a collection of evidence-based resources for mental health and addiction 
professionals provided by CAMH. 
 
References 
 
1. Fergusson, D. M., & Woodward, L. J. (2002). Mental health, educational, and social role outcomes of 
adolescents with depression. Archives of General Psychiatry, 59, 225–231 
2. Masten, A. S., Roisman, G. I., Long, J. D., Burt, K. B., Obradovic´, J. R., Boelcke-Stennes, K., et al. (2005). 
Developmental cascades: Linking academic achievement and externalizing and internalizing symptoms 
over 20 years. Developmental Psychology, 41, 733–746. 
3. Marchette, L.K., Thomassin, K., Hersh, J., MacPherson, H.A., Santucci, L., Weisz, J.R. (2019). Community 
Mental Health Settings. In T.H. Ollendick, S.W. White, & B.A. White (Eds.) The Oxford Handbook of 
Clinical Child and Adolescent Psychology. 
4. Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M.,... & Weersing, V. R. (2017). What five 
decades of research tells us about the effects of youth psychological therapy: a multilevel metaanalysis 
and implications for science and practice. American Psychologist, 72, 79-117. 
5. Masi, G., Muratori, P., Manfredi, A., Lenzi, F., Polidori, L., Ruglioni, L., ... & Milone, A. (2013). Response 
to treatments in youth with disruptive behavior disorders. Comprehensive Psychiatry, 54, 1009-1015. 
6. Hollenstein, T., McNeely, A., Eastabrook, J., Mackey, A., & Flynn, J. (2012). Sympathetic and 
parasympathetic responses to social stress across adolescence. Developmental Psychobiology, 54, 207-
214 
7. Kreibig, S. D. (2010). Autonomic nervous system activity in emotion: A review. Biological Psychology, 
84, 394-421. 
8. Davis, M., Thomassin, K., Bilms, J., Suveg, C., Shaffer, A., & Beach, S.A. (2017). Preschoolers’ genetic, 
physiological, and behavioral susceptibility factors moderate links between parenting stress and 
internalizing, externalizing, and sleep problems. Developmental Psychobiology, 59, 473-485. 
9. El-Sheikh, M., & Erath, S. A. (2011). Family conflict, autonomic nervous system functioning, and child 
adaptation: State of the science and future directions. Development and Psychopathology, 23, 703-
721. 
10. McLaughlin, K. A., Alves, S., & Sheridan, M. A. (2014). Vagal regulation and internalizing 
psychopathology among adolescents exposed to childhood adversity. Developmental Psychobiology, 
56, 1036-1051. 
11. Payne, L. A., Ellard, K. K., Farchione, T. J., Fairholme, C. P., & Barlow, D. H. (2014). Emotional disorders: 
A unified transdiagnostic protocol. In D. H. Barlow (Ed.), Clinical handbook of psychological disorders: A 
step-by-step treatment manual (pp. 237-274). New York, NY, US: The Guilford Press 
12. Lahey, B. B., Krueger, R. F., Rathouz, P. J., Waldman, I. D., & Zald, D. H. (2017). A hierarchical causal 
taxonomy of psychopathology across the life span. Psychological Bulletin, 143, 142-186. 
13. Haltigan, J. D., Aitken, M., Skilling, T., Henderson, J., Hawke, L.,... & Andrade, B. F. (2018). “P” and “DP:” 
Examining symptom-level bifactor models of psychopathology and dysregulation in clinically referred 
children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, 57, 384-
396. 

 
19 
Protocol Version 4.2 Oct 10/24 
14. Aitken, M., Battaglia, M., Marino, C., Mahendran, N., & Andrade, B. F. (2019). Clinical utility of the CBCL 
Dysregulation Profile in children with disruptive behavior. Journal of Affective Disorders, 253, 87 - 95. 
15. Weisz, J. R. (2015). Promoting youth self-regulation through psychotherapy: Redesigning treatments to 
fit complex youth in clinical care. In G. Oettingen & P.M. Gollwitzer. Self-Regulation in Adolescence, 
311-332. 
16. Sloan, E., Hall, K., Moulding, R., Bryce, S., Mildred, H., & Staiger, P. K. (2017). Emotion regulation as a 
transdiagnostic treatment construct across anxiety, depression, substance, eating and borderline 
personality disorders: A systematic review. Clinical Psychology Review, 57, 141-163. 
17. Bain, S. K., & Jaspers, K. E. (2010). Review of Kaufman Brief Intelligence Test, Second Edition. Journal of 
Psychoeducational Assessments 28 (2), 67 – 174.   
 
