Think and Act Cool: A Cognitive Versus Behavioral Approach to Emotion Regulation Training for Externalizing Behavior Problems in Adolescence

Interventions for adolescents with externalizing behavior problems are generally found to be only moderately effective, and treatment responsiveness is variable. Therefore, this study aims to increase intervention effectiveness by examining effective approaches to train emotion regulation, which is considered to be a crucial mechanism involved in the development of externalizing behavior problems. Specifically, we aim to disentangle a cognitive and behavioral approach to emotion regulation training.

We hypothesize that the Think Cool Act Cool emotion regulation training is effective in improving emotion regulation skills and decreasing externalizing behavior problems, compared to care-as-usual. We also hypothesize that the training has a small effect on mood variability and comorbid internalizing problems. In addition, we compare the contrasting hypotheses that the cognitive (Think Cool) module is more effective than the behavioral (Act Cool) module or vice versa and hypothesize that completing both modules is more effective than completing only one module. In addition, we compare the contrasting hypotheses that it is more effective to first receive the cognitive module and secondly the behavioral module (sequence Think Cool + Act Cool) or vice versa (sequence Act Cool + Think Cool). We expect that overall, emotion regulation mediates the effect of the Think Cool Act Cool training on externalizing behavior problems. In particular, we expect that behavioral emotion regulation mediates the effect of the Act Cool module on externalizing behavior problems and that both cognitive emotion regulation and social information processing mediate the effects of the Think Cool module. Regarding moderation effects, we expect that overall, the Think Cool Act Cool training is more effective for adolescents who report higher levels of affective reactivity, and for adolescents whose parents show more acceptance and less rejection. In addition, we expect that the Think Cool module is more effective for adolescents with higher intelligence, whereas the Act Cool module is more effective for adolescents with lower intelligence. Finally, we expect that higher treatment integrity is related to increased effectiveness.

If participants meet the inclusion criteria, they are randomly assigned to either the intervention or the control condition. Randomization takes place at the individual level, by means of computer-generated random numbers. Adolescents, their parents and teachers will obviously notice the condition in which they are participating, so allocation will not be blind. Nevertheless, participants will not be aware of the fact that we examine the difference between two training sequences. Subsequently, adolescent download a questionnaire application on their smartphone and start with the weekly and daily questionnaires. First, a 3-week baseline of the weekly measure (see measures section) will be established. Moreover, adolescents fill in the first Daily Diary measure on five consecutive days. In addition, adolescents, their parents and teachers complete the baseline measures at T1, the first of three assessments. The adolescent questionnaires and tasks are administered individually at school by a trained research assistant at each assessment point. Adolescents fill out the questionnaires on a computer. Teachers fill out the questionnaires on paper. Parents are sent links to the questionnaires via email.

Participants in the intervention condition start with either the cognitive module (Think Cool) or the behavioral module (Act Cool). After five weeks, in which participants in the intervention condition follow five individual therapy sessions, all participants, parents and teachers complete the T2 measures. Next, there is a 3-week training break, which allows us to measure possible delayed effects. During the training break, all participants continue to fill in the weekly questionnaire and fill in the second Daily Diary measure. Subsequently, participants in the intervention condition follow the second module (Think Cool or Act Cool, depending on the first module), which also consists of five individual sessions. Eventually, the post-test measures are completed by all participants at T3. There also is a 3-week post-measure of the weekly measure, in which participants also complete the third Daily Diary measure.

Participants in the intervention condition will receive 11 individual 45-minute sessions of the Think Cool Act Cool emotion regulation training. This is a manualized experimental training, that is designed based on components of evidence-based treatments for adolescents with externalizing behavior problems, such as Coping Power and Aggression Replacement Training. The training is provided at the school of the participant, by a trained clinician with a background in child psychology.

Before the actual modules, participants start with an introduction session, in which they get to know the trainer, the content of the training, and set personal goals. Next, participants first receive either the Think Cool module or the Act Cool module, followed by the other module. Both modules consist of five individual sessions. In both modules, adolescents are instructed to make daily at-home assignments, the “anger thermometer logbook”, in which they briefly describe in which situations they became angry and what strategies they used to regulate their anger and solve the issues. The situations they describe in the logbook are used in the training sessions as practice material. If adolescents do not complete the at-home assignment, clinicians use other situations from adolescents’ lives.