Adjunctive Deep Transcranial Magnetic Stimulation (dTMS) for Managing Emotional Dysregulation in Children and Adolescents with Externalizing Behavior Disorders: An Open-label Trial

Abstract

Background:

High-frequency deep transcranial magnetic stimulation (dTMS) targeting the Anterior Cingulate Cortex (ACC) and Medial Prefrontal Cortex (mPFC) has demonstrated effectiveness in modulating emotional experiences; however, its potential in children and adolescents with externalizing behavior disorders (EBDs) remains unexplored. We aimed to evaluate the safety and efficacy of adjunctive high-frequency dTMS on emotional regulation in children and adolescents with EBDs.

Methods:

Fifteen participants with EBDs experiencing emotional regulation challenges completed this study. During the three weeks, participants received 15 sessions of dTMS. Assessments were conducted at baseline and posttreatment using the Difficulty in Emotional Regulation Scale (DERS), Modified Overt Aggression Scale (MOAS), Affective Reactivity Index (ARI), Barrett Impulsivity Scale (BIS), and Clinical Global Impressions Severity Scale (CGI-S). A side effect checklist was administered after each session to monitor adverse events.

Results:

We observed a significant improvement in emotional regulation, as well as other clinical variables. A significant reduction in DERS score (≥50%) was achieved (p < .001), indicating substantial improvement in emotional dysregulation. Clinical remission, (defined as CGI-S ≤3) was attained (p < .001) with a number needed to treat (NNT) of 2. These results indicate the putative potential of dTMS as an adjuvant intervention for this population.

Conclusions:

The findings of this study suggest a potential role for dTMS as an adjunctive intervention in managing emotional dysregulation in children and adolescents with EBDs, contributing to a promising approach to the existing therapeutic repertoire for this population. Further research with larger sample sizes and a sham-controlled design is needed to support these findings.

Keywords

Anterior cingulate cortex child and adolescent deep transcranial magnetic stimulation (dTMS)externalizing behavior disorders neuromodulation

Key Messages:

This study aimed to investigate the efficacy and safety of dTMS for the treatment of emotional dysregulation in children and adolescents with EBDs.

dTMS lead to significant improvement (p < .001, NNT = 2), with good safety profile.

Findings may contribute to expanding treatment options for emotional dysregulation in children and adolescents with EBDs.

Externalizing behavior disorders (EBDs) involve challenges with impulse control, resulting in rule-breaking, aggressive behavior, impulsivity, and inattention.¹ The DSM-5 disorders of attention-deficit/hyperactivity disorder, conduct disorder (CD), oppositional defiant disorder (ODD), disruptive mood dysregulation disorders (DMDD), mood disorders, and substance use are included in this construct.² Prevalence ranges from 7% to 10%^{3, 4} and strongly predicts the development of impulse control disorders in adulthood, such as substance use disorders and antisocial personality disorders.^{5, 6}

The conceptualization of externalizing behavior has evolved to emphasize its link with emotional processes, recognizing emotion regulation as a core mechanism.⁷ Emotion regulation involves monitoring, analyzing, and altering emotional reactions to attain goals and includes both implicit and explicit strategies for regulating emotions.⁸ The Medial Prefrontal Cortex (mPFC), specifically the Ventromedial Prefrontal Cortex (vmPFC) and the Subgenual Anterior Cingulate Cortex (sgACC), together with other salient regions in the anterior and mid- insula, play a key role in implicit emotion regulation.^{9, 10} The mPFC regions are speculated to interact with important limbic structures, including the amygdala and ventral striatum, to produce regulatory effects, such as reducing negative affect.¹¹ Dysfunctional emotional regulation could lead to failure in handling strong, unpleasant, or enduring emotional states that are bothersome for the adolescent and may result in maladaptive coping behavior, such as self-harm, behavior addiction, and substance use.^{12, 13}