18. Bird,  H. R., Canino, G. J., Davies, M., Ramirez, R., Chavez, L., Duarte, C. & Shen, S. (2005). The Brief 
Impairment Scale (BIS): A Multidimensional Scale of Functional Impairment for Children and 
Adolescents. Journal of American Academy of Child & Adolescent Psychiatry 44 (7), 699 – 707 
19. Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms & Profiles. 
Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. 
20. Coulacoglou, C., & Saklofske, D. H., (2017). The Assessment of Family, Parenting, and Child Outcomes. 
In Psychometrics and Psychological Assessment (pp. 187 – 222). Academic Press. 
21. Achenbach, T. M. & Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms & Profiles. 
Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. 
22. Herren, J., Garibaldi, P., Evans, S. C., & Weisz, J. R. Youth Top Problems Assessment Manual. Harvard 
University. 
23. Weisz, J. R., Vaughn-Coaxum, R. A., Evans, S. C., Thomassin, K., Hersh, J., Lee, E. H., Ng, M. Y., Lau, N., 
Raftery-Helmer, J. N., & Mair, P. (2019). Efficient monitoring of treatment response during youth 
psychotherapy: Development and psychometrics of the behavior and feelings survey. Journal of Clinical 
Child and Adolescent Psychology.  
 
24. Sachser, C., Berliner, L., Holt, T., Jensen, T. K., Jungbluth, N., Risch, E., Rosner, R., & Goldbeck, L. (2017). 
International development and psychometric properties of the Child and Adolescent Trauma Screen 
(CATS). Journal of Affective Disorders, 210, 189 – 195.  
25. Lahey, B. B., Applegate, B., Chronis, A. M., Jones, H. A., Williams, S. H., Loney, J., & Waldman I. D. 
(2008). Psychometric Characteristics of a Measure of Emotional Dispositions Developed to Test a 
Developmental Propensity Model of Conduct Disorder. Journal of Clinical Child & Adolescent 
Psychology, 37 (4) 794 – 807.  
26. Watson, D. Clark, L. A., Tellegen, A. (1988). Development and validation of brief measures of positive 
and negative affect: The PANAS scales. Journal of Personality and Social Psychology, (54), 1063 – 1070.  
27. Buske-Kirschbaum, A., Jobst, S., Wustmans, A., Kirschbaum, C., Rauh, W., & Hellhammer, D. (1997). 
Attenuated Free Cortisol Response to Psychosocial Stress in Children with Atopic Dermatitis. 
Psychosomatic Medicine 59, 419 – 426.  
28. Dickerson, S. S., & Kemeny, M. E. (2004). Acute stressors and cortisol responses: a theoretical 
integration and synthesis of laboratory research. Psychological Bulletin 130 (3), 355 – 391.  

 
20 
Protocol Version 4.2 Oct 10/24 
29. Helfinstein, S. M., Kirwan, M. L., Benson, B. E., Hardin, M. G., Pine, D. S., Ernst, M., & Fox, N. A. (2013). 
Validation of a child-friendly version of the monetary incentive delay task. Social Cognitive and 
Affective Neuroscience 8 (6) 720 – 726.  
30. Forbes, E. E., Hariri, A. R., Martin, S. L., Silk, J. S., Moyles, D. L., Fisher, P. M., Brown, S. M., Ryan, N. D., 
Birmaher, B., Axelson, D. A., & Dahl, R. E. (2009). Altered Striatal Activation Predicting Real-World 
Positive Affect in Adolescent Major Depressive Disorder. American Journal of Psychiatry 166 (1), 64 – 
73.  
31. Steinberg, L. (2008). A Social Neuroscience Perspective on Adolescent Risk-Taking. Developmental 
Review 28 (1), 78 – 106. 
32. Silvers, J.,  Weber, J., Wager, T. D., & Oschner, K. N. (2015). Bad and worse: neural systems underlying 
reappraisal of high- and low-intensity negative emotions. Social Cognitive and Affective Neuroscience 
10 (2), 172 – 179.  
33. Eisenberg, N., Hofer, C., Spinrad, T. L., Gershoff, E. T., Valiente, C., Losoya, S. H., Zhou, Q., Cumberland, 
A., Liew, J., Reiser, M., & Mason, E. (2008) Understanding mother-adolescent conflict discussions: 
concurrent and across-time prediction from youths’ dispositions and parenting. Monographs of the 
Society for Research in Child Development 73 (2), 1 – 160.  
34. Andreu, Y., Galdon, M. J., Dura, E., Ferrando, M., Murgui, S., Garcia, A., & Ibanez E. (2008). 
Psychometric properties of the Brief Symptoms Inventory-18 (BSI-18) in a Spanish sample of 
outpatients with psychiatric disorders. Psichothema 20 (4), 844 – 850.  
35. Abidin, R. R. (1983). Parenting Stress Index – manual. Charlottesville, Virginia: Pediatric Psychology 
Press. 
36. Hallion, L. S., Steinman, S. A., Tolin, D. F., & Diefenbach, G. J. (2018). Psychometric Properties of the 
Difficulties in Emotion Regulation Scale (DERS) and Its Short Forms in Adults with Emotional Disorders. 
Frontiers of Psychology, 9 (539), 1 – 12.  
 
