Professional Documents
Culture Documents
and Psychopathology
in Children and Adolescents
ii
iii
Emotion Regulation
and Psychopathology
in Children and
Adolescents
Edited by
Cecilia A. Essau
Sara Leblanc
Thomas H. Ollendick
1
iv
1
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v
Preface
This contemporary volume brings forefront research in emotion regulation and how processes
underlying emotion regulation have a bearing on the field of child and adolescent psychopathol-
ogy. The book shows continuity by initially introducing the topic of emotion and its regulation
and then narrowing its scope, analyzing the role emotion regulation plays in specific disorders
while critically examining current assessment and treatment strategies. In the concluding chap-
ters, emotion regulation in high risk, targeted groups is assessed and intervention and prevention
is explored.
This book has brought together an array of leading international scholars who specialize in
the emotional disorders. We have asked them to summarize the latest findings in their field
while assessing intervention through a comparative, critical lens in order to pass on this cru-
cial knowledge to the next generation of mental health professionals. Each chapter is unique, as
authors expose the reader to different approaches and outlooks from diverse specialties for diverse
problems.
This 20-╉chapter volume consists of four parts. In Part 1, broad issues are discussed such as
the biological, physiological and cultural factors underlying and impacting emotion regulation
and psychopathology in children and adolescents. In Part 2, specific disorders are delineated and
current treatment programs are discussed, including Attention Deficit Hyperactivity Disorder,
conduct disorder, anxiety disorders, depression, eating disorders, substance use disorders, autism
spectrum disorder, borderline personality disorder, and severe irritability and disruptive mood
dysregulation disorder. Part 3 assesses emotion dysregulation in specific targeted populations,
including children of abuse and neglect, children of divorce, children with incarcerated parents,
children exposed to traumatic stress, and adolescents who engage in nonsuicidal self-╉injury. It
investigates the interplay between environment, behavior and self-╉regulation and the etiology,
maintenance and propagation of psychopathology in these diverse environments. The final part of
this book conceptualizes emotional regulation as a transdiagnostic process and discusses innova-
tive approaches to treatment that arise when viewed through this lens.
This book combines the latest research from leading academics on a variety of clinical top-
ics with an emphasis on intervention from an applied perspective; this combination of appli-
cation and theory makes it a suitable reference for mental health professionals by providing
empirical review and current data on treatment efficacy. However, it was particularly designed
for graduate students taking advanced courses in clinical psychology and psychiatry who want to
remain abreast of current breakthroughs and leading treatment options for child and adolescent
psychopathology.
We wish to acknowledge the efforts of the contributors, whose expertise and dedication to the
project have been outstanding. Without them, a comprehensive coverage of the various topics
would not have been achieved. Additionally, we wish to acknowledge the support and cooperation
of the staff at Oxford University Press.
Cecilia A. Essau, Sara Leblanc, & Thomas H. Ollendick
vi
vi
Acknowledgments
I (Cecilia Essau) feel very honoured to have had this opportunity to co-╉edit this volume with
my highly respected colleague, Tom Ollendick, who’s been a great inspiration, mentor, scientist,
clinician and very good, patient and understanding friend to me, and with Sara Leblanc, who
introduced me to emotion regulation during her research. I wish to thank my family in Malaysia,
Canada and Germany, especially my husband, Juergen, and our daughter, Anna, for their continu-
ing support and inspiration. I dedicate this volume to my late parents, Essau Indit and Runyan
Megat, whose courage, love and belief in me have made me become who I am; had they still been
alive, they would have been most proud of this accomplishment and my choice of emotion regula-
tion strategies.
I (Sara LeBlanc) wish to express gratitude to my respected colleague Cecilia Essau for giving
me the opportunity to serve as a co-╉editor on this influential volume. Over the years Cecilia has
served as a role model, mentor and inspiration due to her humility, grace and impeccable ethic; it
was through her determination and vision that this work came to fruition. I also wish to express
my deepest thanks to Professor Ollendick, I am humbled and inspired by your contribution to
the field of Psychology, it was a privilege and honor to have the opportunity to work with you. I
also wish to thank my family and friends for their unwavering dedication and support, especially
my parents Blaine, Noreen and grandmother, Juanita. Finally, I also wish to thank my late sister
Amanda for our countless adventures; her valuable insights taught me to see the humor in all
things and have given me many memories I will eternally cherish, to her I dedicate this volume.
I (Tom Ollendick) wish to give thanks to my good friend and colleague, Cecilia Essau, who
invited me to serve as one of the co-╉editors of this important volume with her. This has been a
rewarding project and one that would not have been possible without her vision and dedication.
I also wish to thank Sara LeBlanc whom I have met through this project and with whom I would
very much like to work with in the future. Finally, I give thanks to my wife, Mary, our daughters,
Laurie and Katie, and our sons-╉in-╉law, David and Billy, as well as our six grandchildren, Braden,
Ethan, Calvin, Addison, Victoria and William. Without them, my life would be much less interest-
ing and enjoyable. I thank them for their love and support over the years. My own emotion regula-
tion has been much the better with them at my side. To them, I dedicate this work.
vi
ix
Table of Contents
List of Abbreviations╇ xi
List of Contributors╇ xv
x Table of Contents
Part IV Epilogue
20 Transdiagnostic Approaches to Emotion Regulation: Basic Mechanisms
and Treatment Research 419
Brian C. Chu, Junwen Chen, Christina Mele, Andrea Temkin, & Justine Xue
Index 453
xi
List of Abbreviations
List of Contributors
Cecilia A. Essau
University of Roehampton, London, UK
xvi
Christina Mele Michael Sun
Rutgers, The State University University of California, Los Angeles, USA
of New Jersey, USA Roseann Tan-Mansukhani
Gregory A. Miller De La Salle University-Manila, Philippines
University of California, Los Angeles, USA Maria Caridad H. Tarroja
Thomas H. Ollendick De La Salle University-Manila, Philippines
Virginia Polytechnic Institute and State Andrea Temkin
University, USA Rutgers, The State University
Frances Rice of New Jersey, USA
Cardiff University, UK & University College Nicholas D. Thomson
London, UK University of Durham, UK
Faye Riley Timothy J. Trull
University of Roehampton, London, UK University of Missouri, Columbia,
Priscilla Burnham Riosa Missouri, USA
York University, Canada Meghan Vinograd
M. Koa Robinson University of California, Los Angeles, USA
University of Hawaii Cancer Center, David Voon
Honolulu, Hawaii, USA Monash University, Melbourne, Australia
Brandon G. Scott Carl F. Weems
Arizona State University, REACH Iowa State University, USA
Institute, USA
Jonathan A. Weiss
Carla Sharp York University, Canada
University of Houston, Houston, Texas, USA
Thomas A. Wills
Michelle Shiota University of Hawaii Cancer Center,
Arizona State University, USA Honolulu, Hawaii, USA
Jeffrey S. Simons Justine Xue
University of South Dakota, USA Flinders University, Adelaide, Australia
Tracy L. Spinrad Janice Zeman
Arizona State University, USA College of William and Mary, USA
Part I
Emotion Regulation:
General Issues
2
3
Chapter 1
Human emotions
Human emotions are an integral component of everyday life that influence cognitive functioning
(Bebko, Franconeri, Ochsner, & Chiao, 2011; Eysenck, 2004; Gross, 2013) memory (Christianson,
2014) and overall wellbeing (Kotsou, Gregoire, & Mikolajczak, 2011). Emotions impact both intra-
personal and interpersonal processes, and, when dysregulated, they may become destructive and
intrusive in daily life (Frijda, 1986; Slee, Arensman, Garnefski, & Spinhoven, 2007), contributing
to the development, maintenance, and propagation of psychopathology (Castella et al., 2013).
In general, emotion regulation competencies become differentiated as a function of develop-
ment. Children tend to seek support from adults or use behavioral techniques to regulate emo-
tions. As children reach adolescence, they become increasingly self-╉reliant, engaging in planful
problem solving and utilizing cognitive strategies (for example, reappraisal) more frequently
when faced with stressful life events (Zimmer-╉Gembeck & Skinner, 2011). Although the majority
of children and adolescents will successfully navigate these developmental stages by cultivating
adaptive coping skills, for some, this marks the beginning of lifelong challenges with emotion
regulation and resultant dysregulation (Kessler et al., 2005).
This introductory chapter will begin by discussing both the definition and functionality of emo-
tions; it will then turn to a discussion of emotion regulation and associated processes. Critically, it
will consider the importance of this topic as it pertains to emotional wellbeing, whilst also examin-
ing the crucial link between emotion dysregulation and psychopathology in children and adoles-
cents. Later in the chapter, various emotion regulation strategies will be described and categorized
according to their utility, emphasizing strategies that demonstrate adaptive social, cognitive and
physiological benefits. This information is critical in delineating the underlying mechanisms leading
to the development and propagation of psychopathology, which is crucial when tailoring effective
treatment and prevention programs specifically suited to both the child and adolescent populace.
drive goal pursuits (Koole, 2009; Tice, Bratslavsky, & Baumeister, 2001). It has been hypothesized
that emotions evolved to promote the species by eliciting specific action patterned responses to
life threatening circumstance, thereby increasing the likelihood of survival. From this stand-╉point
a negative bias would be adaptive; for example, in prehistoric times hearing a rustling in the bush
if one was likely to interpret this as a threat, feel fear, and ultimately flee, one would be more likely
to survive than if a more positive appraisal was made, viewing the sound as innocuous, rather
than life threatening (Sapolsky, 2007). However, in post-╉industrial societies humans are often
faced with psycho-╉social stressors, which activate the fight-╉or-╉flight response (Hypothalamic–╉
pituitary–╉adrenal axis: HPA axis) in the same manner even though they are no longer placed in
life threatening circumstances. This chronic activation can have a deleterious impact on overall
wellbeing if stress levels are not regulated.
In terms of adaptive function, the positive emotions may be facilitative, as they broaden atten-
tional focus (Derryberry & Tucker, 1994) whilst concurrently enhancing the scope of cognition.
For example, a series of classical experiments demonstrated that when compared with a control
condition, those in a positive state were able to make more unique associations with neutral words
(Isen, Johnson, Mertz, & Robinson, 1985). This led researchers to conclude that positive affect
enhances cognitive processing via the promotion of cognitive flexibility, elaboration, and integra-
tion, whilst concomitantly fostering relatedness and interconnection between cognition, ideas,
and action (Isen, 1987; Isen & Daubman, 1984).
Emotion regulation 5
Emotion regulation
Emotions are complex and dynamic: They can be useful or deleterious. Thus, the key to optimum
emotional functioning is adaptive emotion regulation, which is characterized by implementing
effective strategies that are contextually appropriate and account for individual difference and
personal preference (Gross & John, 2003).
Varying definitions of emotion regulation exist within the developmental literature (Cole,
Martin & Dennis, 2004). For example, according to Gross (1998) emotion regulation refers to the
heterogeneous set of processes individuals implement to modulate their emotional experiences.
This definition subsumes both the “up” and “down” regulation of emotions, as an individual may
decrease, increase or maintain negative and positive emotions (Erber, Wegner, & Therriault, 1996;
Parrott, 1993). Alternatively, emotion regulation has been defined as a “[p]â•„rocess used to man-
age and change if, when, and how (e.g., how intensely) one experiences emotions and emotion-╉
related motivational and physiological states, as well as how emotions are expressed behaviorally”
(Eisenberg et al. 2007, p. 288). Eisenberg and Spinrad (2004) posit that although intrinsic and
extrinsic factors play a role in emotion regulation, it is advantageous to distinguish between exter-
nal and internal regulation. External regulation refers to external forces, such as parents, teachers,
and peers, which influence emotion regulation. This may be particularly pertinent in the early
childhood years, when support seeking from adults is a primary form of affect regulation in nor-
mative development (Zimmer-╉Gembeck & Skinner, 2011). In contrast, internal regulation refers
to effortful, self-╉regulation, which may include a variety of cognitive and behavioral strategies an
individual chooses to implement to modulate their emotional response.
The primary focus of this chapter will be internal self-╉regulation, as this type of regulation
is within the individual’s control and can be shaped through directed intervention, a topic that
will be discussed in greater detail in Chapter 2. The definition utilized within this chapter will
be consistent with the aforementioned definition put forth by Gross (1998), who views emotion
regulation as a varied set of processes individuals engage in to modify their emotional experience.
The ability to effectively regulate emotions is a critical and common place activity (Oschner
& Gross, 2005). Various strategies may be employed that are broadly categorized as antecedent-╉
focused or response-╉focused strategies (Gross, 1998). Antecedent strategies occur early in the
emotion generative process, altering the impact of emotion-╉eliciting cues; whereas, response-╉
focused emotion regulation occurs later in the process, impacting behavioral responses (Gross
& Thompson, 2007). Emotion regulation influences the intensity, duration, and expression of
emotions (Gross, 1999), occurring on a continuum from controlled to automatic, conscious to
unconscious (Koole, 2009).
Research has demonstrated the vast majority of emotional experience can be regulated (Canli,
Ferri & Dunman, 2009). There are a variety of different strategies which can be employed to regu-
late emotions which include: Reappraisal of the event (Hofmann, Heering, Sawyer, & Asnaani,
2009), situation modification (Gross, 1998), change of attentional focus (Rothermund, Voss, &
Wentura, 2008), and suppression (Dalgleish, Schweizer, & Dunn, 2009). The two strategies that
will be primarily focused on in this chapter are reappraisal and emotional suppression, as they
have received the most attention in the literature, with reappraisal primarily associated with posi-
tive health outcomes and suppression, primarily associated with negative health outcomes (Gross
& John, 2003).