Transcranial magnetic stimulation (TMS) is a non-invasive technique that modulates cortical excitability by depolarizing neuronal membranes using extracranial magnetic fields,¹⁴ and may be a new therapeutic tool for emotion regulation intervention. Preliminary research has demonstrated that repetitive transcranial magnetic stimulation (rTMS) is beneficial in treating treatment-resistant depression in children and adolescents, with long-term follow-ups showing no worsening of symptoms or cognitive performance.^{15, 16} In an open trial, 1 Hz rTMS to the L-DLPFC resulted in considerable benefits, with few side effects.¹⁷ TMS research shows that the Bilateral dorsolateral prefrontal cortex (DLPFC) and VLPFC are functionally specialized in controlling negative emotions, underscoring their role in emotional regulation.¹⁸

The existing treatment for EBDs has limitations; thus, it is necessary to look for newer strategies to address these issues, especially in the younger population. Since dTMS stimulates deeper regions such as the Anterior Cingulate Cortex (ACC) and mPFC, which are primarily involved in emotional regulation, it may be a novel non-invasive treatment option for adolescents with EBDs, given its favorable side effect profile. Therefore, the current study attempts to examine the efficacy and safety of adjunctive dTMS on emotional dysregulation in children and adolescents with EBDs. We aimed to evaluate the effectiveness and safety of adjunctive high-frequency dTMS on emotional regulation in children and adolescents with EBDs.

Methods

Study Setting

The study was conducted at Erna Hoch Centre for Child and Adolescent Psychiatry, CIP, Ranchi and K. S. Mani Centre for Cognitive Neurosciences, CIP, Ranchi. The data collection period was from April 1, 2023, to May 15, 2024. Subjects aged 12–18 years of both genders scoring above the cut-off for externalizing behavior, as measured by Child Behavior Checklist (CBCL),¹⁹ were additionally diagnosed with DSM-5 for either attention deficit/hyperkinetic disorder (ADHD), ODD, CD, DMDD, mood disorders (except for those having psychotic symptoms), and substance use were included. Subjects with neurological or medical disorders, developmental delays, and intellectual disability were excluded.

Eighteen patients were assessed for eligibility. Two patients did not meet the criteria for EBDs on the CBCL and were dropped at the beginning. One patient dropped out due to premature discharge from the center. Fifteen patients completed the entire study duration. As determined by the treatment team, patients were kept on a stable dosage of psychotropics throughout the study period.

Tools

The CBCL/6–18 is a tool designed primarily to assess school-age children’s emotional, behavioral, and social functioning during the previous six months to assess externalizing behaviors. On a 3-point Likert scale, 0 represents not true, 1 represents somewhat or occasionally true, and 2 represents very true or often true. Scale scores, including total competence, total adaptive functioning, and total difficulties, have test-retest reliability coefficients ranging from 0.91 to 0.95.¹⁹

Difficulty in Emotional Regulation Scale (DERS),²⁰ was used to assess improvements in emotional regulation. It is a self-report tool comprising 36 items, created to evaluate clinically significant challenges in emotion regulation. Respondents use a Likert scale for indicating the frequency with which each item applies to them, with responses ranging from 1 (almost never) to 5 (almost always). Higher scores on the scale indicate increased challenges in emotion regulation. The evaluation covers six clinically significant aspects of emotion dysregulation: difficulty maintaining goal-directed behavior during emotional arousal, limited emotional awareness, restricted access to emotion regulation techniques, lack of emotional clarity, and nonacceptance of emotional responses. During the scale’s development, it was noted that DERS had adequate validity, a reliable test-retest measure, and good internal consistency.²⁰

Modified Overt Aggression Scale (MOAS)²¹ and Affective Reactivity Index (ARI)²² was used to assess reductions in aggression and irritability, respectively. The MOAS is a four-item Likert rating scale used to measure and document the “frequency and severity” of aggressive episodes. Evaluation of verbal aggression, aggression directed toward objects, aggression toward oneself, and aggression toward others is all included in it. The MOAS has good internal consistency and exceptional inter-rater reliability.²¹ The ARI comprises six symptom items and one impairment item focused on irritability. The basic concept of irritability, a state marked by easily irritated and touchy behavior, frequently coupled with wrath and outbursts of temper, was the basis for the content selection of these items.²² Scores ranging from 0 to 2 are allocated to each item. The first six items’ scores are added up to determine the final score; the seventh item, which is classified as an impairment item, is examined separately. In both parent- report and self-report versions, the ARI constitutes a single factor and has exceptional internal consistency.²²

Barrett’s Impulsivity Scale (BIS),²³ was used to evaluate a decrease in impulsivity. This self-report measure consists of 30 items. Items are scored to yield six first-order factors (attention, motor, self-control, cognitive complexity, perseverance, and cognitive instability impulsiveness) and three second-order factors (attentional, motor, and non- planning impulsiveness).