37. Trivette, C. M., Dunst, C. J., Deal, A. G., Hamer, A. W. & Propst, S. (1990) Assessing Family Strengths 
and Family Functioning Style. Topics in Early Childhood Special Education 10 (1), 16 – 35. 
 
38. Dumas, J. E., Nissley, J., Nordstrom, A., Smith, E. P., Prinz, R. J. & Levine, D. W. (2005). Home Chaos: 
Sociodemographic, Parenting, Interactional, and Child Correlates. Journal of Clinical Child and 
Adolescent Psychology, 34 (1), 93 – 104.  
39. Fabes, R. A., Poulin, R. E., Eisenberg, N., Madden-Derdich, D. A. (2002). The Coping with Children’s 
Negative Emotions Scale (CCNES): Psychometric Properties and Relations with Children’s Emotional 
Competence. Marriage & Family Review 34 (3 – 4), 285 – 310.  
40. Feingold, David. “Pediatric Endocrinology” In Atlas of Pediatric Physical Diagnosis, Second Edition, 
Philadelphia. W.B. Saunders, 1992, 9, 16 – 19.  
41. Riley, S. E., Stromberg, A. J., & Clark, J. (2005). Assessing parental satisfaction with children’s mental 
health services with the youth services survey for families. Journal of Child and Family Studies, 14, 87 – 
99. 
42. Chorpita, B. F., & Weisz, J. R. (2009). MATCH-ADTC: Modular Approach to Therapy for Children with 
Anxiety, Depression, Trauma or Conduct Problems. Satellite beach, FL: PracticeWise.  
 

 
21 
Protocol Version 4.2 Oct 10/24 
43. Chorpita, B. F., Daleiden, E. L., Park, A. L., Ward, A. M., Levy, M. C., Cromley, T.,… & Krull, J. L. 2017). 
Child STEPs in California: A cluster randomized effectiveness trial comparing modular treatment with 
community implemented treatment for youth with anxiety, depression, conduct problems, or 
traumatic stress. Journal of Consulting and Clinical Psychology, 85, 13. 
 
44. Weisz, J. R., Chorpita, B. F., Palinkas, L. A., Schoenwald, S. K., Miranda, J., Bearman, S. K., …Gibbons, R. 
D., and the Research Network on Youth Mental Health. (2012). Testing standard and modular designs 
for psychotherapy with youth depression, anxiety, and conduct problems: A randomized effectiveness 
trial. Archives of General Psychiatry, 69, 274–282. 
45. Chorpita, B. F., & Weisz, J. R. (2009). MATCH-ADTC: Modular Approach to Therapy for Children with 
Anxiety, Depression, Trauma or Conduct Problems. Satellite beach, FL: PracticeWise. 
 
46. Bearman, S. K., Herren, J., & Weisz, J. R. (2012). Therapy Integrity in Evidence Based Interventions: 
Observational Coding System, Coding Manual. Austin: University of Texas at Austin.                                                                       
 
47. McLeod, B. D., & Weisz, J. R. (2005). The Therapy Process Observational Coding System-Alliance Scale: 
Measure Characteristics and Prediction of Outcome in Usual Clinical Practice. Journal of Consulting and 
Clinical Psychology, 73, 323 – 333.  
 
48. Addis, M. E., & Krasnow, A. D. (2000). A National Survey of Practicing Psychologists’ Attitudes toward 
Psychotherapy Treatment Manuals. Journal of Consulting and Clinical Psychology, 68, 331-339.