Cognitive reappraisal is an antecedent technique that involves changing the interpretation of a
situation in order to reduce the emotional impact (Gross & Thompson, 2007). Perception is real-
ity and our thoughts are linked to our actions, which are linked to our behavior: Every situation
can be interpreted in a variety of different ways, and it is this interpretation, rather than the event
6
itself, that impacts thoughts, behaviors, and emotions (Malooly, Genet, & Siemer, 2013; Wilding
& Milne, 2010). In children, reappraisal has been shown to be an adaptive method of managing
emotions, when compared to other strategies, such as suppression (Carthy et al., 2010; Garnefski
& Kraaij, 2009; McKrae, et al., 2012). In addition, both longitudinally and cross-╉sectionally,
Garnefski and colleagues have demonstrated a strong negative relationship between the reported
use of reappraisal and depression in both adolescent and adult populations (Garnefski & Kraaij,
2006; Garnefski, Kraaij, & Spinhoven, 2001; Kraaij, Pruymboom, & Garnefski, 2002). Similarly,
research has shown children possessing a secure attachment style are more empathetic due to
their superior emotion regulation competencies (Panfile & Laible, 2012). These findings are mir-
rored in the adolescent populace, as adolescents demonstrating adaptive emotional regulation
competencies are more likely to achieve their goals and form strong interpersonal relationships;
whereas, adolescents with impaired emotion regulation skills, often manifest behavioral problems
and are less likely to achieve both long and short-╉term goals (Hum & Lewis, 2013).
In contrast to reappraisal, emotional suppression has been shown to have negative health out-
comes, as studies have linked the frequent use of suppression with depressive symptomology
in both children and adolescents (Betts, Gullone, & Allan, 2009; Hughes, Gullone, & Watson,
2011; Larsen et al., 2013). Relatedly, in adolescents, deficits in emotion regulation have been
associated with substance abuse (Wilens et al., 2013), aggressive behavior (Herts, McLaughlin, &
Hatzenbuehler, 2012) and pathological gambling (Potenza, et al., 2011), topics which will be dis-
cussed in greater detail in subsequent chapters. In general, suppression has been associated with
increased negative affect (Srivastava et al., 2009), decreased positive affect (Gross & John 2003),
decreased social functioning (English & John, 2013), and enhanced levels of depressive sympto-
mology and obsessive thinking (Corcoran & Woody, 2009; Marcks & Woods, 2005). Furthermore,
suppression has been linked to decreased life satisfaction (Kashdan & Steger, 2006), decreased
interpersonal skills (Butler et al., 2003), enhanced sympathetic nervous-╉system activation (Egloff,
Schmuckle, Burns, & Schwerdtfeger, 2006), increased stress-╉related symptomology (Moore,
Zoellner, & Mollenholt, 2008) and decreased memory recall (Richards, Butler, & Gross, 2003;
Richards & Gross, 2000). In conclusion, the frequent and inflexible use of emotional suppression
may be damaging as it prolongs the experience of negative affect (Campbell-╉Sills & Barlow, 2007),
makes excessive use of cognitive resources (Gross & John, 2003) and keeps physiological arousal
chronically activated (Eglof et al., 2006; Ohira et al., 2006). Thus, the cultivation of adaptive strat-
egies, such as cognitive reappraisal, is imperative during the formative years so that the use of
emotional suppression is minimized.
Function of ER
Historically, it was hypothesized that emotion regulation functioned to satisfy hedonic needs,
such that pleasure was maximized and pain minimized (Larsen, 2000; Westen, 1994). This may be
due in part to the realization that negative emotions drain an extensive amount of an individual’s
physical and mental resources (Sapolsky, 2004; 2007). However, even though hedonic needs may
fuel emotion-╉regulation in some circumstances, they are not the sole motivation for all regulatory
function (Erber & Erber, 2000; Erber, Wegner, & Therriault, 1996). For example, if one deems
their emotions to be beneficial they may choose to stay in that emotional state even though it is
associated with negative and unpleasant feelings (Gross, 2007).
Relatedly, goal pursuits may influence emotion regulation tendencies, leading to short-╉term
discomfort in the quest towards delayed gratification based on a strong commitment to long-╉term
goals (Mischel et al., 2010; Mischel & Ayduk, 2004). Delayed gratification is a common paradigm
employed in the investigation of emotion regulation competencies in children dating back to the
7
1970’s. Early research showed that some children were able to practice emotion-╉regulation strate-
gies, such as reframing and distraction, to delay gratification in the interest of garnering a greater
reward at a later time. A recent follow-╉up of the original studies conducted by Mischel and col-
leagues, demonstrated the predictive validity of the delayed gratification test across a wide range
of social, cognitive, and mental health indicators (Casey et al., 2011). Thus, one can infer from
this research that the absence of delayed gratification in children can be an early sign of emotion
dysregulation. In support, a study by Krueger and colleagues (1996) determined that, in pre-╉
adolescents, the inability to delay gratification was linked to the externalizing disorders. Relatedly,
the work of Shoda et al. (1990), determined that preschoolers’ performance on the delayed grati-
fication task accurately predicted behavioral problems from age five to eight. In part, this may be
attributed to deficiencies in attentional control and executive function.
an individual’s emotional expressivity and regulation (Hariri & Forbes, 2007). Concordantly,
dysregulation of the dopaminergic system has been associated with major depressive disorder
(Kennedy, Koeppe, Young, & Zubieta, 2006). Moreover, there seems to be a distinct genetic com-
ponent to emotion regulation, as evidenced by twin studies, which have shown that identical
twins are more similar in emotional control, when compared with fraternal twins (Goldsmith,
Buss, & Lemery, 1997).
From a neurobiological stand-point, the development of the prefrontal cortex, hippocampus,
and amygdala is associated with higher decision making processes, sustained attentional control
and the enhanced capacity to regulate one’s emotions (Ochsner & Gross, 2007) (see Chapter 3).
Environmental factors also play a key role in the development of emotion regulation competen-
cies, particularly in infancy and early childhood. By six months of age an infant’s primary form of
emotion regulation occurs through relative interactions with caregivers (Crockenberg & Leerkes,
2004). However, as the child ages, they are influenced by numerous factors such as the parents’
regulatory style, social referencing, peer influence, and parental reactions to their children’s dis-
plays of emotion (Zeman, Cassano, Perry-Parrish, & Stegall, 2006).
Furthermore, culture impacts emotion regulation in a myriad of ways, by determining what
is valued (i.e., saving face, personal autonomy, etc.), which behaviors are socially acceptable and
what is deemed appropriate behavior in varying contexts (see Chapter 4). This was illustrated in
a study by Kagan (2003) who compared cultural norms in American and Chinese cultures. This
study determined that children in the American sample were socialized to be outgoing, assertive,
and bold; thus, children were taught to be highly expressive of both positive and negative affect.
In contrast, in the Chinese sample, shyness was seen as a positive attribute, as it demonstrated the
child was studious, hard-working, and willing to prescribe to social norms. Relatedly, in some
Asian cultures, emotional suppression is considered an adaptive emotion-regulation strategy,
unlike in autonomous cultures (e.g., Australia, America, and the UK); therefore, its consequences
do not manifest negatively in these cultures (Butler, Lee, & Gross, 2007) the way they do in cul-
tures subscribing to Western-European value systems. Thus, adaptive emotion regulation is con-
textually specific and culturally motivated.
prevalence rate for an anxiety disorder was 10.2%, with average onset occurring at eight
years of age and 50% of cases falling between six to twelve years of age. Similarly, an epi-
demiological study investigating general rates of psychopathology in high school students
found 10% of students currently had a clinical disorder and 33% had experienced one in their
life-times. Additionally, within this sample, high relapse rates were found for both substance
abuse (15%) and depression (18%) (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993).
Relatedly, a large scale, longitudinal study by Essau, Lewinsohn, Olaya, and Seeley (2014)
determined that adolescent anxiety predicted poor adjustment across a variety of domains
(work, family etc.); reduced life satisfaction, substance, alcohol abuse/dependency, and anxi-
ety in adulthood in a large, community sample of 800 participants.
In the developmental literature, the primary area of interest has focused on children’s malad-
justed emotion regulation (Eisenberg, Spinrad, & Eggum, 2010). This research has investigated
when normal emotional development is compromised and identified the risk factors associated
with atypical development (Cicchetti & Cohen 2006). Factors influencing the development of
emotion regulation skills include inherent disposition in addition to social and environmental
resources available to the child. Additionally, genetic pre-disposition and parental influences
have been shown to influence the development of psychopathology in adolescents (Rosenstein &
Horowitz, 1996).
From a genetic stand-point, a twin study by Eaves (2006) measuring symptoms of psycho-
pathology, demonstrated that monozygotic twins were more strongly correlated than dizygotic
twins with most measures showing small to moderate genetic effects. Concordantly, in relation
to depression, the majority of twin studies suggest a moderate genetic influence, with heritability
rates ranging between 30–80% (Eley & Plomin, 1997; Murray & Sines, 1996; Thapar & McGuffin,
1997). In general, these studies support genetic susceptibility to psychopathology across a broad
range of disorders in adolescent populations.
In relation to parental influences on emotion regulation propensities, research supports a para-
digm of adolescent psychopathology that is influenced by interpersonal interactions with parents
(Rosenstein & Horowitz, 1996). This is supported by the work of Grant (2006), who found con-
siderable evidence supporting the mediating role that family relationships play in the relation-
ship between stressors and psychological symptoms in both children and adolescents. A study
by Rosenstein and Horowitz (1996) determined, in a clinical sample of 60 adolescents psychiatri-
cally hospitalized, both child and maternal attachment style were highly concordant, manifesting
insecure attachments styles in both the adolescent and the parent. In general, when researching
parental influence on adolescent psychopathology, fathers have been highly underrepresented.
However, research shows there is substantial paternal influence; with particularly strong effects
found with relation to externalizing problems manifested in adolescents. In most cases these
effects were comparable to those associated with maternal psychopathology (Phares & Compas,
1992). A study by Achenbach (1991) determined that in four-to eight-year-olds, externalizing
problems were associated with difficulties in emotion regulation including increased levels of
anger and impulsivity. Similarly, internalizing problems were associated with enhanced levels of
sadness, impulsivity, and reduced attentional control (Eisenberg et al., 2001). These relationships
were investigated via a longitudinal design and similar findings were obtained two years later
(Eisenberg et al., 2005). In children, certain components of emotion regulation have been associ-
ated with particular behavioral difficulties. For example, inhibiting anger or expressing anger in
a maladaptive way has been linked to internalizing problems (Zeman, Shipman, & Suveg, 2002).
Similarly, in a sample of eight-to twelve-year olds with various anxiety disorders, a significant
relationship was demonstrated between psychiatric disorder and maladaptive emotion regulation
as assessed via both self and parent report measures (Suveg & Zeman, 2004). More specifically,
1
Conclusion 11
children with anxiety disorders were more likely to be inflexible, demonstrating heightened worry,
anger and negative affect when compared with children in the control conditions. Likewise, a
recent study by Tortella-╉Feliu, Balle, and Sesé (2010), determined that adolescents scoring high in
negative affect were prone to implement dysfunctional emotion regulation coping styles.
Conclusion
Emotion dysregulation is strongly associated with psychiatric illness in youth. As mentioned pre-
viously, in both children (Hughes, Gullone, & Watson, 2011) and adolescents, the use of emotional
suppression has been linked to depressive and anxious symptomology (Betts, 2009; Hannesdottir
& Ollendick, 2007; Larsen et al., 2013). Furthermore, in adolescents, deficits in emotion regu-
lation have been linked with aggressive behavior (Herts, McLaughlin, & Hatzenbuehler, 2012),
substance abuse (Wilens et al., 2013), and pathological gambling (Potenza, et al., 2011). Due to the
strong association between emotion dysregulation and psychopathology and related problems in
living, many studies have been conducted on this topic in the past 15–╉20 years. This book includes
a collection of these studies, touching on numerous contemporary topics, such as developmen-
tal psychology, developmental psychopathology, transdiagonostic issues, and cultural aspects of
emotion regulation with exciting incites from leading researchers in the field.
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Chapter 2
Self-regulation in children
The lack of emotional or behavioral regulation is often viewed as a component of psychopathology;
indeed, some types of problems are defined in part by the lack of self-╉regulation (e.g., some exter-
nalizing problems and depression/╉anxiety; American Psychiatric Association, 2013). However,
empirically, agreement has not been reached regarding what capacities are included in the con-
struct of “regulation” or “self-╉regulation” (e.g., see Eisenberg, Hofer, Sulik, & Spinrad, 2014). In
this chapter, we consider some useful conceptual distinctions in the domain of control, briefly
present heuristic hypotheses regarding the relations between regulation-╉relevant constructs and
externalizing and internalizing behaviors, and review representative empirical findings.