Clinical Global Impressions Severity Scale (CGI-S),²⁴ was used to assess the severity of illness. It is a 7-point Likert scale, where the severity of illness is indicated by responses ranging from 1 (normal) to 7 (among the most severely ill patients). The symptoms, behavior, and function observed and reported over the last seven days form the basis of this assessment. The score should represent the average severity level over seven days, as it is evident that symptoms and behavior might change for a week.

Design/Intervention

Clinical ratings were completed at baseline prior to the onset of dTMS (day one) and three weeks after the conclusion of dTMS sessions. Ours was an open-label trial. The BrainsWay dTMS system was used to administer stimulation, which comprises four main components: an electromagnetic H-Coil, a TMS stimulator, a cooling system, and a positioning arm. The dTMS system is connected to the H7 coil, which is housed inside a helmet. Both high-and low-frequency pulses can be delivered through the coil, and a variety of parameters, such as frequency, train length, train duration, and time duration, can be altered.

An electromyography (EMG) system was used to measure the resting motor threshold (RMT). To measure the motor evoked potential (MEP), the EMG’s active electrode will be positioned on both tibialis anterior muscles. The scalp was stimulated with an H7 TMS coil, which was rotated posteriorly along the sagittal plane. The stimuli were gradually increased until a noticeable twitch in both muscles was observed. The minimal TMS intensity required to elicit a predetermined MEP in the contralateral abductor pollicis brevis in at least 50% of trials²⁵ is known as the motor threshold. The patient wore the helmet with the H7 dTMS coil, which was set to provide maximum stimulation to the ACC and mPFC. Following the previous studies on adult ADHD,¹¹ treatment was delivered at 100% of RMT, 18 Hz with a train duration of 2 seconds (for 40 trains per session) and an inter-train interval of 20 seconds. Considering the safety and tolerability in the young population, the stimulus intensity was kept at 100% of RMT instead of 120% as mentioned in previous studies. A total of 1,440 pulses were delivered per session per day. A total of 15 sessions were delivered over three weeks by trained clinicians. The stimulation parameters and the assessments were carried out according to our previously published protocol.²⁶

The TMSens_Q,²⁶ a TMS side effect checklist, was used to track any side effects during each session. The TMS Adverse Events and Associated Sensations Questionnaire²⁷ was created through a Delphi procedure with international TMS experts and is intended to record secondary effects after TMS application. Monitoring the safety of TMS in our study will be significantly aided by the regular use of this standardized TMS questionnaire and the continuous reporting of unwanted TMS effects. This is especially helpful for putting new procedures into practice and improving comprehension of experimental findings.

Ethical Considerations

The ethics approval of the study was obtained from the Institute Ethics Committee of the xxx, xxxx, xxx. Assent and written informed consent were obtained from the participants and their parents.

Statistical Analysis

The Statistical Package for Social Sciences, version 27.0 (SPSS-27.0) for Windows→, was used to analyze the data. Descriptive statistics were used to analyze this sample’s clinical and demographic features. A paired t-test was conducted to assess changes in clinical scales pre-and postintervention. A level of significance (P) of .05 (two-tailed) was taken. Response rate and remission were defined as ≥50% reduction in DERS score and ≤3 CGI-S score, respectively, and the number needed to treat (NNT) was calculated to evaluate clinical significance.

Primary Outcome Variables

Safety of dTMS in young subjects as assessed by TMS adverse events and associated sensation questionnaire (TMSens_Q).

Secondary Outcome Variables

Reduction in the scores of the DERS, BIS, ARI, (MOAS), and CGI-S.

