Cultural Adaptation and Implementation of DBT for Adolescents With Emotional Disorders

Cultural Adaptation and Implementation of Dialectical Behavior Therapy Skills Training Group for Adolescents With Emotional Disorders: a Feasibility Study and a Randomized Controlled Trial

The goal of this study is to learn if Dialectical behavior therapy Skills

Training for Adolescents (DBT-A-ST) works on emotional disorders in adolescents. The main questions it aims to answer are:

Does DBT-A-ST produce faster improvements (i.e., steeper slopes), compared to ASG, on primary and secondary outcome measures during treatment and 3-month follow-up?

Does DBT-A-ST produce greater improvements, compared to SBG, on primary and secondary outcome measures?

Participants is:

Randomly assigned to (a) a culturally adapted DBT-A-ST or (b) Satir-based group (SBG).

Received five assessments before the start of the trial (T1), after 4, 8 sessions (T2, T3), at post-intervention (T4), and 3-month follow-up (T5).

Study Overview

• Status: Recruiting
• Conditions: Emotional Disorders
• Intervention / Treatment: Behavioral: Culturally adapted DBT-A-ST group; Behavioral: Satir-based group (SBG)

Detailed Description

The 1st-year project is to develop the culturally adapted DBT-A-ST using a consensus method and to test its feasibility and acceptability through a pilot study and focus groups. Twenty adolescents with emotional disorders attended a 15-session 120-min DBT-A-ST. After finishing the treatment, they were invited to participate in a 90-min focus group. Cultural adaptation of the treatment is based on these results. From the 2nd to 4th year, a partially randomized patient preference (PRPP) trial is conducted in the child and adolescent psychiatry department of a medical center. Participants aged 12-18 years with current depressive or anxiety disorders as diagnosed using the K-SADS-E are recruited and randomly allocated 1:1 or patient preference to one of two study arms: a) culturally adapted DBT-A-ST group, b) Satir group. Both interventions in group format include 15 weekly sessions, 120 min/ each session. A target sample size of 160 youths is included, based on power calculation. Five assessments are conducted: before the start of the trial (T1), after 4 sessions (T2), after 8 sessions (T3), at post-intervention (T4), and at 3-month follow-up (T5). Primary outcomes are the severity of depression and anxiety, rated by blind assessors. Secondary outcomes include general psychopathology, number of DSM-5 disorders, quality of life, and a battery of self-reported measures. The treatment mechanisms and implementation processes are also examined.

• Study Type: Interventional
• Enrollment (Estimated): 160
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Hui-Chun Huang, Ph.D; Phone Number: 3055 886-2-28094661; Email: aihch@mmh.org.tw

Study Locations

• Taiwan
  • Taipei, Taiwan
    • Recruiting
    • Mackay Memorial Hospital
    • Contact: Dr.Hui-Chun Huang; Phone Number: 3055 886 2 28094661; Email: aihch@mmh.org.tw
  • Taipei, Taiwan
    • Active, not recruiting
    • Mackay Memorial Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Age 12-18 years.
2. Informed consent provided by the youth and one parent.
3. Sufficient Mandarin Chinese proficiency to complete study questionnaires.
4. Total score of PHQ-9 ≥ 8 or GAD-7 ≥ 8, or SDQ total score ≥ 10, or SDQ hyperactivity subscale score ≥ 3.

5. Primary diagnosis of depressive, anxiety disorder, or ADHD based on K-SADS-

   E interview, including:

   Depression (F32-33) Persistent mood disorder (F34) Phobic anxiety disorder (F40) Other anxiety disorder (F41) Adjustment disorders (F43.2) ADHD (F90)

6. Stable medication use for at least four weeks and willingness to maintain stable dosage during the study.
7. Individuals with comorbid emotional disorders are included; comorbidities are not stratified to avoid increasing study design complexity.

Exclusion Criteria:

1. Educational level of elementary school or university.
2. Comorbid intellectual disability or psychotic disorder.
3. Acute suicidality.
4. Insufficient Chinese language skills.
5. Unwillingness to discontinue current psychotherapy.
6. Unwillingness to accept video recording during group therapy.
7. Medication changes during the trial are not exclusionary if judged necessary or clinically important by the treating clinician, to maintain a naturalistic setting.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Culturally adapted DBT-A-ST group; The culturally adapted DBT-A-ST consists of 15 weekly group sessions, each lasting 120 minutes, including a 10-minute break. It maintains the core elements of standard DBT-A, including its philosophical foundation and treatment strategies. Therapists focus on teaching DBT skills through various methods such as modeling, structured behavioral rehearsals, and feedback. Each session begins with a 40-minute group mindfulness exercise and homework review, followed by 60 minutes dedicated to skill-specific didactics and experiential activities, concluding with a 10-minute homework assignment. Two group leaders facilitate the sessions, and participants track their skill usage daily with diary cards, which are reviewed weekly.	Behavioral: Culturally adapted DBT-A-ST group; The culturally adapted DBT-A-ST consists of 15 weekly group sessions, each lasting 120 minutes, including a 10-minute break. It maintains the core elements of standard DBT-A, including its philosophical foundation and treatment strategies. Therapists focus on teaching DBT skills through various methods such as modeling, structured behavioral rehearsals, and feedback. Each session begins with a 40-minute group mindfulness exercise and homework review, followed by 60 minutes dedicated to skill-specific didactics and experiential activities, concluding with a 10-minute homework assignment. Two group leaders facilitate the sessions, and participants track their skill usage daily with diary cards, which are reviewed weekly.
Placebo Comparator: Satir-based group (SBG); SBG, grounded in Satir's Iceberg Theory, aims to enhance self-awareness and communication by exploring participants' deeper emotions and beliefs. Sessions include emotional sharing, communication skills training, and role-play exercises. The program spans 15 weekly sessions (2 hours each): 10 for adolescents and 3 involving both adolescents and their parents. Activities focus on practicing communication stances, reflection, and group discussion to foster personal growth and improved relationships. The inclusion of parents is designed to help teens build supportive, resilient connections.	Behavioral: Satir-based group (SBG); SBG, grounded in Satir's Iceberg Theory, aims to enhance self-awareness and communication by exploring participants' deeper emotions and beliefs. Sessions include emotional sharing, communication skills training, and role-play exercises. The program spans 15 weekly sessions (2 hours each): 10 for adolescents and 3 involving both adolescents and their parents. Activities focus on practicing communication stances, reflection, and group discussion to foster personal growth and improved relationships. The inclusion of parents is designed to help teens build supportive, resilient connections.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Youth Self Report (YSR)	The Youth Self Report (YSR) is a self-reported measure assessing emotional and behavioral problems in adolescents. Each item is rated on a 3-point scale (0 = not true, 1 = sometimes true, 2 = mostly or completely true). The scale includes internalizing problems (withdrawal, anxiety/depression, and somatic complaints) and externalizing problems (rule-breaking and aggressive behaviors). Raw scores are converted to standardized T-scores based on normative data, with higher scores indicating more severe emotional and behavioral problems. T scores range approximately from 50 to 100, with scores above 70 indicating the clinical range.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Child Behavior Checklist about their adolescents (CBCL)	The Child Behavior Checklist (CBCL) is used to assess behavioral and emotional problems in children and adolescents. Each item is rated on a 3-point Likert scale (0-2). Raw scores are converted to standardized T-scores based on age- and gender-specific norms, with higher scores indicating more severe behavioral and emotional problems. T scores of ≤59 indicate nonclinical symptoms, scores of 60-64 suggest a risk for problem behaviors, and scores ≥65 indicate clinically significant symptoms.	at baseline, at 15 weeks, and at 3 months after completion of the intervention

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Hamilton Depression Scale-17 item (HAMD-17)	HDRS-17 is a clinician-rated measure of depressive symptoms that consists of 17 items rated using a semi-structured interview. Eight of the 17 HDRS-17 items are rated on a 5-point scale (0=absent; 1=doubtful or mild; 2=mild to moderate; 3=moderate to severe; 4=very severe), while the remaining 9 items are rated on a 3-point scale (0=absent; 1=doubtful or mild; 2=clearly present), yielding a minimum total score of 0 (least severe) and a maximum score of 52 (most severe).	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Hamilton Anxiety Scale (HAM-A)	The Hamilton Anxiety Scale (HAM-A) comprises 14 items. Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0-56, where <17 indicates mild severity, 18-24 indicates mild to moderate severity, and 25-30 indicates moderate to severe severity.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Clinical Global Impressions-Severity (CGI-S)	Clinical Global Impressions-Severity (CGI-S) is a standardized assessment tool used by clinicians to rate illness severity, monitor changes over time, and evaluate medication efficacy. It is rated on a seven-point scale: 1=normal, not at all ill; 2=borderline mentally ill; 3=mildly ill; 4=moderately ill; 5=markedly ill; 6=severely ill; 7=among the most extremely ill patients.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Clinical Global Impressions-Improvement (CGI-I)	The Clinical Global Impression-Improvement (CGI-I) is a 7-point scale that measures the extent to which the patient's illness has improved or worsened relative to baseline at the start of treatment. It is rated on a scale from 1 to 7: 1 = very much improved since the beginning of treatment; 2 = much improved; 3 = minimally improved; 4 = no change from baseline (the start of treatment); 5 = minimally worse; 6 = much worse; 7 = very much worse since the start of treatment.	at 15 weeks, and at 3 months after completion of the intervention