Conceptual issues
Eisenberg, Hofer, Sulik, and Spinrad (2014) defined emotion-╉related self-╉regulation as a process
used to “manage and change whether, when and how (e.g., how intensely) one experiences emo-
tions and emotional-╉related motivational and physiological states, as well as how emotions are
expressed behaviorally. Thus, it includes processes used to change one’s own emotional state, to
prevent or initiate emotion responding (e.g., by selecting or changing situations), to modify the
significance of an event for the self, and to modulate the behavioral expression of emotion (e.g.,
through verbal or nonverbal cues)” (p. 157). The term “emotion-╉related” self-╉regulation is used
because many of the processes/╉abilities that are part of emotion-╉related regulation can be involved
in regulating multiple aspects of functioning, which include not only the expression and experi-
ence of emotion, but also aspects of cognition, attention, and behavior that do not involve (or
secondarily or minimally involve) modulating the expression and experience of emotion. Thus,
emotion regulation, defined by Gross (2014) as “shaping which emotions one has, when one has
them, and how one experiences or expresses these emotions” (p. 6), can be viewed as occurring
when emotion-╉related self-╉regulatory skills are applied directly to the experience or expression of
emotion. Of course, external influences such as parents or providers of social support can contrib-
ute to the modulation of emotion and its expression, but for clarity, we have argued it is clearer to
differentiate such external controlling factors from self-╉regulation (Eisenberg & Spinrad, 2004).
Regardless of the specific terminology, we have suggested it is useful to distinguish between
self-╉regulatory processes that can readily become volitional when required to adapt or achieve
91
Conceptual issues 19
a goal and those “regulating” or controlling processes that affect emotion and behavior but are
harder to control volitionally. As has been discussed by researchers from multiple subdisciplines
of psychology (see Carver, 2005), many non-╉volitional processes have important modulating
(in a sense, regulating) effects on attention, behavior, cognition, and physiological responding.
Eisenberg et al. (2014) used the term “self-╉regulation” to refer to “potentially volitional, self-╉
regulatory processes.”
The interconnectedness of these constructs makes it difficult to differentiate emotion from its
self-╉regulation; someone who expresses little emotion in a potentially evocative context may be
regulating his or her emotion or simply may not be responding emotionally. Thus, it is beneficial
to focus on the processes used to manage emotion, cognition, and associated behavior, rather than
to measure the amount of emotion experienced or expressed. Consequently, when studying the
regulation of emotion, rather than look for possible self-╉regulation of emotional displays, there
are advantages to focusing on and measuring aspects of executive functioning that contribute
to self-╉regulation (e.g., executive attention) and dispositional differences in self-╉regulation that
employ the skills used for the regulation of emotion and related cognitive, physiological, and
behavioral responses.
likely than some less volitional aspects of control (see below) to result in adaptive outcomes, or
at least in desired goals (regardless of whether or not they are actually socially or functionally
adaptive) because they can be flexibly applied when needed to accommodate contextual demands
rather than being applied in a rigid manner.
Externalizing problems
Externalizing behaviors—╉“behaviors that violate the rights of others (e.g., aggression, destruc-
tion of property) and/╉or that bring the individual into significant conflict with societal
norms or authority figures” (American Psychiatric Association, 2013)—╉are associated with
adjustment problems in the academic, social, and emotional domains across the lifespan.
Externalizing problem behaviors, unified by a common theme of outward behaviors, con-
stitute a variety of behaviors: Aggression, delinquency, hyperactivity, defiance (American
Psychiatric Association, 2013), and subtypes of reactive aggression (e.g., emotionally-╉driven
aggression), covert externalizing (e.g., stealing, lying), proactive externalizing (e.g., aggression
for self-╉gain), and callous-╉unemotional trait conduct problems (e.g., unprovoked and unemo-
tional aggression; Frick, Ray, Thornton, & Kahn, 2014). Growing empirical evidence supports
the premise that emotion regulation is negatively associated—╉and impulsivity is positively
associated—╉with externalizing problem behaviors across development (Eisenberg, Spinrad, &
Eggum, 2010).
EXTERNALIZING PROBLEMS 23
combined measure of emotionality and regulation) was consistently negatively associated with
externalizing across time, but not vice versa (Blandon, Calkins, Grimm, Keane, & O’Brien, 2010).
Associations between effortful control and externalizing behaviors have also held across longer
spans of time and/or for older children (e.g., Eisenberg, Zhou, et al., 2005; Lengua, 2008). Effortful
control (i.e., attention control, inhibitory control, low activity levels) at four-and-a-half years old
was associated with lower externalizing and risk-taking behaviors at 15 years old (Honomichl &
Donnellan, 2011). Similarly, Belsky, Pasco Fearon, and Bell (2007) found that at 54 months, first
grade, and fifth grade, attention problems (measured with a continuous performance test) were
positively associated with externalizing behaviors even when controlling for their prior levels.
Wang, Brinkworth, and Eccles (2013) observed that misconduct behaviors decreased substan-
tially from 13 to 18 years of age for adolescents with higher effortful control (i.e., attention shift-
ing, activation control) at age 13. Relatedly, among nine-and-a-half-year-olds, individual growth
in effortful control (but not growth in impulsivity) predicted lower externalizing problems three
years later (King, Lengua, & Monahan, 2013).
In a recent study, among 36-month-olds assessed four times until 90 months of age in a cross-
lagged panel design, executive functioning (assessed with a set of behavioral tasks closely related
to effortful control) consistently predicted lower externalizing behaviors (Sulik et al., 2015). In
one instance, however, externalizing behaviors also predicted lower executive functioning from
48 to 60 months of age. In contrast, Eisenberg, Spinrad, Eggum, et al. (2010) found that external-
izing (and internalizing) at 30 months old significantly and negatively predicted effortful control
at 42 months old (measured with a delay task and parent/caregiver reports). However, effortful
control (although correlated with) did not significantly predict externalizing across time while
controlling for the stability of all measures (also see Eisenberg, Taylor, Widaman, & Spinrad, 2015,
with the same sample at 30 to 54 months). Thus, although executive functioning/effortful control
frequently predicts low levels of later externalizing problems, there may be age-or context-depen-
dent periods (e.g., in the transition to formal schooling) when externalizing behaviors and execu-
tive functioning abilities form a reciprocal process or, perhaps, when externalizing problems have
a stronger effect on self-regulation.
Indeed, although effortful control frequently has been associated with subsequent externalizing
problems, the relation of self-regulatory abilities to concurrent and later externalizing problems
varies across studies and samples, especially when controlling for initial levels (e.g., Eisenberg,
Spinrad, Eggum et al., 2010; Spinrad et al., 2012). Among children of Chinese immigrant parents
in the United States, effortful control (i.e., parent-and teacher-reported inhibitory control, atten-
tion focusing) measured among first and second graders was positively associated with social
competence but not with externalizing behaviors in fifth and sixth grade (Zhou, Main, & Wang,
2010). Also, among Dutch children, effortful control (i.e., parent-reported inhibitory control and
attention focusing) and delayed gratification among preschoolers (36-month-olds) were nega-
tively associated with concurrent hyperactivity and conduct problems but did not significantly
predict later measures of maladjustment in kindergarten when controlling for initial levels at 36
months old (Gusdorf, Karreman, van Aken, Dekovic, & van Tuijl, 2011). Similarly, Lengua (2003)
found that difficulty in delay of gratification was positively associated with externalizing symp-
toms concurrently, but not one year later, among third through fifth graders; however, inhibitory
control did predict lower levels of later externalizing symptoms (Lengua, 2003). These results echo
findings from a meta-analysis showing that inhibitory control, compared to executive function-
ing, was more strongly associated with externalizing behaviors among preschoolers (Schoemaker,
Mulder, Deković, & Matthys, 2013).
In examining effortful control, some researchers have also distinguished “hot” and “cool”
aspects based on the emotional and cognitive demands of the different tasks used to assess
42
effortful control (“cool” tasks often are executive functioning tasks). Di Norcia, Pecora, Bombi,
Baumgartner, and Laghi (2014) found that hot (i.e., delayed gratification), but not cool (e.g., slow
down, reverse categorization) effortful control, was negatively associated with concurrent aggres-
sion and anger among Italian preschoolers. Similarly, Kim, Nordling, Yoon, Boldt, and Kochanska
(2013) found that only “hot” effortful control (i.e., delayed gratification) was negatively associ-
ated with behavioral problems at 67–╉100 months of age. Effortful control measured with “cool”
tasks (e.g., day/╉night, motor inhibition) did not significantly predict behavioral problems unless
estimated together with delayed gratification (Kim et al., 2013). Thus, although most research
has examined effortful control as one construct given conceptual concordance and measurement
properties (Eisenberg et al., 2013), continued examination of the aspects of different effortful
control measures is warranted given that in some studies not all components of effortful self-╉
regulation have significantly predicted maladjustment (Di Norcia et al., 2014; Kim et al., 2013).
Externalizing problems 25
A type of externalizing problem that is generally proactive is conduct problems with callous
unemotional traits (i.e., unprovoked/╉unemotional aggression, lack of guilt and concern for oth-
ers; Frick et al., 2014). Temperamental fearlessness (assessed with parent-╉report measures) has
been positively associated with conduct problems or callous-╉unemotional traits among older
children and adolescents (Barker, Oliver, Viding, Salekin, & Maughan, 2011; Lengua, 2003); how-
ever, compared to children without conduct problems, first graders with conduct problems and
callous-╉unemotional behaviors exhibited more intense fear reactions (during a mask task) and
higher baseline cortisol levels at the age of two (Mills-╉Koonce et al., 2015). Perhaps intense fear
observed in toddlers, a sign of emotion dysregulation and heightened sensitivity, is a precursor to
or marker of conduct problems with callous-╉unemotional traits, and fearlessness develops later.
Alternatively, relations of fearfulness (and its regulation) may vary as a function of method of
assessing fear (e.g., observations versus parents’ reports; Mills-╉Koonce et al., 2015).
delinquent behavior, and negative urgency positively predicted aggression (Settles et al., 2012).
Continued examination of the predictive validity of impulsivity subscales and combined mea-
sures of emotion self-╉regulation will help inform various pathways to externalizing across devel-
opment (e.g., Eisenberg, Spinrad et al., 2004). For example, Morales, Beekman, Blandon, Stifter,
and Buss (2015) found that exuberance (i.e., combined measures of impulsivity and activity) was
positively associated with later externalizing in kindergarten, particularly for children with high
physiological dysregulation (e.g., low baseline respiratory sinus arrhythmia [RSA], higher RSA
suppression during an emotion stimulus).
Internalizing problems 27
training components for low-╉income parents and their preschool children attending Head Start
(Neville et al., 2013). Compared to no-╉preschool/╉Head Start-╉only control participants, PCMC-╉
A children showed increased attention regulation (measured with event-╉related potentials
[ERP] during attention tasks) and decreased problem behaviors after the eight week interven-
tion. Parents in PCMC-╉A also showed decreased parenting stress. Physiological measures, such
as those assessed with ERP, provide additional support for the regulatory mechanisms modi-
fied by intervention. Similarly, among homeless youth participating in an intervention with
emotional self-╉regulation and parenting guidance components, intervention effects on reduced
conduct problems were mediated by improvements in children’s executive functioning (Piehler
et al., 2014).
Some interventions have addressed specific needs of children. For example, Fast Track
Promoting Alternative Thinking Strategies (PATHS) integrated the classroom-╉ based socio-╉
emotional curriculum from Fast Track and additional intervention components (i.e., parent-
ing support classes, home visits) for children identified by teachers at higher risk for aggression
(Conduct Problems Prevention Research Group, 2010). Compared to controls, participants in
Fast Track PATHS showed lower aggression and higher prosocial behavior from first to third
grade, with some effects strongest for boys and children originally high in aggression (Conduct
Problems Prevention Research Group, 2010). Thus, programs addressing socio-╉emotional learn-
ing through curriculum in the classroom and home (especially for children identified at higher
risk for behavior problems) show promising results.
Across development, children increase in their regulatory capabilities but also encounter dif-
ferent sets of challenges that may require varied skills and support; for example, risk taking and
problem behaviors often show increases in the transition to adolescence (Duckworth, Gendler,
& Gross, 2014). Family-╉based interventions intended to address system-╉level factors (e.g., fam-
ily, peers, school) have found reduced problem behaviors among children and adolescents (e.g.,
Chang, Shaw, Dishion, Gardner, & Wilson, 2014; Prado et al., 2013). Together, empirical results
suggest that interventions that target different levels of the child’s system (e.g., child-╉, parent-╉,
peer-╉, and/╉or school-╉level factors) modify emotion self-╉regulation and adjustment.
Internalizing problems
Effortful control (particularly attentional control) is expected to reduce the internalizing symp-
toms of depression, anxiety, and social withdrawal. In contrast, children who are rigid, con-
strained, and behaviorally inhibited (i.e., discomfort with novel stimuli, including people; Kagan
& Fox, 2006) may be prone to internalizing problems. Thus, as discussed previously, it may be
hypothesized that children with internalizing symptoms are somewhat low in effortful control
(particularly attentional control) and reactive undercontrol (i.e., impulsivity), but high in reactive
overcontrol (i.e., behavioral inhibition).
data also support the negative relation (Eisenberg et al., 2005; 2009; Kiff, Lengua & Bush, 2011;
King, Lengua, & Monohan, 2013; Lengua, 2006; Oldehinkel, Hartman, Ferdinand, Verhulst,
& Ormel, 2007; Valiente, Eisenberg, Spinrad et al., 2006). Nonetheless, in a sample of tod-
dlers, effortful control was negatively related to toddlers’ separation distress at both 18 and
30 months of age. However, the relations became nonsignificant once stability in separation
distress was controlled (Spinrad et al., 2007; see Eisenberg, Spinrad et al., 2010, for similar find-
ings at 42 months of age).
