Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article addresses a highly relevant and still often underestimated topic in the ADHD literature, namely the central role of emotion dysregulation and emotion regulation difficulties in children and adolescents. The decision to provide a narrative review focused on psychosocial interventions represents a useful and timely contribution, especially considering the limited number of studies specifically targeting these outcomes.

The organization of the review is particularly appreciable, as it clearly distinguishes between transdiagnostic interventions (CBT, UP-C/A, DBT, ACT, and mindfulness-based interventions) and interventions specifically developed for youth with ADHD. This structure facilitates readability and helps the reader better understand the level of evidence available for each approach.

The section dedicated to DBT is particularly strong and interesting, especially because of its attention to individual variability in treatment response and the focus on subgroups of patients with higher baseline levels of emotion dysregulation. This clinical perspective has important practical implications.

It would be useful to further expand the discussion on the role of positive emotion dysregulation, which is introduced in the introduction as an emerging area but receives less attention in the subsequent sections. Considering the recent studies cited (McQuade et al., 2024, 2025), a more in-depth discussion of this aspect could significantly enrich the manuscript.

It could also be valuable to include a more detailed reflection on the relationship between pharmacological treatments and psychosocial interventions for emotion regulation. Although the review explicitly focuses on non-pharmacological approaches, a brief integrative section on the potential complementarity between these two treatment modalities could enhance the clinical relevance of the paper.

The review appropriately highlights the limited number of studies involving adolescents with ADHD; however, it would be helpful to discuss more explicitly the possible methodological and clinical reasons behind this gap (for example, difficulties in engagement, reduced family involvement, and greater symptom heterogeneity).

Table 1 is a very useful summary tool; its usability could be further improved by adding a column dedicated to the “level of empirical evidence” or by more clearly distinguishing interventions in which ER/ED outcomes are the primary focus from those in which these outcomes are secondary.

Overall, the manuscript is well written, up to date, and clinically relevant. It provides an important foundation for future research and for the development of more targeted interventions aimed at improving emotion regulation in youth with ADHD, an area that certainly deserves greater attention both in research and in clinical practice.

Author Response

Comment 1. The article addresses a highly relevant and still often underestimated topic in the ADHD literature, namely the central role of emotion dysregulation and emotion regulation difficulties in children and adolescents. The decision to provide a narrative review focused on psychosocial interventions represents a useful and timely contribution, especially considering the limited number of studies specifically targeting these outcomes.

Response 1: We appreciate the reviewer acknowledging the importance of this topic and the appropriateness of a narrative review to discuss the existing literature for psychosocial interventions.

Comment 2. The organization of the review is particularly appreciable, as it clearly distinguishes between transdiagnostic interventions (CBT, UP-C/A, DBT, ACT, and mindfulness-based interventions) and interventions specifically developed for youth with ADHD. This structure facilitates readability and helps the reader better understand the level of evidence available for each approach.

Response 2: We are delighted to hear that the reviewer found the organization of our review to be strong and helpful in terms of readability.

Comment 3. The section dedicated to DBT is particularly strong and interesting, especially because of its attention to individual variability in treatment response and the focus on subgroups of patients with higher baseline levels of emotion dysregulation. This clinical perspective has important practical implications.

Response 3: We are glad to hear the reviewer found this section to be interesting and to have important clinical implications.

Comment 4. It would be useful to further expand the discussion on the role of positive emotion dysregulation, which is introduced in the introduction as an emerging area but receives less attention in the subsequent sections. Considering the recent studies cited (McQuade et al., 2024, 2025), a more in-depth discussion of this aspect could significantly enrich the manuscript.

Response 4: We thank the reviewer for raising this important point. We now discuss this more in the revised discussion and use the RELAX intervention as an example of how most content may focus on negative emotions, but can be modified to work with and target positive ED (page 13).

Comment 5. It could also be valuable to include a more detailed reflection on the relationship between pharmacological treatments and psychosocial interventions for emotion regulation. Although the review explicitly focuses on non-pharmacological approaches, a brief integrative section on the potential complementarity between these two treatment modalities could enhance the clinical relevance of the paper.

Response 5: We agree with this important suggestion and have added a paragraph discussing this and mentioning some recent and promising evidence regarding the benefits of pharmacological treatments for ED/ER in youth with ADHD.

Comment 6. The review appropriately highlights the limited number of studies involving adolescents with ADHD; however, it would be helpful to discuss more explicitly the possible methodological and clinical reasons behind this gap (for example, difficulties in engagement, reduced family involvement, and greater symptom heterogeneity).

Response 6: We appreciate this recommendation and have added in discussion of why this might be including those suggested by you and CBT-based interventions not originally being designed for individuals with ADHD and thus manuscripts either not providing information on co-occurrence of these diagnoses or trying to exclusively select for internalizing samples (page 14).