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient Health Questionnaire-9 item (PHQ-9)	It consists of nine items evaluating the presence of the nine DSM-5 criteria of major depression in the past 2 weeks. Each item is scored 0-3. Total scores indicate: 0-4 (None/Minimal), 5-9 (Mild), 10-14 (Moderate), 15-19 (Moderately Severe), and 20-27 (Severe).	at baseline, at 4, 8, and 15 weeks, and at 3 months after completion of the intervention
Generalized Anxiety Disorder Scale-7 item (GAD-7)	It is a self-report 7-item scale to measure the severity of anxiety and has been validated in Chinese adolescent populations. The total scores of the GAD-7 range from 0 to 21, with the higher scores indicating higher severity of anxiety disorders. For the cutoff points of the GAD-7 scores, in general, the scores of 5, 10, and 15 match categorization of none/normal (0-4), mild anxiety (5-9), moderate anxiety (10-14), and severe anxiety (15-21), respectively.	at baseline, at 4, 8, and 15 weeks, and at 3 months after completion of the intervention
The number of the DSM-5 diagnoses	The number of DSM-5 diagnoses is assessed using the Mandarin version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children - Epidemiologic version (K-SADS-E), modified to align with DSM-5 criteria.	at baseline, at 15weeks, and at 3 months after completion of the intervention
The Strengths and Difficulties Questionnaire (SDQ)	It aims to evaluate emotional and behavioral challenges in children and adolescents, covering four problem areas: emotional symptoms, conduct issues, hyperactivity/inattention, and peer relationship difficulties. All items are rated on a three-point scale (0=not true, 1=somewhat true, and 2=certainly true). Five positively worded items from different SDQ difficulty scales are reverse-coded. High scores on the difficulties scales indicate a high degree of difficulty; a high score on the prosocial scale indicates a high degree of prosocial behavior.	Baseline
10-item Positive and Negative Affect Schedule- Child/Parent (PANAS-C/P)	The 10-item Positive and Negative Affect Schedule for Children/Parents (PANAS-C/P) is used to assess positive and negative emotional states in youth, based on self-report or parent-report of recent emotional experiences. The measure yields two subscale scores: Positive Affect (range 10-50; higher scores indicate greater positive affect) and Negative Affect (range 10-50; lower scores indicate less negative affect).	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Perceived Stress Scale (PSS-10)	The Perceived Stress Scale (PSS) is a self-reported measure used to assess the degree to which individuals appraise situations in their lives as stressful. Each item is rated on a 5-point Likert scale (0 = never to 4 = very often). Total scores range from 0 to 40, with higher scores indicating greater perceived stress. Scores of 0-13 indicate low stress, 14-26 indicate moderate stress, and 27-40 indicate high perceived stress.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
World Health Organization Quality of Life Scale, Brief Version (WHOQOL-BREF)	The WHOQOL-BREF assesses quality of life across physical, psychological, social, and environmental domains. Each item is rated on a 1-5 scale. Domain scores are transformed to a 0-100 scale, with higher scores indicating better quality of life. Interpretation is based on comparisons across domains, changes over time, and reference to population norms; lower scores (e.g., below the 30th percentile) may indicate areas requiring clinical attention.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
The Adult Self-Report (ASR)	The Adult Self-Report is a self-report instrument assessing behavioral, emotional, and social functioning over the past 6 months. Items are rated on a 3-point scale (0 = not true, 1 = somewhat true, 2 = very true). A Total Problems score is calculated by summing all problem items, with higher scores indicating greater overall difficulties.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Academic Pressure subscale of Inventory of Influencing Factors of Trait Anxiety	It includes 10 items that describe daily events related to students' academic pressure. Each item is rated on a 5-point Likert scale ranging from 1 = never to 5 = always. The items are averaged to calculate scale scores; the higher the average score, the higher the level of self-reported academic pressure.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Chinese Adolescent Life Event Scale checklist	The Stressful Life Events Scale assesses the occurrence of stressful life events. In this study, only eight items related to controllable negative events are included. Each item is rated as 0 = no, 1 = yes, and a Total Score is calculated by summing all items, ranging from 0 to 8, with higher scores indicating a greater number of stressful life events.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
The Treatment History Interview (THI)	The Treatment History Questionnaire assesses the types and amounts of previous medical and psychological treatments received. Items include self-reported hospital admissions, days in hospital, emergency department visits, medications, and outpatient psychosocial treatments. Each item is rated 0 = no, 1 = yes, and a Total Score is calculated by summing all items, with higher scores indicating greater use of treatment resources.	Baseline