Moreover, some investigators have found a positive relation between self-regulation and inter-
nalizing problems. For example, Murray and Kochanska (2002) reported that children with high
effortful control exhibited higher internalizing symptoms than did those with moderate effort-
ful control, although very few children in the study had severe internalizing problems. Other
researchers have reported no relations (see Lengua, 2008).
In most research, investigators have used continuous measures of internalizing and external-
izing and have not dealt with the reality of frequent co-occurrence of the externalizing and
internalizing symptoms. Thus, relations of low regulation to internalizing symptoms could be
due to the co-occurrence of externalizing symptoms. In research that examined pure internal-
izing problems, Eisenberg and colleagues (2001, 2005; Eisenberg, Valiente, et al., 2009; Wang,
Eisenberg, Valiente, & Spinrad, 2016) found little evidence of relations of effortful control to
pure (non-co-occurring) internalizing problems except in the early school years. Oldehinkel et
al. (2004) found that preadolescents with pure internalizing symptoms were lower in effortful
control than nondisordered children, but that difference was not nearly as great as for youths
with co-occurring problems. In a more at-risk adolescent sample, low effortful control pre-
dicted higher pure (non-co-occurring) depression (Wang et al., 2015). Thus, co-occurrence
and age may affect the strength of relations between indices of self-regulation and internalizing
symptoms.
It is important to differentiate between aspects of effortful control in understanding the rela-
tions. It is likely that some aspects of effortful control, such as attentional control, may be par-
ticularly important for children with internalizing problems. Specifically, attentional control is
thought to reduce bias toward negative emotions such as sadness and anxiety and may serve to
move attention from negative to neutral or positive thoughts (Derryberry & Rothbart, 1997). On
the other hand, other components of effortful control, such as inhibitory control, may be related
to internalizing problems due only to its negative associations with externalizing problems; that is,
relations of inhibitory control to internalizing problems may be inflated because of co-occurring
externalizing problems (see Eisenberg, Spinrad, & Eggum, 2010).
Indeed, children with pure internalizing symptoms, compared to non-disordered children,
exhibited deficits in attentional control at 55 to 97 months (Eisenberg et al., 2001), although
not two or four years later (Eisenberg, Sadovsky, et al., 2005; Eisenberg, Valiente, et al., 2009).
Attentional control also has been negatively associated with anxiety disorder symptoms (Muris
et al., 2004) and with boys’ anxiety and depression (Emerson et al., 2005). In longitudinal
research, low attentional control has been associated with more internalizing problems from
four-and-a-half to eleven years (or consistently high internalizing problems; Kim & Deater-
Deckard, 2011) and with withdrawal that was high and declined over six years (Eggum et al.,
2009).
Another aspect of effortful control, inhibitory control, has been examined in relation to inter-
nalizing problems, although it is conceptually less related to internalizing than attentional con-
trol. Findings have been somewhat mixed. Some researchers have reported a negative relation
between the two constructs, but potential co-occurring externalizing problems were not con-
trolled in these studies (Lengua, 2003; Rhoades, Greenberg, & Domitrovich, 2009; Riggs, Blair, &
92
Internalizing problems 29
Greenberg, 2003). On the other hand, Eisenberg and colleagues (2001) found that internalizing
children (without externalizing symptoms), compared to nondisordered children, had similar
levels of inhibitory control.
As previously noted, children’s age may moderate the relations between effortful control/╉reac-
tive control and internalizing problems. In a series of studies, Eisenberg and colleagues (Eisenberg
et al., 2001; Eisenberg, Sadovsky, et al., 2005; Eisenberg, Valiente, et al., 2009) found that whereas
the relation between effortful control and pure internalizing problems was evident in young
children, it was not found in mid-╉to late-╉elementary school. Effortful control may be linked
to children’s internalizing in younger age groups because effortful control at younger ages may
be particularly important when effortful control is rapidly developing. Further, effortful control
may be particularly important in early development when internalizing problems may require the
regulation of negative emotions of sadness and anxiety as opposed to more cognitive processes.
As further evidence for moderation by age, Dennis, Brotman, Huang, and Gouley (2007) reported
that children’s observed effortful control was negatively related to internalizing problems at age
four but not at ages five and six. However, it is clear that internalizing problems are associated with
deficits in executive functioning—╉including overlapping self-╉regulatory capacities—╉in adulthood
(see Snyder, 2013, for a meta-╉analysis). Continued research on age-╉related changes in the relations
of effortful control to internalizing problems is needed.
Other emotion regulation strategies, such as cognitive reappraisal or suppression of emotion,
have been studied in association with internalizing symptoms. Lougheed and Hollenstein (2012)
found that adolescents who had a range of emotion regulation strategies were lower in internal-
izing problems than those with limited emotion regulation strategies. In addition, adolescents’
cognitive reappraisal has been found to predict lower levels of depression, whereas suppressing
emotional expressions has been related to higher social anxiety (Eastabrook, Flynn, & Hollenstein,
2014). Similarly, rumination, defined as “the process of thinking perseveratively about one’s feel-
ings and problems rather than in terms of the specific content of thoughts” (p. 400), often has been
viewed as reflective of the lack of effective coping or self-╉regulation (Nolen-╉Hoeksema, Wisco, &
Lyubomirsky, 2008), is thought to be related to maladaptive suppression, and has been related
to a variety of internalizing problems (Nolen-╉Hoeksema, Stice, Wade, & Bohon, 2007; Nolen-╉
Hoeksema et al., 2008). Thus, it appears that internalizing problems are associated with specific
maladaptive methods of regulating emotion.
colleagues (2012) reported that children’s shyness (a construct highly related to behavioral inhibi-
tion) was positively related to internalizing problems, even after controlling for earlier levels of
internalizing symptoms. Further, Spinrad et al. (2007) found that toddlers’ inhibition to novelty
was positively correlated with separation distress at both 18 and 30 months, controlling for the
effect of effortful control.
Internalizing problems 31
understand whether relations of effortful and reactive control to internalizing problems dif-
fer across ethnic groups. In one of the few studies to examine such relations, Loukas and
Roalson (2006) reported that effortful control was negatively related to depression in both
European American and Latino adolescents. Consistent with these findings, in a sample of
Head Start preschoolers, the negative relation between regulation and internalizing problems
was not moderated by ethnicity/╉race (Hispanic versus African American; McCoy & Raver,
2011). Thus, the evidence thus far suggests that the relations of effortful and reactive control
to children’s internalizing problem behaviors are quite similar across countries and cultural
groups.
Moderating processes
Perhaps some of the inconsistencies in the relations of effortful control and reactive control to
internalizing problems are due to interactions between effortful control (or impulsivity) and other
aspects of temperament (i.e., negative emotionality, shyness) when predicting internalizing prob-
lems. Indeed, there is evidence that effortful control moderates the positive relations between
negative affect and depression/╉internalizing problems (Muris, 2006; Oldehinkel et al., 2007;
Verstraeten et al., 2009; Yap et al., 2011). Specifically, the positive relations between negative emo-
tionality and internalizing problems appear to be stronger for children low in effortful control. In
contrast, Eisenberg and colleagues (2004) found no evidence of an interaction between negative
emotionality and effortful control when predicting internalizing problems.
Relations between reactive control and children’s internalizing problems also may be mod-
erated by effortful control. White, McDermott, Degnan, Henderson and Fox (2011) found that
behavioral inhibition (reactive overcontrol) at 24 months predicted parent-╉reported anxiety dur-
ing preschool, but only for children with poor attention shifting. Similarly, in a study conducted
with adolescents in the Netherlands, behavioral inhibition predicted higher internalizing prob-
lems, particularly for children with low attentional control (Sportel, Nauta, de Hullu, de Jong, &
Hartman, 2011). Contrary to the findings for attentional control, the positive relations between
behavioral inhibition and anxiety have been found for children high in inhibitory control but
not for those with low inhibitory control, suggesting that children who are high in both inhibi-
tory control and behavioral inhibition may be somewhat overcontrolled and anxious (White
et al., 2011).
Mediating processes
The relation between effortful control and internalizing symptoms may also be mediated by
dispositional factors such as ego-╉resiliency. That is, effortful control may allow for flexible and
adaptive behavior in the face of challenge, and this flexibility may counter the development
of internalizing problems. In a number of studies, ego-╉resiliency mediated the relations of
effortful control to low levels of internalizing (but usually not externalizing) problems (e.g.,
Eisenberg, Spinrad, et al., 2004; Valiente et al., 2006). This mediated relation also has been
found in Chinese (Eisenberg, Chang, Ma, & Huang, 2009) and French (Hofer, Eisenberg, &
Reiser, 2010) samples.
In sum, the relations of effortful control and reactive control to children’s internalizing problems
are somewhat complex. Although most literature supports a negative relation between effortful
control and internalizing problems, findings are somewhat mixed. A more nuanced approach
indicates that perhaps attentional components of effortful control are more strongly related to
internalizing problems than are behavioral components (i.e., inhibitory control). Further attention
23
to moderating and mediating processes might help to clarify the relation between self-╉regulation
and internalizing problems.
Summary 33
Other research suggests that children and adolescents with co-╉occurring internalizing
and externalizing symptoms, like those with pure externalizing problems, have difficulties
with self-╉regulation. For example, in research with a behavioral measure of inhibitory con-
trol administered to aggressive children, eight-╉to 12-year-olds with pure externalizing prob-
lems, had somewhat greater problems with slowing down and monitoring responding when
needed than those with co-╉occurring internalizing problems, although the latter group still
exhibited marginally less response slowing than did nondisordered children (Stieben et al.,
2007). In a study of adolescents, Garnefski, Kraaij, and van Etten (2005) found that those
with co-╉occurring symptoms or pure internalizing were higher on the maladaptive emotion
regulation strategies of self-╉blame and rumination than those with pure externalizing or no
symptoms.
Moreover, Pang and Beauchaine (2013) found that eight-╉to 12-╉year-╉old children with co-╉
occurring internalizing (diagnosed depression) and externalizing (conduct disorder) problems
exhibited lower resting RSA and greater RSA withdrawal to emotion evocation beyond com-
promised RSA responding for pure diagnoses. Baseline RSA is often viewed as reflecting physi-
ological self-╉regulation and excessive RSA withdrawal is viewed as an index of emotional lability.
However, results on RSA and co-╉occurring internalizing and externalizing problems vary across
studies (e.g., see Hinnant & El-╉Sheikh, 2013). In contrast, in research with eight-╉to 12-╉year-╉old
aggressive children (Stieben et al., 2007), ERP responding to an emotional induction supported
the conclusion that children with pure externalizing problems had greater regulatory difficul-
ties. Results in regard to regulatory deficits may differ depending on whether the measure of
regulation taps inhibition of behavior (which may be worse to pure externalizers) or modula-
tion of emotion and related attention (which may be exacerbated by co-╉occurring internalizing
problems).
Summary
In summary, investigators have frequently found that children’s self-╉regulation is related to their
externalizing and internalizing symptoms. However, research on co-╉morbidity is limited, and
relatively little is known about differential relations with self-╉regulatory processes for various
types of internalizing problems (e.g., anxiety, depression, and social withdrawal) and externaliz-
ing problems (e.g., overt versus covert, behaviors that vary in destructiveness to others). Similarly,
more research is needed to determine if some aspects of self-╉regulation (e.g., delay skills versus
“cooler” executive attention abilities) relate to externalizing and/╉or internalizing symptoms more
than others (Kim et al., 2013).
In addition, it would be useful to examine additional moderators (besides negative emotional-
ity) of the association between self-╉regulation and children’s externalizing and internalizing symp-
toms. For example, impulsivity may interact with self-╉regulatory skills to predict maladjustment,
perhaps more at periods of development when individual differences in impulsivity are relatively
marked (e.g., in the early years and in adolescence; see Wang et al., 2015). More attention to the
mediators of the relation between self-╉regulation and children’s symptoms would also be useful;
coping efficacy or self-╉efficacy come to mind as potential mediators.
Moreover, there is limited research examining potential causal relations between self-╉regulation
and maladjustment, either in experimental designs or in longitudinal research that controls for
prior levels of maladjustment. The research suggests that relations are bi-╉directional and may vary
in causal predominance at different ages (Sulik et al., 2015).
The results from interventions suggest that children, especially those high in baseline levels
of maladjustment or other risk factors, improve more in regulation/╉lower externalizing than
43
do children with lesser levels of risk. However, there is less work on which aspects of interven-
tions (e.g., training in self-╉regulation, teaching an understanding of emotions) have the obtained
effects on reducing maladjustment. In addition, factors in children’s ecologies that might mod-
erate the association between maladjustment and effortful control, such as stress from poverty,
poor schools, or neighborhood violence, merit attention. Moreover, such contextual factors, if
they affect self-╉regulation and/╉or maladjustment, could play a role in mediated relations (e.g.,
from poverty to self-╉regulation to maladjustment; see Lengua et al., 2015).