Comment 7. Table 1 is a very useful summary tool; its usability could be further improved by adding a column dedicated to the “level of empirical evidence” or by more clearly distinguishing interventions in which ER/ED outcomes are the primary focus from those in which these outcomes are secondary.

Response 7: Thank you for this suggestion. In the revised manuscript, we have added a column to note whether ER/ED outcomes are a primary focus of the intervention. To help address other concerns regarding organization the prior last column now provides citations for studies of the various treatment approaches with youth with ADHD (even if ER/ED was not an outcome) and then the final column notes how/if ER/ED was assessed (Table 1).

Comment 8. Overall, the manuscript is well written, up to date, and clinically relevant. It provides an important foundation for future research and for the development of more targeted interventions aimed at improving emotion regulation in youth with ADHD, an area that certainly deserves greater attention both in research and in clinical practice.

Response 8: Thank you again for this generally positive review of our manuscript. We are appreciative of the feedback and suggestions you have provided and believe addressing these have improved the overall revised manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

This narrative review addresses a clinically important and timely topic—psychosocial interventions targeting emotion regulation and emotion dysregulation in youth with ADHD. The summary table is a useful contribution. However, the manuscript still requires substantial revisions.

Abstract

Add a brief sentence specifying scope/selection approach, even for a narrative review, to anchor readers in methodology.

Introductio

The brief mention of positive emotion dysregulation (McQuade et al., 2024, 2025) is welcome but underdeveloped; revisit in the Discussion to flag whether reviewed interventions actually target positive ED.

A short "Scope and Approach" subsection is needed: how studies were identified, what counts as "ER-relevant," and why a narrative (vs. systematic) format was chosen.

Transdiagnostic section

The phrase "UP-C is one of the primary ER transdiagnostic interventions in youth" is awkward

.

CBT subsection

The conclusion that CBT effects on ER are "comparatively underpowered" is sound but could be strengthened by explicitly distinguishing trials where ER was a primary vs. secondary endpoint.

DBT subsection

The null SSTG primary findings (Meyer et al., 2020) and positive moderator findings (Meyer et al., 2022) sit in tension; please more explicitly frame this as a hypothesis-generating signal rather than confirmatory evidence.

ACT subsection

Given the very small evidence base (n = 6 studies in Munawar et al., 2021), conclusions should be tempered. Several sentences currently read more affirmatively than the evidence warrants.

Mindfulness subsection

Wong et al. (2023) is described in the text but absent from Table 1 under MYmind; please add and ensure consistency between text and table.

ADHD-specific section, p. 7. Typo: "Beyond these transdiagnostic interviews" should read "interventions."

Table 1. Multiple cells are incomplete or have formatting issues (CBT row lacks age range/session count/studies; UP-C/A row lacks the studies column; DBT cell layout merges sub-interventions confusingly). Recommend rebuilding the table with a consistent schema.

References

Diaz citation. Text cites "Diaz, 2025"; reference list shows "Diaz, Y. (2015). 87.1 Incorporating…" with a 2025 DOI. Reconcile the year and verify the source (appears to be a 2025 JAACAP conference abstract).

Linehan (2025) and Chronis-Tuscano (2016). Verify the dating of Linehan's DBT Skills Training Manual; the two Chronis-Tuscano 2016 entries (refs 23, 24) require "2016a/2016b" disambiguation in the text.

Discussion

"Hoffman, 2014" in text vs. "Hofmann" in reference list (#51).

Author transparency regarding RELAX is appropriate. However, the RELAX subsection reads more enthusiastically than comparably evidenced interventions. Consider tightening tone for balance and adding a clinician-facing recommendations paragraph in the Conclusions.

Author Response

Comment 1. This narrative review addresses a clinically important and timely topic—psychosocial interventions targeting emotion regulation and emotion dysregulation in youth with ADHD. The summary table is a useful contribution. However, the manuscript still requires substantial revisions.

 Response 1: Thank you for the positive feedback on the importance of this narrative review. We note how we have addressed each of your concerns in our revised manuscript, and believe this has strengthened it overall.

Comment 2. Abstract. Add a brief sentence specifying scope/selection approach, even for a narrative review, to anchor readers in methodology.

 Response 2: We appreciate this suggestion and have added a sentence to the abstract as recommended (page 1).

Comment 3. Introduction. The brief mention of positive emotion dysregulation (McQuade et al., 2024, 2025) is welcome but underdeveloped; revisit in the Discussion to flag whether reviewed interventions actually target positive ED.

Response 3: Thank you for this recommendation, which was also raised by the other reviewer. We have expanded the discussion section in the revised manuscript to further address the focus of interventions on negative emotions, and use the RELAX intervention as an example of how most content may focus on negative emotions, but can be modified to work with and target positive ED (page 13).