Results

Fifteen patients completed 15 sessions of dTMS each over a period of more than three weeks. There was a history of substance use in 30% of the participants. Most of the subjects received a diagnosis of CD and bipolar disorder, followed by other diagnoses such as ODD and ADHD (Table 1). The mean age of the subjects was 14.73 years, with a standard deviation of 1.83. The disorder had an early onset, as evidenced by the mean age of illness onset of 11.87 ± 2.30 years. The average length of illness was 3.00 ± 1.06 years, corresponding to the baseline stage of illness progression (Table 1). Table 1 depicts the baseline sociodemographic and clinical characteristics of subjects.

Table 1.

Baseline Sociodemographic and Clinical Characteristics of Subjects (N = 15).

Variables		n (n%)/Mean ± SD
Sex	Male	10 (66.7)
Sex	Female	5 (33.3)
Religion	Hindu	11 (73.3)
Religion	Muslim	4 (26.7)
Diagnosis	Conduct disorder	6 (40)
	Bipolar disorder	6 (40)
	Other	3 (20)
Substance use	Present	3 (20.0)
Substance use	Absent	12 (80.0)
Clinical characteristics	Age (in years)	14.73 ± 1.83
	Age of onset (in years)	11.87 ± 2.30
	Duration of illness (in years)	3.00 ± 1.06

Improvement in outcome measures is presented in Table 2. Our study’s mean baseline DERS score was 58.53 (SD = 10.34), which decreased significantly to 20.9 (SD = 11.98) after three weeks of dTMS treatment. This reduction attests to a marked improvement in the participants’ capacity to manage their emotions, demonstrating the efficacy of dTMS in addressing emotional dysregulation. In our study, the mean baseline rating MOAS subscale for verbal aggression was 3.20 (SD = 0.94), which decreased to 1.20 (SD = 0.41) following three weeks of dTMS treatment. The baseline rating for the MOAS subscale concerning aggression against property was also 3.20 (SD = 0.94), and this dropped to 0.00 (SD = 0.00) after three weeks of dTMS treatment. The initial score for the MOAS subscale related to auto-aggression was 2.13 (SD = 1.12), and after three weeks of treatment, it changed to 0.13 (SD = 0.35). The baseline score for the MOAS subscale for physical aggression stood at 1.93 ± 0.88, which reduced to 0.00 (SD = 0.00) after three weeks of therapy. There was a noteworthy decrease observed in all MOAS subscales after three weeks of dTMS treatment.

For impulsivity, following three weeks of dTMS therapy, the Attentional Facet I score dropped from 15.87 (SD = 3.06) to 8.73 (SD = 2.01), and the baseline score for Attentional Facet II dropped from 8.33 (SD = 2.84) to 4.47 (SD = 1.35). The Motor Aspect I score declined from 20.60 (SD = 3.43) at baseline to 11.40 (SD = 2.44), and the Motor Facet II score reduced from 6.20 (SD = 1.08) to 4.67 (SD = 1.11), after treatment. Likewise, the Planning Facet I score went from 19.26 (SD = 2.15) at baseline to 12.40 (SD = 2.89), and the Planning Facet II score dropped from 14.80 (SD = 2.62) to 9.80 (SD = 2.98) after treatment. The significant reduction in scores post-dTMS treatment indicates a promising effect of the intervention on impulsivity facets. In our study, the mean baseline ARI subscale, parent score was 10.8 (SD = 2.36), which after three weeks of dTMS treatment had reduced to 3.20 (SD = 1.56). The mean baseline ARI subscale self-score was 7.67 (SD = 2.38), which after three weeks of dTMS treatment was 2.27 (SD = 1.67). All patients had a significant reduction in irritability after three weeks of treatment. In our study, the mean baseline CGI-S score was 5 (SD = 0.75), which after three weeks of dTMS treatment was 1.73 (SD = 0.70). A significant improvement was observed in symptom severity after three weeks of dTMS treatment.

Out of 15 participants, three had reported a history of substance use. During the intervention duration, these participants remained abstinent with no reports of continued or new substance use given by the caregiver on clinical follow-ups.

Table 2 shows improvement in symptoms as assessed by DERS, MOAS, BIS, ARI, and CGI-S (N = 15) using the paired t-test.

Table 2.

Improvement in Symptoms as Assessed by DERS, MOAS, BIS, ARI, and CGI-S (N = 15) Using the Paired-T test.