Finally, although there seem to be more similarities than differences across cultural groups
in the relations of self-╉regulation to problem symptoms, researchers have emphasized the need
to understand the cultural processes (e.g., acculturation, cultural values) associated with child
development and demographic heterogeneity within cultural groups (García Coll et al., 1996;
Li-╉Grining, 2012). For example, Telzer and colleagues (2011) found that adolescents of European-╉
and Latino-╉American origin who endorsed strong familism values (e.g., cultural attitudes of fam-
ily respect and obligation) showed more neural activation of regions involved with self-╉control
(i.e., ventral striatum regions associated with reward processing) when making costly contribu-
tions to family in a “family assistance task” in early adulthood. That is, cultural processes (rather
than cultural group differences) were associated with self-╉regulatory processes in the context of
a culturally relevant reward task. Moreover, cultural values may affect the degree to which self-╉
regulation is valued and the degree to which externalizing or internalizing symptoms are deemed
problematic, with the consequence that acceptance of these values affects the relation between
self-╉regulation and problem behaviors. Future research examining the cultural processes associ-
ated with the development of self-╉regulation, as well as the relation between self-╉regulation to
externalizing and internalizing symptoms, could contribute to an understanding of the role of
cultural factors in self-╉regulation and maladjustment.
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34
Chapter 3
& Schweizer, 2010; Gross & John, 2003). In experimental designs, individuals are taught to use
different strategies in the laboratory, and the success of each strategy is determined based on the
degree to which emotion measures are influenced by its use (Gross, 1998; Gross & Levenson,
1993; Jackson, Malmstadt, Larson, & Davidson, 2000). Emotion outcome measures commonly
include self-╉reported affect (how emotional people report feeling at any point in time), facial
expressions of emotion, measures of peripheral psychophysiology that reflect bodily responses to
emotion, and functional signals from brain regions thought to be involved in emotion, such as the
amygdala, insula and nucleus accumbens (McRae, 2016). The changes in these different measures
are not always coordinated (Mauss, Levenson, McCarter, Wilhelm, & Gross, 2005), but concur-
rent changes in multiple measures of emotion are taken as convergent evidence that successful
emotion regulation has occurred.
Emotion regulation strategies can be organized according to the point in the emotion genera-
tion process in which they are enlisted. Referred to as the process model of emotion regulation
(Gross, 1998; Gross, 2015), this organizational framework highlights five broad categories of emo-
tion regulation strategies, those that implement regulation by: 1) situation selection, 2) situation
modification, 3) attentional deployment, 4) cognitive restructuring, and 5) response modulation.
Comparison of specific strategies across these categories has proven to be extremely fruitful, but
studies have contrasted strategies within categories as well. Because much of the empirical litera-
ture has focused upon cognitive reappraisal, it is discussed in the greatest detail below.
Cognitive reappraisal refers to attempts to reconsider, reframe, or gain new perspective on
an emotional situation in a way that changes its emotional meaning (Giuliani & Gross, 2009).
Cognitive interventions, including cognitive therapy and cognitive behavioral therapy, refer to
cognitive reappraisal as cognitive reframing (Beck & Dozois, 2011). Reappraisal itself is a nod to
the fact that our emotions are a downstream consequences of interpreting what a given stimulus
means for our goals and well-╉being (Arnold, 1960; Frijda, 1988; Lazarus & Folkman 1984; Scherer,
1997). The same objective situation or stimulus can thus evoke different emotions, depending on
whether it is appraised as consistent with, or inconsistent with, our goals. Reappraisal involves
replacing or supplementing one’s initial (often negative) interpretation of a situation’s meaning
with another meaning (often, though not always, neutral or even positive; McRae 2016). For
example, if one initially appraises the end of a romantic relationship as a loss, evoking sadness,
one might regulate this emotion in part by thinking of the benefits associated with being single
(not having to consult another person about meals, regaining activities given up during the rela-
tionship), or even looking forward to the possibility of finding a new partner. Reappraisal involves
still thinking about the emotion eliciting event, but reframing the event’s perceived meaning and
implications, and therefore the emotions that follow.
Butler et al., 2003), and what psychological mechanisms are needed to employ each strategy (e.g.,
Kanske, Heissler, Schönfelder, Bongers, & Wessa, 2011; McRae et al., 2010; Ochsner et al., 2004).
One design commonly used to investigate the effects of different emotion regulation strategies
has been to instruct participants to use a particular emotion regulation strategy, and measure one
or more dependent variables while that strategy is being used during some emotion-eliciting task.
This can be done in a between-subjects design, randomly assigning some participants to one strat-
egy (for example, expressive suppression) and others to a no-regulation control condition, and/or
another regulation condition (for example, cognitive reappraisal). Where feasible, within-subjects
designs in which participants are asked to alternate between multiple strategies, or between regu-
lation and control instructions, provide additional statistical power.
With these designs, biological measures can be used in two ways. First, they can be used to doc-
ument the extent to which some emotion regulation strategy is effective in producing the desired
emotional change. Strong negative emotions, in particular, commonly include “fight-flight” sym-
pathetic nervous system responses that can be detected peripherally with non-invasive sensors
(Cacioppo, Berntson, Larsen, Poehlmann, & Ito, 2000; Kreibig, 2010). Stressors—especially social
stressors—lasting longer than 15–20 minutes evoke a rise in cortisol that can be detected in saliva
(Kirschbaum, Pirke, & Hellhammer, 1993). Emotional stimuli also elicit increased activity in neu-
ral structures such as the amygdala (Costafreda, Brammer, David, & Fu, 2008; Phelps & LeDoux,
2005), insula (Kurth, Zilles, Fox, Laird, & Eickhoff, 2010; Phan, Wager, Taylor, & Liberzon, 2002),
and anterior cingulate cortex (Etkin, Egner, & Kalisch, 2011; Phan et al., 2002). In a typical study,
where the goal of emotion regulation is to reduce the intensity of emotional distress, such mea-
sures provide a more objective index of regulation success than subjective self-reports of affect.
These uses of biological measures are outcome-focused—measures of emotion regulation success.
Biological measures can also be used to better characterize the process of regulating emotion.
For example, a growing body of research documents the activation of brain structures known to
mediate cognitive control, such as the prefrontal cortex, while people are engaged in instructed
cognitive reappraisal (Buhle et al., 2013). Rather than documenting success in altering emotional
experience, these studies indicate that effortful cognitive control is required to implement the
instructed strategy. Although somewhat more controversial, measures of parasympathetic ner-
vous system influence on the heart (e.g., respiratory sinus arrhythmia, high-frequency heart rate
variability) have also been linked to emotion regulation effort (Butler, Wilhelm, & Gross, 2006).
These uses of biological measures are process-focused, capturing emotion regulation as a psycho-
logical experience in its own right. In the sections below, we offer more detailed explanations of
the biological measures used in each type of question, as well as offering examples from the exist-
ing literature of how these approaches have been applied.
if it is effective. However, self-╉report scales are used by participants in highly idiosyncratic ways
(Clark & Watson, 1995), and can be susceptible to bias associated with demand effects (Watson &
Vaidya, 2003). For these reasons, convergent evidence from more objective measures of emotional
reactivity is often desirable.
up-╉and down-╉regulating amusement (Giuliani, McRae, & Gross, 2008), an emotional state that is
also characterized by heightened physiological arousal (Kreibig, 2010). Developments in psycho-
physiology increasingly demonstrate, however, that the sympathetic nervous system is not quite
that simple. Although the neurons carrying sympathetic messages to the various visceral organs
do tend to travel together, they use at least two different neurotransmitters, and there is differen-
tiation of receptors as well. At a minimum, it has proved important to distinguish among effects
mediated by alpha-╉adrenergic receptors, including vasoconstriction and piloerection and among
effects mediated by beta-╉adrenergic receptors, including cardiac effects; and effects mediated by
cholinergic receptors, including sweat gland activity (Stemmler, 2003). Each major receptor type
has subtypes as well, with consequences that are still under investigation. The physiological effects
mediated by these various mechanisms often diverge, and in patterns that correspond to different
psychological states (Kreibig, 2010; Shiota, Neufeld, Yeung, Moser, & Perea, 2011).
Recognition of this diversity and fine-╉tuning of sympathetic responses is recharging research
on autonomic specificity, or the extent to which different emotions show different physiological
profiles, and has proved important for emotion regulation research as well. For example, beta-╉
adrenergic receptor-╉mediated cardiac effects (i.e., increased heart rate and cardiac output, short-
ened pre-╉ejection period) are seen when people engage in a difficult task, regardless of whether
they’ve been instructed to appraise that task as a threat or a challenge (Tomaka, Blascovich, Kibler,
& Ernst, 1997). With threat appraisal (wherein instructions emphasize task difficulty), increased
cardiac activity is accompanied by an increase in total vasoconstriction, consistent with a com-
prehensive sympathetic response. With challenge appraisal (wherein task instructions encourage
participants to “think of the task as a challenge” and of “yourself as someone capable of meeting
that challenge”), the increase in cardiac activity is intensified, yet accompanied by a reduction
in peripheral vasoconstriction, suggesting withdrawal of sympathetic influence on the arteries.
This discovery has paved the way for a rich body of research documenting threat vs. challenge
responses in a variety of important situations, as well as the benefits of challenge appraisal as
a strategy for regulating emotion in the face of stress (e.g., (Mendes, Reis, Seery, & Blascovich,
2003). As we learn more about the diversity of ANS responses that can accompany emotions
and their regulation, research may uncover similar kinds of distinctions in the effects of specific
regulation strategies.
(with blunted morning peaks but higher levels throughout the day) and reduced reactivity to
stress tasks (Elzinga et al., 2008; Miller, Chen, & Zhou, 2007). As a result, it can be difficult to
interpret individual differences in people’s cortisol responses to some tasks—╉do smaller responses
indicate successful regulation, or an individual who is so depleted that they no longer show a
healthy response to a challenging situation? Given these developments, caution is needed in inter-
preting cortisol reactivity data while these issues are being worked out.
Two important caveats are needed in conducting and interpreting research using RSA and HRV
as operational measures of emotion regulation as a process. First, as noted earlier, these mea-
sures serve as markers for effortful control processes that generalize to a variety of tasks requiring
executive function or cognitive control (Hansen, Johnsen, & Thayer, 2009; Segerstrom & Nes,
2007; Thayer, Hansen, Saus-╉Rose, & Johnsen, 2009). This means not only that these measures are
not specific to emotion regulation, but also that they are only likely to capture emotion regulation
processes that require effortful control. Second, there is ongoing debate over whether it is nec-
essary and appropriate to control for respiration rate and depth when analyzing RSA/╉HF-╉HRV
data, as changes in breathing have their own effects on vagal activation (Porges, 2007). Although
this step is commonly recommended, it should be done with an eye to theory, and the extent to
which breathing might itself reflect or covary with a psychological process of interest. Consider
that “taking a deep breath” is, in fact, a common emotion regulation strategy; by controlling for
this behavior one may actually wipe out covariation linking regulatory effort to RSA or HF-╉HRV.
Our recommendation is to report analyses both with and without controlling for respiration, and
to consider these issues carefully when interpreting findings.
period (Goldin et al., 2009). Finally, suppression also recruits the right inferior gyrus to a greater
extent than reappraisal, a region that is thought to be engaged during the inhibition of prepo-
tent responses more broadly (Garavan, Hester, Murphy, Fassbender, & Kelly, 2006; Rubia, Smith,
Brammer, & Taylor, 2003).
tight, or an emotional situation is of high intensity, distraction may be a great short-╉term strategy.
Once the individual has more time, more cognitive resources at his or her disposal, and/╉or the
initial intensity of the experience has diminished, reappraisal might be a good choice to ensure
more lasting effects.
responses to positive stimuli, rather than contrasting the regions recruited in detached versus
positive reappraisal of negative stimuli. These studies have been helpful in demonstrating that up-╉
regulation of positive emotion and down-╉regulation of negative emotion activate similar neural
regions: Left-╉lateralized dorso-╉and ventro-╉lateral prefrontal cortex, midline prefrontal regions
and bilateral parietal regions. However, some subtle differences may exist. Specifically, in one
study the rostral medial prefrontal cortex (mPFC), associated with focusing on current affec-
tive experience, was recruited more during up-╉regulation of positive emotion than during down-╉
regulation of negative emotion (Waugh et al., in press 2016).
However, one study has directly compared implications of detached versus situational reap-
praisal of negative stimuli for neural activity (Ochsner et al., 2004). A region of the left lateral PFC
was recruited more strongly during instructed situational reappraisal, whereas an area of the right
medial PFC region was recruited more strongly during detached reappraisal. This distinction may
reflect the greater emphasis on reducing perceived self-╉relevance of the stimulus in detached reap-
praisal, in contrast with the greater emphasis on manipulating information about the outside
world in situational reappraisal (Ochsner et al., 2004). Much more information is needed about
the differential cognitive mechanisms recruited by detached versus situational reappraisal, and
neuroimaging studies are likely to prove valuable in this endeavor.
Conclusion
Studies of emotion regulation have compared and contrasted several emotion regulation strategies,
using multiple measures. Measures of self-╉reported affect, sympathetic responding, and neural
activation from regions thought to index emotional intensity have been used to evaluate the suc-
cess of various emotion regulation strategies. In addition, measures of subjective effort, RSA/╉HRV,
and engagement of neural regions have been used to characterize the effortful processes engaged
during regulation. This framework has allowed for the rich characterization of a number of emo-
tion regulation strategies, but has been particularly useful for documenting the success of cognitive
reappraisal, as well, inspiring new hypotheses about the contexts in which it works best. Compared
with other strategies, cognitive reappraisal is thought to be a relatively effective way to decrease
negative emotion, although it does require intact cognitive control resources. The importance of
cognitive reappraisal in various disorders can be seen in the various chapters in this volume.