Comment 4. A short "Scope and Approach" subsection is needed: how studies were identified, what counts as "ER-relevant," and why a narrative (vs. systematic) format was chosen.

Response 4: We have added a Scope and Approach section after the introduction and included additional information regarding how studies were identified and why we chose to do a narrative review (page 2). As noted in the revised manuscript, searches have now been conducted by three of the authors, with the first/lead author doing another round of searches during the revision process and adding in additional relevant articles that were identified to the revised manuscript.

Comment 5. Transdiagnostic section. The phrase "UP-C is one of the primary ER transdiagnostic interventions in youth" is awkward

Response 5: We have removed this portion of the sentence so that it now reads “Importantly, UP-C can improve ER-relevant processes alongside symptom reduction…” (page 5).

Comment 6. CBT subsection. The conclusion that CBT effects on ER are "comparatively underpowered" is sound but could be strengthened by explicitly distinguishing trials where ER was a primary vs. secondary endpoint.

Response 6: Thank you for raising this point. We have added in a sentence acknowledging that none of the existing CBT studies for youth with ADHD have included ER or ED as a primary or secondary endpoint (page 4).

Comment 7. DBT subsection. The null SSTG primary findings (Meyer et al., 2020) and positive moderator findings (Meyer et al., 2022) sit in tension; please more explicitly frame this as a hypothesis-generating signal rather than confirmatory evidence.

Response 7: Thank you for this suggestion. First while addressing this comment, we realized a typo in our manuscript as the primary findings from the RCT should be Meyer et al., 2022 not 2020. Given that there are two Meyer et al., 2022 manuscripts, we now include the second author for all in-text citations for these references. To address this comment, in the revised manuscript, we have softened the language and specifically noted

Comment 8. ACT subsection. Given the very small evidence base (n = 6 studies in Munawar et al., 2021), conclusions should be tempered. Several sentences currently read more affirmatively than the evidence warrants.

Response 8: We appreciate this advice and have tempered conclusions in the revised manuscript and specifically called for more research examining the benefits of ACT for ER deficits and/or ED directly (page 6).

Comment 9. Mindfulness subsection. Wong et al. (2023) is described in the text but absent from Table 1 under MYmind; please add and ensure consistency between text and table.

Response 9: Thank you for pointing this out. We have added this under the MYmind subsection of the mindfulness-based interventions and checked throughout the revised manuscript to make sure articles with youth with ADHD mentioned in text are also cited in the table.

Comment 10. ADHD-specific section, p. 7. Typo: "Beyond these transdiagnostic interviews" should read "interventions."

Response 10: Thank you for catching this, we have fixed this typo in the revised manuscript.

Comment 11. Table 1. Multiple cells are incomplete or have formatting issues (CBT row lacks age range/session count/studies; UP-C/A row lacks the studies column; DBT cell layout merges sub-interventions confusingly). Recommend rebuilding the table with a consistent schema.

Response 11: Thank you for pointing this out. We have rebuilt the table now that it is in the formatting used by the journal to ensure readability and that no cells are blank. We also have added lines within sections to note when there are examples of specific types of interventions (e.g., UP-C/A within CBT, MYmind within Mindfulness-Based Interventions). We also have made edits to ensure that words are not split across lines to improve readability for the table overall.

Comment 12. References. Diaz citation. Text cites "Diaz, 2025"; reference list shows "Diaz, Y. (2015). 87.1 Incorporating…" with a 2025 DOI. Reconcile the year and verify the source (appears to be a 2025 JAACAP conference abstract).

Response 12: Thank you we have updated the reference list to make this Diaz, Y. (2025).

Comment 13. References. Linehan (2025) and Chronis-Tuscano (2016). Verify the dating of Linehan's DBT Skills Training Manual; the two Chronis-Tuscano 2016 entries (refs 23, 24) require "2016a/2016b" disambiguation in the text.

Response 13: We have verified that Linehan (2025) is correct, but added in that this is the revised edition of the manual in the reference list. We have added in the second author for the two Chronis-Tuscano et al., 2016 citations to disambiguate these in text. Thank you for pointing this out.

Comment 14. Discussion. "Hoffman, 2014" in text vs. "Hofmann" in reference list (#51).

Response 14: Thank you for catching this, we have corrected the in-text citation to be Hofmann.

Comment 15. Author transparency regarding RELAX is appropriate. However, the RELAX subsection reads more enthusiastically than comparably evidenced interventions. Consider tightening tone for balance and adding a clinician-facing recommendations paragraph in the Conclusions.

Response 15: We appreciate the reviewer pointing out this bias in language currently. We intentionally had one of the authors who was not the developer of RELAX write this section to try to avoid such biases, but have now added in the following sentence “Given the lack of a control group, these promising findings need to be tempered until further evidence from a randomized trial can be obtained.” to highlight the preliminary enthusiasm for this intervention and need for a randomized controlled trial to replicate pilot findings (page 13).