Variable	Time	Treatment Group (n = 15) Mean ± SD	t (df = 14)	p
DERS	Baseline	58.53 ± 10.34	16.80	<.001***
DERS	Week 3	20.93 ± 11.98	16.80	<.001***
MOAS Verbal aggression	Baseline	3.20 ± 0.94	9.16	<.001***
MOAS Verbal aggression	Week 3	1.20 ± 0.41	9.16	<.001***
MOAS Aggression against property	Baseline	3.20 ± 0.94	13.17	<.001**
MOAS Aggression against property	Week 3	.00 ± .00	13.17	<.001**
MOAS Auto aggression	Baseline	2.13 ± 1.12	7.75	<.001***
MOAS Auto aggression	Week 3	0.13 ± 0.35	7.75	<.001***
MOAS Physical aggression	Baseline	1.93 ± 0.88	8.47	<.001***
MOAS Physical aggression	Week 3	0.00 ± 0.00	8.47	<.001***
BIS Attentional facet I	Baseline	15.87 ± 3.06	9.07	<.001***
BIS Attentional facet I	Week 3	8.73 ± 2.01	9.07	<.001***
BIS Attentional facet II	Baseline	8.33 ± 2.84	5.50	<.001***
BIS Attentional facet II	Week 3	4.47 ± 1.35	5.50	<.001***
BIS motor facet I	Baseline	20.60 ± 3.43	14.69	<.001***
BIS motor facet I	Week 3	11.40 ± 2.44	14.69	<.001***
BIS motor facet II	Baseline	6.20 ± 1.08	3.94	.001
BIS motor facet II	Week 3	4.67 ± 1.11	3.94	.001
BIS planning facet I	Baseline	19.26 ± 2.15	12.64	<.001***
BIS planning facet I	Week 3	12.40 ± 2.89	12.64	<.001***
BIS planning facet II	Baseline	14.80 ± 2.62	6.40	<.001***
BIS planning facet II	Week 3	9.80 ± 2.98	6.40	<.001***
ARI parent	Baseline	10.80 ± 2.36	13.016	<.001***
ARI parent	Week 3	3.20 ± 1.56	13.016	<.001***
ARI self	Baseline	7.67 ± 2.38	9.96	<.001***
ARI self	Week 3	2.27 ± 1.67	9.96	<.001***
CGI-S	Baseline	5 ± 0.75	14.39	<.001***
CGI-S	Week 3	1.73 ± 0.70	14.39	<.001***

P < .05; **P < .01; ***P < .001.

DERS: Difficulty in Emotional Regulation Scale, MOAS: Modified Overt Aggression Scale, ARI: Affective Reactivity Index, BIS: Barrett Impulsivity Scale, CGI-S: Clinical Global Impressions Severity Scale.

dTMS safety and tolerability were monitored after each session using TMSens_Q, a TMS side effect checklist. Two patients reported scalp discomfort during the initial few sessions. One patient reported headaches at the beginning of sessions for the first four sessions (Table 3). There were no adverse effects that required stopping treatment. There were no other significant or incapacitating adverse effects noted. With the proper safeguards, TMS is safe and tolerated in children and adolescents. Table 3 shows the frequency of side effects among 15 patients. The most commonly reported side effect was scalp discomfort, experienced by 13.3% of patients. A headache was reported by 6.6% of the patients, while the majority, 80%, did not experience any side effects. Table 4 depicts the number needed to treat for response and remission (by three weeks) in the active group.

Table 3.

Side Effects Observed.

Side Effects	Number of Patients (Out of 15)	%
Headache	1	6.6
Scalp discomfort	2	13.3
None	12	80

Table 4.

Number Needed to Treat for Response and Remission (by Three Weeks) in the Active Group.

S. No.	Variable	Outcome Definition	ARR (95% CI)	NNT (95% CI)
1	Response	DERS >50% Reduction from baseline	63.3 (47.7 to 78.9)	2 (1.27 to 2.86)
2	Remission	CGI-S ≤ 3	56.0 (41.1 to 70.9)	2 (1.41 to 4.3)

ARR: Absolute risk reduction, DERS: Difficulty in emotional regulation scale, CGI-S: Clinical Global Improvement-Severity Scale, Confidence interval, NNT: Number needed to treat.