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06
Chapter 4
Managing emotions
In the last two decades, the field of psychology has witnessed a substantial interest in human emo-
tionality, including how emotions are experienced, expressed, and managed. Emotion regulation
is critical for well-╉being given that studies have demonstrated the positive relationship between
healthy emotion regulation and well-╉being domains such as adjustment, mental health, and posi-
tive social relationships (Gross, 2007). Research also shows that failure to regulate emotions is
linked to a wide range of psychopathology as well as interpersonal, social and cognitive impair-
ments (Aldao, Nolen-╉Hoeksema, & Schweizer, 2010; Rottenberg & Gross, 2003; 2007).
Despite the growing literature on emotional processes, researchers continue to debate whether
emotions are inborn, evolutionary reactions to the outside world or if they are a result of social
and cultural practices (Ekman & Friesen, 1971; Lutz, 1988). Early research on emotion sug-
gested emotions are universal and are accompanied by distinct bodily reactions (Ekman, 1965;
1984; Mead, 1975). For instance, although Ekman discussed the ability of individuals to regulate
their emotions based on what cultures determine is the appropriate emotion expression, he also
proposed that emotions should be perceived as cross-╉culturally invariant. However, contempo-
rary research using a culture-╉specific perspective of emotions suggests that emotions are social
constructions and can be best understood on the social level (Kitayama, Markus, Matsumoto, &
Norasakkunkit, 1997; Markus & Kitayama, 1991; Matsumoto, 1990). In fact, today, the universal
nature of emotions is widely accepted, but the important role socialization processes and cultural
values play on emotional expressions and processes is also considered. As such, emotions are
perceived to be the product of cultural and social processes by which their physiological, neuro-
logical, and psychological components are elicited (Cole, Tamag, & Shrestha, 2006; Kitayama &
Markus, 1994).
Cultural theories propose that the self and emotion are shaped by cultural meanings and
practices (Bruner, 1990; Markus & Kitayama, 1991; Miller, 1999). The self is closely linked to
regulation since regulatory processes have an effect on the way emotions are experienced as well
as how those emotions are expressed in social situations (Srivastava, Tamir, McGonigal, John, &
Gross, 2009). Besides, culture functions to maintain social order, and describes certain norms
regarding emotion regulation (Keltner, Ekman, Gonzaga, & Beer, 2003). In line with these
assumptions, past research has shown that there are cultural differences with respect to many
aspects of emotion regulation including emotion-╉related appraisals (Mauro, Sato, & Tucker,
1992; Roseman, Dhawan, Rettek, Naidu, & Thapa, 1995), coping (Taylor, Sherman, Kim, Jarcho,
Takagi, & Dunagan 2004; Yeh & Inose, 2002), and suppression (Matsumoto, Yoo, Hirayama, &
Petrova, 2005).
16
This chapter focuses on the social and cultural aspects of emotion regulation by examining
cultural explanations of emotional regulation differences, and documenting empirical evidence
garnered from cross-╉cultural research.
be explained in strictly physiological terms. Rather, they are social constructions, and they can be
fully understood only on a social level of analysis” (p. 309).
The way parents respond to children’s emotions is crucial to children’s self-and emotion-
regulation capabilities. Parents can either directly affect children’s emotion regulation by coach-
ing self-regulation of children or indirectly by managing the emotional demands in the family
(Thompson & Meyer, 2007). One study revealed that mothers’ problem solving responses to their
children’s negative emotions were correlated with children’s constructive coping with problems
(Eisenberg, et al., 1996). In other studies it was revealed that children of mothers who valued guid-
ing emotion development had a better emotional understanding, emotional competence and psy-
chosocial adjustment (Dunsmore & Karn, 2001; Katz, Maliken, & Stettler, 2012). Cunningham,
Kliwer, and Garner (2009) showed that mothers’ emotion coaching is negatively associated with
later internalizing and externalizing behavior. In a more recent study by Meyer et al. (2014), it
was found that children of parents who attended to and accepted emotional experiences, and
maintained more positive emotion socialization had children who had more constructive self-
regulatory strategies.
Parents’ socialization of emotions in their children seems to be important for the well-being of
children. However, cultural differences are also present in relation to the socialization of emotions.
Cross-cultural research provides us with an understanding of the similarities and differences in
the way emotions are experienced across different cultures as well as the socialization practices
that play a role in the variations of emotions (Wang & Fivush, 2005). Both the experience and
the expressions of emotion are culturally constructed and shaped by a given context (Lutz, 1988;
Russell, 1991). People are socialized in a way that teaches them which emotions are appropriate
and inappropriate in varying contexts (Elfenbein & Ambady, 2002; Parkinson, 1996). A variety
of emotional processes show cultural differences given that different beliefs and values shape our
affective life (Matsumoto, Kudoh, Scherer, & Walbott, 1988; Parkinson, 1996). Therefore, it is dif-
ficult to understand emotion regulation without an understanding of the context of the practices
that the sociocultural world creates (Cheung & Park, 2010).
Gross and Thompson (2006) in their modal model theory of emotion regulation asserted that
cognitive appraisals related to emotions are constructed by significant others’ and environment
reactions to the specific behaviors in the concept of reasons and results. They concluded that chil-
dren’s emotion regulation processes are highly influenced by their own culture in terms of their
overt versus covert behavior, the level at which it is deemed socially acceptable to express personal
goals and the degree of coping with problems. Besides, one’s goals, which are not only shaped
by internal processes but also the socio-cultural environment, are important in deciding how to
manage a particular emotion. Prosocial goals, such as the desire to avoid negatively affecting oth-
ers with one’s emotional expressions, can be an example of interpersonal goals shaped by others.
Among the emotion processes, emotion regulation is crucial for physical and mental health
and well-being. Emotion regulation consists of processes through which individuals modulate
their emotions either consciously and nonconsciously so that they appropriately respond to the
environment (Rottenberg & Gross, 2003; Thompson, 1994). Matsumoto (2006) defined emotion
regulation as “the ability to manage and modify one’s emotional reactions to achieve goal-directed
outcomes” (Matsumoto, 2006, p. 421). The concept of emotion regulation is based on the idea that
individuals are active agents in their emotional processes, and that they can control their emo-
tions by using different regulation processes (Gross, 2007). It consists of selections of and changes
in the duration, intensity, and balance of emotion-related behaviors (Cole, Martin, & Dennis,
2004; Thompson, 1990). Thus, emotion regulation is a dynamic construct and does not only imply
the suppression or control of emotion, but it also includes emotional substitution and the altera-
tion of one’s emotions depending on the purposes.
36
Knowing one’s feelings, what emotions should be expressed when, and what to do with
emotions are skills that are essential for adaptive social interactions and behavioral develop-
ment (Halberstadt, Denham, & Dunsmore, 2001; Hubbard & Coie, 1994). In the development
of these skills (i.e., emotion regulation), socialization plays a key role. To some extent, emo-
tion regulation is learned through observation of others and the teachings of parents as to the
accepted ways of expressing emotions (Denham, 1998). However, it is important to note that
the norms and beliefs of the appropriateness of emotional experience and expression change
among cultures. As Saarni (1999) states, cultural expectations from an individual are funda-
mental for emotion regulation. Learning and understanding which group of emotions are
appropriate to express, the way of expressing them, the best time to express them and selecting
the appropriate person to express them to are all constructed depending on the familial values
(Southam-Gerow, 2013).
There have been a limited number of studies that have examined the links between emotion
socialization processes and children’s emotive functioning in different cultures. For example, in a
study that examined parenting practices of mothers of pre-school-age children living in Mainland
China and those living in the Unites States, Chinese mothers’ tendency to encourage modesty in
their children was found more often as compared to American mothers (Wu et al., 2002). Chinese
mothers also considered shaming and love withdrawal to be more acceptable in terms of emotion
parenting styles in comparison with American mothers. Suveg and collaegues (2014) compared
families from the United States and China regarding family emotional expressiveness, children’s
emotional experiences and regulation. Children and families from the United States were found to
have greater emotional expressiveness than their Chinese counterparts. Furthermore, American
children reported greater under-controlled emotion that comprised externalizing types of manag-
ing emotional experiences, such as slamming doors when angry and fussing/whining when sad
when compared to the Chinese children cohort. This study also showed that family expression of
positive emotion was related to effortful emotion regulation among American children, whereas
family expression of negative emotion was associated with under-controlled emotion for both
United States and Chinese children.
It is known that typical emotion socialization of European American parents is supportive
(Warren & Stifter, 2008). Western parents also prefer to talk about the causes and consequences
of emotions (Wang, 2006). On the other hand, East Asian mothers use minimization as much
as expressive encouragement (Tao, Zhou, & Wang, 2010), and do not support children’s emo-
tion expression (Wang, 2006). In one study, to their child’s aggression toward peers, European
American mothers reported non-supportive responses such as punishment as compared to
Chinese mothers who used discussion and education to a greater extent (Cheah & Rubin, 2004).
Additionally, European American mothers reported that they would be disappointed by child
aggression whereas Chinese mothers thought they would be angry. Culture, thus, affects how
parents use socialization of emotions.
In sum, parents’ beliefs about emotion socialization and their child rearing practices are impor-
tant in children’s emotion regulation. In fact, caregivers’ emotion socialization is key to emo-
tion regulation development throughout childhood. Children take these beliefs as “… a meaning
system for constructing the self, others, and social relations.” (Trommsdorff & Heikamp, 2013,
p. 69). In general, supportive and constructive responses of parents (e.g., encouragement of emo-
tion expression) facilitate the development of competent emotion regulation skills in children
(Thompson & Meyer, 2007), while non-supportive responses (e.g., punitive responses) are associ-
ated with children’s poorer emotional competence (Denham & Grout, 1993). Besides, the experi-
ence and expression of emotion is culturally constructed, and emotions are socialized in line with
socially and culturally appropriate norms and expectations in different contexts. Therefore, it is
46
important to understand the socialization processes in different cultures in order to make sense
of emotion regulation differences.
is concerned with individual autonomy and self-╉achievement, the latter is concerned primarily
with social goals and maintaining harmony. This kind of a difference helps us to understand not
only the differences among different cultural groups, such as Western and Eastern cultures, but
also individuals who dominantly operate at either of these levels. To what extent relationships
are valued and the ways they are evaluated differ as one’s independent and interdependent selves
function. For example, in those cases in which independence is valued, relationships are evaluated
in terms of meeting one’s personal needs (Rothbaum, Weisz, Pott, Miyake, & Morelli, 2000). On
the other hand, in interdependent cultures, people want to fit in the social relationships, and one’s
self is evaluated in terms of meeting the expectations of others (Oishi & Diener, 2003; Mesquita &
Markus, 2004; Rothbaum et al, 2000).
These arguments and empirical findings have several implications for the experience of human
emotionality. The majority of the cross-╉cultural studies discuss cultural differences in emotion
regulation in relation to the American notion of emotion regulation versus non-╉Western notions.
These studies were based on the discussed cultural differences in individualism and collectiv-
ism and the micro-╉level self. The following is a review of studies that examined the relationship
between culture and emotion regulation.
One fundamental aspect of emotion regulation, which is also particularly relevant for under-
standing the role of culture, is expressive suppression. Suppression is concerned with the inhibi-
tion of the expressive, behavioral component of emotion, such as gestures or verbal expressions. It
is well known that collectivist cultures are more likely than individualistic cultures to emphasize
adjusting the self and behavior in order to maintain relationship harmony and social cohesion.
This characteristic of the culture suggests that when the expression of an emotion is possibly det-
rimental for one’s relationships, people tend to use emotional suppression which is in line with
the interdependent model of the self. Thus, suppression of emotions may be more encouraged in
collectivist cultures, with a motive to fulfill prosocial goals (e.g., suppression of anger to preserve
group harmony). On the other hand, given that suppression may create a discrepancy between
one’s inner experience of emotion and observable expressive behavior, the use of suppression may
interfere with one’s self-concept which is a characteristic of the independent self. Therefore, indi-
viduals from Western cultures could be expected to be less likely than individuals from East Asian
cultures to use emotional suppression as a regulatory process.
In line with these assumptions, Matsumoto and colleagues (2008) determined that cultures
emphasizing social order and hierarchy scored higher on emotion suppression. Additionally,
they reported that a positive correlation exists between emotion suppression and reappraisal for
cultures emphasizing social order and hierarchy. On the other hand, for cultures emphasizing
autonomy and egalitarianism, suppression scores were lower, and there was a negative correlation
between suppression and reappraisal. Other studies support this finding, as they have demon-
strated that suppression is not only more frequently applied in collectivistic cultures (Gross &
John, 2003), but it is also associated with less negative social consequences and lower negative
affect (Butler, Lee, & Gross, 2007; Soto, Levenson, & Eberling, 2005). An earlier study (Scherer,
Matsumoto, Wallbott, & Kudoh, 1988) noted that Japanese individuals reported fewer gestures
and body movement than Americans in situations of fear, anger, and sadness, as well as happiness.