Emotion Regulation Questionnaire, Child and Adolescent Form (ERQ-C/A)	The Emotion Regulation Questionnaire for Children and Adolescents is a 10-item self-report measure assessing emotion regulation strategies, including cognitive reappraisal and emotion suppression. Items are rated on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Subscale scores range from 6-30 for cognitive reappraisal and 4-20 for emotion suppression. Higher scores indicate greater emotion dysregulation.	at baseline, at 8 and 15 weeks, and at 3 months after completion of the intervention
The Distress tolerance Scale-Short Form (DTS-SF)	The DTS-SF is a modification of the DTS and contains the highest-loading item from each subscale, forming a single DT factor. As with the DTS, items are rated on a 5-point Likert scale (1 = strongly agree, 5 = strongly disagree), with lower scores indicating poorer ability to withstand and tolerate distress.	at baseline, at 4, 8, and 15 weeks, and at 3 months after completion of the intervention
DBT skills subscale (DSS) of the DBT Ways of Coping Checklist	The Dialectical Behavior Therapy Skills Use Scale is a 38-item self-report measure assessing the frequency of DBT skills use over the past month. Participants rate how often they used specific skills when facing stressors on a 4-point scale (0 = never to 3 = regularly). A Total Score (range: 0-114) is calculated by summing item scores, with higher scores indicating more frequent use of DBT skills.	at baseline, at 15 weeks, and at 3 months after completion of the intervention
Mindful Attention Awareness Scale-Children	The Mindful Attention Awareness Scale is a 15-item self-report measure assessing mindfulness across cognitive, emotional, physical, interpersonal, and general domains. Items are rated on a 6-point scale (1 = almost always to 6 = almost never), reverse-scored, and averaged to yield a total score. Higher scores indicate greater mindfulness.	at baseline, at 8 and 15 weeks, and at 3 months after completion of the intervention
Group Climate Questionnaire-Short Form (GCQ-S)	It is a 12-item self-report instrument used to measure youths' perceptions of the atmosphere in therapy groups. It contains 12 items rated on a 7-point Likert scale, indicating the extent of agreement, ranging from "not at all" (0) to "extremely" (6).	at 4, 8, and 15 weeks
Therapy Alliance Scale for Adolescence	It is widely used to measure therapeutic alliance in research with adolescent populations. The higher the score, the better the therapeutic alliance. Items are rated on a 4-point Likert scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree) and summed to create a single Total score with a maximum of 48.	Completed by adolescents: at 4, 8, and 15 weeks Completed by therapists: at 8 and 15 weeks
Client Satisfaction Questionnaire (CSQ-8)	It consists of eight questions (quality of service, kind of service, whether needs were met, likelihood to recommend to a friend, amount of help received, handling of problems, overall satisfaction, and likelihood to return), each rated on a 4-point Likert scale (1-4). Total scores range from 8 to 32, with higher scores indicating greater satisfaction.	at 15 weeks
Satisfaction of each session	This 4-item, content-specific scale is completed by patients after each session using a 5-point Likert scale (1 = very unsatisfied to 5 = excellent). Total scores range from 4 to 20, with higher scores indicating better session evaluation. It is designed to facilitate collaborative adjustments to therapy, including the therapeutic alliance, session content, and relevance.	From the first group session to the final (15th) group session, satisfaction for each session was assessed immediately after each session.
The Adolescent Dialectical Behavior Therapy Group Skills Learning Experience Scale (ADBT-SLES)	The ADBT-SLES is a 12-item questionnaire assessing adolescents' perceived helpfulness of DBT group skills, rated on a 5-point Likert scale (1 = not helpful at all, 5 = extremely helpful). It also includes four open-ended questions exploring participants' learning experiences in the group.	at 15 weeks
A short drop-out questionnaire	It contains 6 questions (i.e., reason for drop-out, date of drop-out, number of sessions attended, person who initiated the stop of treatment) to gather information about drop-outs, which is filled in by adolescents.	at the time of participant withdrawal during the 15-session group treatment program (up to 15 sessions)

Collaborators and Investigators

• Sponsor: Mackay Memorial Hospital
• Investigators: Principal Investigator: Shen-Ing Liu, Ph.D, Mackay Memorial Hospital

Study record dates

Study Major Dates

• Study Start (Actual): October 24, 2024
• Primary Completion (Estimated): July 31, 2028
• Study Completion (Estimated): July 31, 2028

Study Registration Dates

• First Submitted: August 10, 2024
• First Submitted That Met QC Criteria: August 19, 2024
• First Posted (Actual): August 22, 2024

Study Record Updates

• Last Update Posted (Actual): May 12, 2026
• Last Update Submitted That Met QC Criteria: May 7, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Adolescents; Emotional Disorders; Dialectical Behavior Therapy Skills Training Group
• Additional Relevant MeSH Terms: Mental Disorders; Mood Disorders
• Other Study ID Numbers: NSTC 113-2314-B-195 -012 -MY3

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No