In this study, dTMS resulted in significant reductions in impulsivity and improvements in clinical results. Specifically, 63.3% of participants experienced a ≥50% decrease in DERS scores, indicating a significant positive response, with an NNT of 2 (Table 4). A 50% DERS response rate was selected as the clinical significance criterion for this investigation. A 50% improvement is a sign of significant therapeutic success in psychiatric studies, consistent with this criterion.²⁸ 56.0% of participants achieved remission, a CGI-S score of ≤3, with an NNT of 2. This implies that treating two patients will yield one additional favorable outcome. These findings illustrate considerable clinical improvement, underscoring the efficacy of dTMS in diminishing impulsivity and improving overall clinical results.

Discussion

Despite the increasing research on interventions for externalizing behavior problems in adolescence, these interventions remain only moderately effective and have variable treatment responsiveness.²⁹ This underscores the need for new and effective treatment for these disorders. There has recently been growing agreement that addressing the underlying causes of many internalizing and externalizing symptoms transcending diagnostic boundaries may be more advantageous than preventing and treating specific diagnostic issues.³⁰ Emotion regulation is one such concept that has attracted a remarkable amount of attention within the transdiagnostic approach.³¹ Difficulties in emotion regulation are not limited only to internalizing disorders; instead, an increasing amount of data indicates that the difficulties with the regulation of emotions are found in a wide range of disorders, including substance abuse, ADHD, and CDs.³¹

A cognitive control model of ER states that its neural implementation is the consequence of interactions between the (ACC) and prefrontal cortical regions and their impact on subcortical structures, specifically the amygdala.³² Abnormal neuronal activity in limbic and emotion regulatory regions, along with a reduced capacity to adaptively control affect and stress, are hallmarks of mood and anxiety disorders.³³

A tDCS study targeting the mPFC was found to modulate subjective negative emotional experience by altering activity and connectivity in emotion regulation circuits, particularly involving the vmPFC, sgACC, and limbic regions.³³ (DLPFC) repetitive stimulation using TMS has been shown to help with emotional dysregulation in borderline personality disorder and may have therapeutic applications.³⁴ Therefore, mPFC stimulation might serve as the foundation for non-invasive therapeutic interventions that support the systems involved in emotion regulation.³⁵

In our open-label pilot study, significant improvement was observed in emotional regulation, the key mechanism underlying EBDs, along with significant improvements seen in aggression, impulsiveness, and irritability in all patients. The stimulation protocol was well tolerated with minimal side effects, such as headaches and scalp discomfort. This study adds to the increasing amount of evidence demonstrating the role of the mPFC and ACC in the modulation of emotional experiences, which holds promise for the development of neuroscience-guided treatments for disorders linked to emotional dysregulation, even though our findings must be regarded as preliminary due to the open-label design.

Limitations

The important limitations of our study include its small sample size, the absence of a sham control group, and the absence of objective markers to measure improvement using techniques such as task-based MRI (fMRI). These factors necessitate a cautious interpretation of the results and underscore the need for future research with larger, controlled designs.

Conclusions

The study has demonstrated a reduction in emotional dysregulation, impulsivity, irritability, and aggression in children and adolescents with EBDs using dTMS. While the findings suggest the role of ACC and mPFC in emotional dysregulation, the results need to be interpreted with caution, considering the lack of a sham control and a small sample size. Moving forward, further investigations with rigorous methodologies will be crucial in establishing the efficacy and safety of TMS as a therapeutic intervention for children and adolescents with EBDs. Such advancements hold the potential to significantly enhance the quality of life for individuals affected by these disorders, as well as to alleviate the societal and economic burdens associated with untreated EBDs.

Supplemental Material

Supplemental material for this article available online.

Supplemental Material

Supplemental material for this article available online.

Footnotes

Acknowledgements

The authors are truly grateful to the young subjects and their guardians who supported the study.

Consent to Participate

After a complete description of the study to the subjects and guardians, written informed consent/assent was obtained as approved by the Institute’s ethics committee.