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for your careful and constructive engagement with the prior round of review. However, a small number of issues remain unresolved before acceptance.

The sentence "DBT was first extended for use with children with disruptive mood dysregulation disorder…but ER/ED outcomes were not directly assessed [81]" cites Oliva et al. (2021), which is a mindfulness meta-analysis. The intended citation appears to be reference 84 (Perepletchikova et al., 2017).

The reference to "sequencing of behavioral parent training and stimulant medications [65, 84]" includes reference 84 (Perepletchikova, DBT-C for DMDD), which does not fit this context. The intended citation appears to be reference 82 (Pelham et al., 2016).

Table 1

Munawar et al. (2021), an ACT scoping review, and Murrell et al. (2015), an ACT pilot study, are listed under SSTG but belong elsewhere.

Hafiz Ahmet et al. is dated "2025" in the table but "2026" in reference 47; Miranda & Presentación is dated "2002" in the table but "2000" in reference 74. Please verify and reconcile.

The studies column contains a truncated "Vanzin," and an ambiguous "Mauri et al., 2020" (presumably Vanzin, Mauri et al., 2020). Please complete these entries.

Consider strengthening the scope and approach further by specifying the search date range, articulating explicit inclusion/exclusion criteria beyond English-language availability, and briefly noting your screening procedure.

Positive ED illustration in the Discussion (page 13). Using RELAX as the worked example of how a reviewed intervention could address positive emotion dysregulation may, despite the appropriate conflict-of-interest disclosure, read as a further foregrounding of the authors' own intervention. You might consider whether MFC, a mindfulness-based program, or PCIT-ECo could equally illustrate the point, or supplement RELAX with one of these.

Thank you again for your thoughtful work on a clinically important and timely review.

Author Response

Comment 1: The sentence "DBT was first extended for use with children with disruptive mood dysregulation disorder…but ER/ED outcomes were not directly assessed [81]" cites Oliva et al. (2021), which is a mindfulness meta-analysis. The intended citation appears to be reference 84 (Perepletchikova et al., 2017).

Response 1: Thank you for catching this. We have corrected the citation and checked all citations carefully, given the several issues you noted. 

Comment 2. The reference to "sequencing of behavioral parent training and stimulant medications [65, 84]" includes reference 84 (Perepletchikova, DBT-C for DMDD), which does not fit this context. The intended citation appears to be reference 82 (Pelham et al., 2016).

Response 2: Thank you for bringing this to our attention. This was meant to be 85, though we have also added in 82 here. 

Comment 3: Table 1. Munawar et al. (2021), an ACT scoping review, and Murrell et al. (2015), an ACT pilot study, are listed under SSTG but belong elsewhere.

Response 3:  These have been moved to the ACT row. 

Comment 4: Hafiz Ahmet et al. is dated "2025" in the table but "2026" in reference 47; Miranda & Presentación is dated "2002" in the table but "2000" in reference 74. Please verify and reconcile.

Response 4: We have corrected the table to be 2026 for reference 47 and 2000 for 74. 

Comment 5: The studies column contains a truncated "Vanzin," and an ambiguous "Mauri et al., 2020" (presumably Vanzin, Mauri et al., 2020). Please complete these entries.

Response 5: Thanks for catching this. We have moved Mauri et al., 2020 to the end of this section, where it was meant to be, with the truncated Vanzin reference. This was moved inadvertently. 

Comment 6: Consider strengthening the scope and approach further by specifying the search date range, articulating explicit inclusion/exclusion criteria beyond English-language availability, and briefly noting your screening procedure.

Response 6: Because this was intended to be a narrative review, we did not have a formal screening procedure or formal inclusion/exclusion criteria. We now note in the revised manuscript (page 2) that our inclusion criteria were relevant for treating ER/ED among youth with ADHD (by either directly working with this population, targeting these constructs, or both). Narrative reviews are meant to be flexible and not necessarily fully exhaustive of the literature, allowing authors to select literature based on their knowledge/expertise and thematic relevance, while providing an overview of the literature, interpretation, and critique (see Sukhera, 2022).

Comment 7: Positive ED illustration in the Discussion (page 13). Using RELAX as the worked example of how a reviewed intervention could address positive emotion dysregulation may, despite the appropriate conflict-of-interest disclosure, read as a further foregrounding of the authors' own intervention. You might consider whether MFC, a mindfulness-based program, or PCIT-ECo could equally illustrate the point, or supplement RELAX with one of these.

Response 7: We have added another example using a mindfulness-based program, so that we have one example for a transdiagnostic intervention and one example for a youth with ADHD specific intervention, including providing a citation supporting that such mindfulness training can increase positive affect in daily life.