This can be explained by the argument that emotional expressions and behaviors are exhibited in
a consistent manner that fits with cultural models.
Cultures also differ with respect to the promotion of events that are associated with particular
emotions. In other words, the extent to which certain events are created or facilitated varies in
accordance with cultural goals. For people in Western/individualistic cultures, the dominant cul-
tural pattern is to promote or create events that will maximize the experience of positive emotions
and minimize negative emotions (Kitayama, Markus, & Kurakawa, 2000; Tsai & Levenson, 1997).
In the typical North American culture, for instance, happiness activation is valued to a great
extent, people are encouraged and reinforced to feel happy, many contexts in which happiness is
likely to occur are created or promoted, and happiness is perceived as a result of fulfilling one’s
personal goals (Hochschild, 1995; Mesquita & Walker, 2003; Wierzbicka, 1994). Besides, indi-
viduals themselves tend to select situations in which they would engage in activities that promote
happiness (Diener & Suh, 1999). In contrast, in Japan, happiness is not one of the most important
goals of life. Pursuit of one’s individual happiness is not encouraged in the context of the society.
Instead, pursuit of the happiness of the groups or the society is the main focus. Furthermore, indi-
viduals in collectivist cultures are more likely to approach situations that foster contribution to
others and emotions are cultivated as the means to harmonious relationships (Heine et al., 1999).
Cultural differences in emotion regulation are also evident in terms of situation modification
which is an important component of emotion regulation. Individuals with a dominant indepen-
dent self emphasize personal well-being, and their own preferences; hence they tend to change the
situations to fit their needs. On the contrary, since individuals with an interdependent self are pri-
marily focused on the expectations and needs of others, they tend to accommodate others in dif-
ficult situations (Kitayama, Duffy, & Uchida, 2007; Rothbaum & Trommsdorf, 2007). Given that
76
individuals with an independent self-╉concept aim for happiness and autonomy, they use strategies
to increase self-╉confidence. For individuals with an interdependent self-╉concept, harmony is a
common goal and thus they are more willing to accept other people. Research shows that children
who are motivated by autonomy tend to change stress-╉eliciting situations to ones that facilitates
happiness (Heine et al., 2001). On the other hand, in stress-╉eliciting environments, children who
are motivated by social harmony tend to restore calmness rather than seek happiness.
Differences in emotion regulation styles within cultures were studied more than a decade ago by
Weisz, Suwanlert, Chaiyasit, Weiss, Achenbach, and Eastman (1993) within Thai and American
adolescents. In this study, parents’ reports were used to measure the differences. Researchers
reported that Thai adolescents showed more control over (e.g., shyness, compulsivity) problems
than Americans and their emotion regulation strategies were different from each other such that
Americans were more direct, open and controlled aggressive towards others under controlled
situations whereas Thai adolescents showed introversion behaviors.
Morelen and colleagues (2012) compared the way in which children in Ghana, Kenya and
America manage their anger in times of sadness. Children in Ghana were found to report display-
ing their anger in more overt, under controlled ways than Kenyan and American children. Kenyan
children on the other hand reported suppressing their anger more than children in Ghana and in
the US. These findings suggested that children in Ghana were more expressive with wider fluctua-
tions in their emotionality than children from the US and Kenya. In terms of sadness, American
children were found to exert more control over this emotion than the two groups of African
children; however, Kenyan children responded calmly to their sadness more than Ghanaian and
American children. The authors argued that these differences may be related to socialization expe-
riences, in that emotional expressivity is shaped by the expectations and responses of others to
anger expression. Specifically, most of the children who lived in the village often received harsh
repercussions for their overt emotional displays by family, whereas similar responses were not
observed in the suburban areas. Speculatively, the village children might have learned to control
their anger in response to the expectation that they would receive a punitive response to emo-
tional displays.
In another study, Zhou and Bishop (2012) examined experiential and cardiovascular out-
comes of three anger regulation strategies (expression, suppression and reappraisal) in Chinese
and Caucasian undergraduate students during a role-╉play that was used to induce anger. Results
indicated that Chinese students reported using reappraisal more frequently in anger situations
than did Caucasians; whereas, no differences were obtained for suppression. Their findings also
showed that cultural background moderated the effects of regulation strategy on cardiovas-
cular reactivity (CVR) following anger provocation. Specifically, when asked to suppress their
emotions, Caucasians showed stronger CVR, whereas, Chinese students showed stronger CVR
when instructed to express their anger. The Chinese students’ greater use of reappraisal com-
pared with Caucasians is interpreted as being consistent with the “other orientation” among the
Chinese, indicating that Chinese people are attuned to others on psychological and behavioral
levels (Yang, 1995). “Other orientation” is also related to a tendency to conform to others, strong
concern about social norms, and an attempt to create a better impression on others through self-╉
monitoring (Zhou & Bishop, 2012). Furthermore, the ability to control the impulse to express
anger is regarded by the Chinese as a good quality and is pursued as an achievement (Yang, 1995).
(2002) found that Americans appraised emotional situations as positively different from neutral;
however, Japanese and Taiwanese perceived situations in their lives as neither positive nor nega-
tive. Other studies (e.g., Kitayama at al., 2000) also evidenced that Americans were more likely to
report a higher frequency of positive than negative emotions than Japanese. These findings are in
line with the cultural models that account for the differences between independent and interde-
pendent orientations of the self.
The general assumption is that people want to feel positive emotions (Larsen, 2000), however,
the extent to which people want to regulate hedonically (i.e., to dampen their positive emotions
or to not savor them) differs across cultures. For example, Americans have been found to mainly
focus on the positive aspects of happiness; whereas, Japanese are more likely to indicate negative
aspects of happiness more so than positive ones. Research has also shown that Easterners when
compared to Westerners are more likely to experience positive and negative emotions in pre-
dominantly pleasant situations while no differences are observed in the experience of emotions
in predominantly unpleasant situations (Miyamoto, Kumagai, Lang, & Nunn, 2010). According
to Gross (1998), these cultural differences in emotional experiences are determined by cultural
scripts. The dominant cultural script in Western culture is to maximize positive emotions and
minimize negative emotions (Kitayama et al., 2000). On the other hand, the cultural script that
is dominant in Eastern culture is characterized by a tendency to seek a middle way by balancing
positive and negative emotions.
In many Eastern cultures, emotion moderation which refers to balancing positive emotions is a
more preferred emotion regulation strategy (Miyamoto & Ma, 2011). It is also possible to under-
stand the emphasis on positive-negative balance in Eastern cultures by looking at the relationship
between positive and negative emotions. Studies have revealed no significant correlation between
positive and negative affects among Western samples; whereas, in individualistic cultures there
is a negative, though small, correlation (Schimmack, Osihi, & Diener, 2002). This is in line with
the findings of other studies that observed that for Americans, positive and negative emotions are
opposites, whereas in Eastern cultures all emotions are accepted more readily (Heine et al., 1999;
Miyamoto et al., 2010).
Some emotions, such as guilt, are more valued in collectivistic cultures than individualistic cul-
tures; whereas, emotions such as pride are perceived as more positive in individualistic cultures
(Eid & Diener, 2001). The intensity and level of arousal of emotions also has a cultural component.
For instance, low arousal, pleasant emotions such as relaxation are valued to a greater extent in
collectivist cultures given that these emotions promote adjustment to others, while high arousal,
pleasant emotions such as excitement, are more valued in individualistic cultures since these emo-
tions promote influencing others (Tsai, Knutson, & Fung, 2006; Tsai et al., 2007). Westerners are
also known to be more likely to think that positive emotions are desirable and appropriate and
negative emotions are undesirable and inappropriate (Eid & Diener, 2001).
It should be noted, however, that in some cultures, collectivism versus individualism may not
be a relevant cultural dimension in terms of emotion regulation. For example, although Mexican
culture is a relatively collectivist culture, in this culture there is a culture script called simpatia
which basically emphasizes promotion of group harmony through the expression of positive emo-
tion (Triandis, Marin, Lisansky, & Betancourt, 1984). Individuals in this culture tend to prefer
high arousal emotions such as enthusiasm over low arousal emotions such as relaxation (Ruby et
al., 2012) which contradicts with other studies (e.g., Tsai et al., 2006). Therefore, it is important to
recognize that two different collectivist cultures may hold different cultural scripts; thus, research-
ers should be careful about generalizing their findings.
Cultural differences have also been reported in the prevalence and appreciation of anger, such
that anger tends to be less prevalent in interdependent than in independent cultures (Markus &
96
Kitayama, 1991). In a study by Miyake et al. (1986), infants from relatively interdependent cul-
tures were found to react stronger to their mother’s vocal expression of anger (but not joy or fear).
This finding was explained in terms of the low frequency of anger in interdependent cultures.
Moreover, the control of anger is related to high social functioning among Chinese school chil-
dren (Zhou et al., 2004). Anger not only occurred in a low frequency in interdependent culture,
but individuals from interdependent cultures also tolerated less anger. When anger was expressed
in simulated negotiations Asians and Asian Americans made smaller concessions, whereas
European Americans made larger concessions (Adam et al., 2010).
Zahn-Waxler et al. (1996) investigated how compared Japanese and American preschool
children by investigating how preschoolers reacted to hypothetical interpersonal dilemmas.
American, compared to Japanese children were reported to show more anger and undercon-
trolled emotions such as disorganized, unusual, or incoherent displays of emotion. American
mothers also encouraged their children to express emotions more than Japanese mothers.
Japanese mothers, on the other hand, used more guilt and anxiety induction strategies and
showed disappointment in the child if they failed to meet parental expectations when com-
pared with American mothers. In a study by Lewis and colleagues (2010), white American,
black American, and Japanese pre-schoolers were compared on how they reacted to success
and failure on a sticker matching task. Results showed that during the failure manipulation
condition, American children expressed more sadness than Japanese children. During the
success condition, American compared to Japanese children showed more pride; Japanese
children, on the other hand, expressed more embarrassment than American children. In dis-
cussing this finding, Lewis and colleagues argued that the Japanese children’s greater display
of embarrassment across conditions is most likely related to cultural differences in response to
being the object of another’s attention.
In attempting to understand the above findings, it is important to note that children are
socialized to regulate their emotion in accordance to their cultural script. A study by Miller,
Wang, Sandel, and Cho (2002) indicated that American mothers considered it important to
highlight their children’s success; Chinese mothers on the other hand considered it important
to discipline children. Children’s emotional responses are closely tied to the differences in
their parent’s response patterns to an event. For instance, while American parents empha-
size their children’s academic success, for Chinese children the case is the opposite (Ng,
Pomerantz, & Lam, 2007). In this study it was found that American mothers were more likely
to provide positive comments (e.g., “You are so smart!”) than Chinese mothers; Chinese
mothers on the other hand were more likely than American mothers to provide neutral and
task-relevant statements (e.g., “Did you understand what the questions were asking or did
you just randomly guess?”). Furthermore, Chinese children were reported to experience
fewer positive emotions after success, and more negative emotions after a failure as com-
pared to American children. Thus, cultural differences in parenting may affect children’s
emotional expression towards certain events. Considering the cultural models of the self, it
can be argued that being raised in an interdependent context can make it possible to be more
sensitive to negative information.
In a recent study by Miyamoto and Ma (2011), Easterners (i.e., East Asian Undergraduates)
were found to recall engaging in hedonic emotion regulation less than Westerners (i.e., European
American undergraduates) did. They also found cultural differences in emotion regulation to be
mediated by dialectical beliefs about positive emotions. Furthermore, cultural differences in emo-
tion that changed over time were partly explained by dialectical beliefs about positive emotions.
These findings were interpreted in terms of the role that cultural scripts have in shaping emotion
regulation and emotional experiences.
07
Conclusion 71
observed. Additionally, for European Americans, but not immigrant Asians, positive emotions
were associated with decreased depression. Furthermore, pure positive emotions predict better
health outcomes among Western samples, whereas mixed emotions predict better physical health
outcomes among Japanese (Miyamoto & Ryff, 2011).
Conclusion
Despite the general understanding that emotion regulation has a biological basis, the important
role of cultural context in emotion regulation has been recognized both theoretically and empiri-
cally in recent years (Cheung & Park, 2010). The process of emotion regulation takes place in
socio-╉cultural contexts and thus is affected by the environment in which it occurs. As such, how
individuals regulate their emotions is imperative in order to successfully live in social contexts
(Keltner & Haidt, 2001; Lazarus, 1991). In this chapter we reviewed research to document to what
extent an individual desires to start, intensify, or terminate emotions depends on cultural factors
as well as cultural scripts and cultural models of the self.
Several aspects of emotion regulation are influenced by cultural differences such as emotional
expression (Matsumoto & Kupperbusch, 2001), cognitive reappraisal (Yeh & Inose, 2002), and
emotional suppression (Matsumoto, Yoo, Hirayama, & Petrova, 2005). The larger social context
offers standards for what is appropriate to feel and express, and how frequently an emotion regu-
lation strategy is to be used. These standards provide expectations about the ways emotions are
regulated (Kitayama et al., 2000; Mesquita, 2001). In Western cultures, promoting one’s autonomy
and maintaining a positive self-╉view serves as important goals for emotion regulation. On the
other hand, in many non-╉Western cultures the most important goal for emotion regulation is
meeting the expectations of others and maintaining harmonious relationships.