Consent for Publication

Not applicable.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Declaration Regarding the Use of Generative AI

None Used.

Ethical Considerations

This study was approved by the Institute Ethics Committee (Registration No: ECR/891/Inst/JH/2016) on 09/02/2023. All participants provided written informed consent/assent prior to enrollment in the study. This research was conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Prior Presentations

None.

Registration

The trial has been prospectively registered in Clinical Trial Registry-India (CTRI) on www.ctri.nic.in, bearing CTRI registration number: CTRI/2023/03/050701.

Simultaneous Submission to Another Journal or Resource

No.

References

Samek

and Hicks

. Externalizing disorders and environmental risk: Mechanisms of gene-environment interplay and strategies for intervention. ClinPract (Lond), 2014; 11(5): 537–547.

American Psychiatric Association. Disruptive, impulse-control, and conduct disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. DSM Library. American Psychiatric Association; 2013.

Burt

, Krueger

, McGue

, . Sources of covariation among attention-deficit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder: The importance of shared environment. J Abnorm Psychol, 2001; 110(4): 516–525.

Kessler

, Berglund

, Demler

, . Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 2005; 62(6): 593–602.

Babinski

, Hartsough

and Lambert

. Childhood conduct problems, hyperactivity-impulsivity, and inattention as predictors of adult criminal activity. J Child Psychol Psychiatry, 1999; 40(3): 347–355.

Elkins

, McGue

and Iacono

. Prospective effects of attention-deficit/hyperactivity disorder, conduct disorder, and sex on adolescent substance use and abuse. Arch Gen Psychiatry, 2007; 64(10): 1145–1152.

Koole

and Rothermund

. “I feel better, but I don’t know why”: The psychology of implicit emotion regulation. CognEmot, 2011; 25(3): 389–399.

Gyurak

, Gross

and Etkin

Explicit and implicit emotion regulation: A dual-process framework. CognEmot, 2011; 25(3): 400–412.

Adamaszek

, D’Agata

, Ferrucci

, . Consensus paper: Cerebellum and emotion. Cerebellum, 2017; 16(2): 552–576.

10.

Bai

, Dokos

, Ho

, . A computational modelling study of transcranial direct current stimulation montages used in depression. Neuroimage, 2014; 87: 332–344.

11.

Bleich-Cohen

, Gurevitch

, Carmi

, . A functional magnetic resonance imaging investigation of prefrontal cortex deep transcranial magnetic stimulation efficacy in adults with attention-deficit/hyperactive disorder: A double-blind, randomized clinical trial. Neuroimage Clin, 2021; 30: 102670.

12.

Waugh

. The roles of positive emotion in the regulation of emotional responses to negative events. Emotion, 2020; 20(1): 54–58.

13.

Van Beveren

, Goossens

, Volkaert

, . How do I feel right now? Emotional awareness, emotion regulation, and depressive symptoms in youth. Eur Child Adolesc Psychiatry, 2019; 28(3): 389–398.

14.

Pell

, Roth

and Zangen

Modulation of cortical excitability induced by repetitive transcranial magnetic stimulation: Influence of timing and geometrical parameters and underlying mechanisms. Prog Neurobiol, 2011; 93(1): 59–98.

15.

Donaldson

, Gordon

, Melvin

, . Addressing the needs of adolescents with treatment-resistant depressive disorders: A systematic review of rTMS. Brain Stimul, 2014; 7(1): 7–12.

16.

Mayer

, Aviram

, Walter

, . Long-term follow-up of adolescents with resistant depression treated with repetitive transcranial magnetic stimulation. J ECT, 2012; 28(2): 84–86.

17.

Gómez

, Vidal

, Morales

, . Low frequency repetitive transcranial magnetic stimulation in children with attention deficit/hyperactivity disorder: Preliminary results. Brain Stimul, 2014; 7(5): 760–762.

18.

Zhao

, Mo

, Bi

, . The VLPFC versus the DLPFC in downregulating social pain using reappraisal and distraction strategies. J Neurosci, 2021; 41(7): 1331–1339.

19.

Achenbach

. International findings with the Achenbach System of Empirically Based Assessment (ASEBA): Applications to clinical services, research, and training. Child Adolesc Psychiatry Ment Health, 2019; 13: 30. DOI: 10.1186/s13034-019-0291-2.

20.

Gratz

and Roemer

Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. J Psychopathol Behav Assess, 2004; 26: 41–54.

21.

Oliver

, Crawford

, Rao

, . Modified Overt Aggression Scale (MOAS) for people with intellectual disability and aggressive challenging behaviour: A reliability study. J Appl Res Intellect Disabil, 2007; 20(4): 368–372.

22.

Stringaris

, Goodman

, Ferdinando

, . The affective reactivity index: A concise irritability scale for clinical and research settings. J Child Psychol Psychiatry, 2012; 53(11): 1109–1117.

23.

Patton

, Stanford

and Barratt

. Factor structure of the Barratt impulsiveness scale. J Clin Psychol, 1995; 51(6): 768–774.

24.

Guy

. ECDEU assessment manual for psychopharmacology. US Department of Health, Education, and Welfare, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, Psychopharmacology Research Branch, Division of Extramural Research Programs; National Institute of Mental Health, 1976.

25.

Rossini

, Barker

, Berardelli

, . Non-invasive electrical and magnetic stimulation of the brain, spinal cord, and roots: Basic principles and procedures for routine clinical application. Report of an IFCN committee. Electroencephalogr Clin Neurophysiol, 1994; 91(2): 79–92.

26.

Shukla

, Sharma

, Roy

, . Safety and efficacy of deep transcranial magnetic stimulation for management of emotional dysregulation in children and adolescents with externalizing behavior disorders: Protocol of a transdiagnostic sham-controlled fMRI study. Indian J Psychol Med. 2024. DOI: 10.1177/02537176241231027.

27.

Giustiniani

, Vallesi

, Oliveri

, . A questionnaire to collect unintended effects of transcranial magnetic stimulation: A consensus-based approach. Clin Neurophysiol, 2022; 141: 101–108.

28.

Hett

, Rogers

, Humpston

, . Repetitive transcranial magnetic stimulation (rTMS) for the treatment of depression in adolescence: A systematic review. J Affect Disord, 2020; 277: 651–663. DOI: 10.1016/j.jad.2020.09.058.

29.

te Brinke

, Schuiringa

, Menting

ATA

, . A cognitive versus behavioral approach to emotion regulation training for externalizing behavior problems in adolescence: Study protocol of a randomized controlled trial. BMC Psychol, 2018; 6: 49. DOI: 10.1186/s40359-018-0261-0.

30.

Dalgleish

, Black

, Johnston

, . Transdiagnostic approaches to mental health problems: Current status and future directions. J Consult Clin Psychol, 2020; 88(3): 179–195. DOI: 10.1037/ccp0000482.

31.

Aldao

, Gee

, De Los Reyes

, . Emotion regulation as a transdiagnostic factor in the development of internalizing and externalizing psychopathology: Current and future directions. Dev Psychopathol, 2016; 28(4pt1): 927–946. DOI: 10.1017/S0954579416000638.

32.

Barreiros

, Almeida

, Baía

, . Amygdala modulation during emotion regulation training with fMRI-based neurofeedback. Front Hum Neurosci, 2019; 13: 89. DOI: 10.3389/fnhum.2019.00089.

33.

Abend

, Sar-El

, Gonen

, . Modulating emotional experience using electrical stimulation of the medial-prefrontal cortex: A preliminary tDCS-fMRI study. Neuromodulation, 2019; 22(8): 884–893. DOI: 10.1111/ner.12787.

34.

Smits

, Schutter

DJLG

, van Honk

, . Does non-invasive brain stimulation modulate emotional stress reactivity?. Soc Cogn Affect Neurosci, 2020; 15(1): 23–51. DOI: 10.1093/scan/nsaa011.

35.

Molavi

, Aziziaram

, Basharpoor

, . Repeated transcranial direct current stimulation of dorsolateral-prefrontal cortex improves executive functions, cognitive reappraisal emotion regulation, and control overemotional processing in borderline personality disorder: A randomized, sham-controlled, parallel-group study. J Affect Disord, 2020; 274: 93–102.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.28 MB

0.04 MB