Most of the cross-╉cultural research in this field has compared samples selected from Western
and non-╉Western samples and arrived at similarities as well as differences in emotion regulation.
For example, studies showed that emotion suppression is quite common among Asians (Gross
& John, 1998; Matsumoto et al., 2008) while emotion expression is more common in Western
cultures (Kim & Sherman, 2007). Empirical findings also suggest that the same emotion regu-
lation strategies have different effects in different cultures. Although many studies have shown
that emotional suppression is associated with psychopathology in Western countries, suppressing
emotions leads to positive outcomes for East Asians (Matsumoto et al., 2008). Therefore, behav-
iors are more likely to appear and feel right when it fits the individual’s goals. Since different
socializing practices put differing emphases on autonomy versus harmony, emotion regulation
strategies need to be tailored to these goals whilst considering the cultural microcosm in which
the person resides.
Despite the increasing studies on the social and cultural differences in emotion regulation, most
studies use Japan or China as representations of collectivist cultures and the American as repre-
sentative of individualistic cultures. More studies are needed in other Western and non-╉Western
cultures in order to reach more reliable and generalizable conclusions. For instance Middle
Eastern cultures or cultures balancing both individualism and collectivism may be interesting
to compare. Besides, since cultures are not homogenous and often support both autonomy and
harmony, within-╉culture differences should be investigated more closely. Although cross-╉national
comparisons involving cultural variables are common methods of cross-╉cultural research, coun-
tries cannot be considered cultures. The findings obtained from studies in social and cultural
aspects of emotion regulation should be examined to determine the degree to which they replicate
in other cultural groups.
27
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Chapter 5
Emotion control
The ability to control one’s emotional experiences can lead to richer, more productive, and
healthier lives. For this reason, the study of emotion regulation has played a growing role in
cross-╉disciplinary psychological research over the last two decades. As a result, we know that
appropriate emotion regulation in childhood is associated with better mental (Gross & Muñoz,
1995) and physical health (Gross & Levenson, 1993, 1997; John & Gross, 2004), reduced stress
(Martin & Dahlen, 2005), improved relationships (John & Gross, 2004; Lopes et al., 2011; Lopes,
Salovey, Côté, Beers, & Petty, 2005), increased resistance to temptation (Casey et al., 2011), and
more efficient workplace organization (Coté, 2005; Grandey, 2000). On the other hand, poor emo-
tion down-╉regulation can lead to slower reaction times to emotional pictures (Ortner, Zelazo, &
Anderson, 2013) and poorer long-╉term memory (Richards & Gross, 1999, 2000). Emotion regula-
tion has established itself as a valuable domain of inquiry in psychological science given its associ-
ations with a variety of important outcomes. Although emotion regulation has often been invoked
as a concept of relevance to the etiology, pathophysiology, and presentation of mental disorders
(e.g., Aldao, Nolen-╉Hoeksema, & Schweizer, 2010; Campbell-╉Sills & Barlow, 2007; Cicchetti,
Ackerman, & Izard, 1995; Gross, 1998; Gross & Muñoz, 1995), the concept itself has been met
with confusion (e.g., Bridges, Denham, & Ganiban, 2004; Gross & Barrett, 2011; Thompson,
1994). A theoretical understanding of emotion generation and regulation that incorporates rel-
evant findings emerging from the neuroscience literature is essential for scientific advancement
and new avenues for clinical treatment.
edition of the International Classification of Diseases (ICD-6), which included 17 categories for
mental health and psychological traits for the first time (American Psychiatric Association, 2016).
The American Psychiatric Association (APA) Committee on Nomenclature and Statistics com-
missioned the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I)
in 1952. This initial version was poorly accepted and, when utilized, exhibited poor reliability.
Clinicians could not agree which individuals belonged in which category, and it was lambasted by
Dr. Erwin Stengel who was commissioned by the World Health Organization to provide a com-
prehensive review of diagnostic issues facing both DSM-I and ICD-6 and 7 (American Psychiatric
Association, 2016). Stengel recommended progress be made toward explicitly defining mental
disorders for the purposes of reliable clinical diagnosis. It was not until DSM-III in 1980 that these
suggestions were taken fully into consideration through the construction of several important
conceptual innovations: 1) An effort toward explicit diagnostic criteria with more emphasis on
overt behavioral manifestations and 2) a multiaxial diagnostic assessment system that included
acute symptoms, trait abnormalities, medical concerns, and other psychosocial considerations
(American Psychiatric Association, 2016). Its 494 pages provided 265 diagnostic categories
(American Psychiatric Association, 1980), but concerns regarding diagnostic reliability and valid-
ity continued.
Efforts were made in subsequent revisions of the DSM to improve reliability. The DSM-5, pub-
lished in 2013, features 157 diagnostic categories. Despite attempts to improve its reliability as a
diagnostic tool, concerns remained. The traditional problem of under-accounting for dysfunction
(i.e., a disorder yet to be discovered or separated from another disorder) persisted, and another
problem emerged: The over-accounting and over-separation of mental disorder concepts which
required scientific and clinical reconceptualization (e.g., Asperger’s and autism being moved to a
single diagnostic spectrum; American Psychiatric Association, 2013). Moreover, the progression
of the DSM has historically given more attention to reliability over validity, although the DSM-5
did make significant advances in terms of validity (e.g., Clarke et al., 2013; Freedman et al., 2013;
Narrow et al., 2013; Regier et al., 2013). As such, diagnostic nosologies such as the DSM and the
ICD are continual works in progress, but each is a cultural artifact that roots itself in the language
of clinical research, clinical practice, and broader traditions and trends extant at the time.
The invocation of diagnostic categories reifies conceptualizations of mental function and dys-
function. While generally reliable across health care providers, the literature often indicates that
conventional diagnostic categories fail to achieve validity through convergent evidence with allied
disciplines such as neuroscience (e.g., Casey et al., 2013; Cuthbert, 2014; Insel et al., 2010). It is
anticipated that rapid developments in new methodologies such as genetics and neuroscience will
enhance the granularity of analysis of mental disorders. Diagnostic categories describe subgroups
with wide-ranging symptom profiles, leading to problematically heterogeneous patient groups
(e.g., Chen, Eaton, Gallo, & Nestadt, 2000; Litten et al., 2015; Wåhlstedt, Thorell, & Bohlin, 2009).
The categories limit the capacity to identify new concepts that may advance our understanding of
etiology, pathophysiology, and treatment for mental disorders. Solutions to these problems may
be found by interweaving behavioral sciences with genetics, molecular biology, cellular biology,
and neuroscience.
In response to these issues with the DSM, the National Institute of Mental Health (NIMH)
began an initiative in 2008 known as the Research Domain Criteria (RDoC; National Institutes of
Mental Health, 2008). The RDoC calls for the “development … of new ways of classifying psycho-
pathology based on dimensions of observable behaviors and neurobiological measures” (National
Institutes of Health, 2014). The RDoC is a framework in-progress, mapping current psychological
concepts onto seven units of analysis: genes, molecules, cells, brain circuits, physiology, behav-
ior, and self-report. The RDoC also offers space to accommodate current and to-be-developed
18
paradigms designed to elicit data relevant to putative psychological concepts. The ultimate goal
of the RDoC is to foster research that identifies relationships between the psychological and
biological phenomena central to mental illness and, to the extent possible, develop new, hybrid
constructs (Kozak & Cuthbert, 2016) and conceptualizations (detailed below in “Importing New
Concepts”) to better understand and improve mental health.
The research and developing perspectives on emotion and emotion regulation will be used in
this chapter to illustrate the application of the RDoC methods and models. The integration of
emotion regulation within the RDoC framework fosters intellectual cross-╉fertilization and inter-╉
disciplinary progress in understanding psychopathology. Furthermore, the controversy between
contemporary diagnostic systems and the RDoC mimics the controversy between the basic and
the dimensional conceptualization of emotion (e.g., Barrett, 1998; Barrett et al., 2007; Hamann,
2012; Izard, 2010, 2011; Panksepp & Watt, 2011). By extension, the field of emotion regulation
is also routinely criticized for issues of reliable conceptualization (e.g., Gross & Barrett, 2011;
Thompson, 1994). The RDoC, a unifying framework that is substantially agnostic theoretically,
can be a useful approach for organizing the current state of research on emotion and emotion
regulation. In doing so, it can identify key gaps on which to focus future inquiry. The aim of
this chapter is to describe the RDoC’s relevance to the study of emotions, their regulation, and
dysregulation. We outline how the tension between emphasizing DSM/╉ICD categories versus
the RDoC dimensions parallels historic disputes between views that emphasize discrete ver-
sus dimensional accounts of emotions. The two common views described here—╉the Bradley-╉
Lang view and the Gross-╉Ochsner view—╉are dimensional accounts of emotion that complement
rather than oppose common-╉sense discrete emotion (e.g., anger, sadness, fear, disgust, surprise,
happiness) views. The RDoC readily accommodates each of these views of emotion in the service
of understanding psychological disorders. At the same time, it preserves the option for viewing
them categorically.
system. Two major ideas have emerged from the important work of Bradley and Lang. First is the
biphasic model of emotion, with the notion that emotions are organized along two motivational
systems: Approach and avoidance systems. The second is the bioinformational model of emotion,
the notion that emotion-related information is linked to neural activity via propositions. This
second model posits that emotions are linked to neural activity that specifically represents the
organism’s response propositions (i.e., actions and action tendencies) distinct from its stimulus or
meaning propositions. In this section, we review insights derived from these models, explore what
they mean for emotion regulation, and evaluate them from the RDoC perspective.
The biphasic model of emotion is historically rooted in James’s hypothesis that physiology is
the basis for every emotional response—that the peripheral physiology is the emotion. Based on
the James-Lange theory of emotion, Bradley and Lang evaluated whether discrete emotions (e.g.,
fear, joy, sadness) have unique physiological profiles. Results from this line of inquiry have thus far
been largely disappointing (see Cacioppo, Berntson, & Hatfield, 1993). Instead, the physiological
reactions to emotion-laden stimuli relative to non-emotional stimuli support the idea that there
are several robust physiological indicators of emotion in general, such as electrodermal, skeletal
muscle, pupillary, and cardiac activity as well as numerous non-invasive electromagnetic, opti-
cal, and hemodynamic metrics of central nervous system activity. These indicators are loosely
correlated with one another and form valenced motivational sets (or phases) of approach and
avoidance behaviors that clearly diverge at increasing levels of emotion arousal. In other words,
increases in the coupling of central and peripheral psychophysiological indicators seems to be
determined by whether the organism is motivated to approach or avoid based on whether the
focal stimulus in question (real or imagined) is appetitive or aversive. The regulation of emotion
from this standpoint is a stimulus-induced change in one or more of these action indicators. Its
dysregulation therefore can be viewed as some inappropriate deviation from adaptive elicitation
of an approach or avoidance action set.
The biphasic motivational view complements learning and memory phenomena that play the-
oretically important roles in the etiology and pathophysiology of mental disorders and behav-
ioral dysfunction. For example, the conditioning equations described by Rescorla-Wagner and
their theoretical progeny (Mackintosh, 1975; Pearce & Hall, 1980; Rescorla, Wagner, & others,
1972) feature formulations that include summations of the intensity of both non-emotional
conditional stimuli and emotional unconditional stimuli, as well as the organism’s learning rate.
In studies of conditioned fear or reward learning, typical physiological and behavioral patterns
related to avoidance and approach to unconditional stimuli are robustly elicited. As the associa-
tion between conditional stimuli and unconditional stimuli increases over repeated trials, the pat-
terns elicited in response to conditional stimuli increasingly resemble the response elicited by the
unconditional one, demonstrating the phenomenon of emotional learning—one route of emotion
regulation to a stimulus.
Of course, emotions are elicited by imagined as well as environmental stimuli. Recognizing
this, Lang and Bradley posited that emotions are elicited through mentalization conceptualized
in a bioinformational theory of emotion (Lang, 1979), which they study through imagery para-
digms. This theory conceives of emotion as based on sensory, conceptual, and action informa-
tion in a network of propositions that includes biology as encoded neural action units. Sensory
information is coded as stimulus propositions (e.g., the spider is black), and conceptual informa-
tion is coded as meaning propositions (e.g., the spider is dangerous). Response propositions (not
stimulus or meaning propositions) are directly linked to emotions, since emotions are viewed as
actions and action tendencies: In this model, physiological activity that accompanies an emotion
is viewed as being part of, not a response to, the emotion (Miller & Kozak, 1993; Miller, 1996).
When imagining stimuli, stimulus-induced neural activation that corresponds to features and
38
meanings that do not result in action (e.g., “a black circle that is a shape” leads to no action)
is unemotional. Nonetheless, such activation may influence response proposition-╉related neural
activation that is emotional (e.g., “a black spider that is dangerous and should be avoided”, leads to
flinching upon presentation of a spider). Imagined stimuli may prompt a different physiological
profile than in vivo stimuli, in that the mental generation of such stimuli typically induces a non-╉
valence-╉specific cardiac acceleration (thus for both positive and negative imaginal stimuli), which
is viewed as reflecting emotional action engagement (e.g., Cuthbert, Vrana, & Bradley, 1991). In
contrast, in vivo stimuli such as pictures and sounds seem to elicit differential patterns of heart
rate and corrugator electromyography (EMG) based on affective valence, with negative and posi-
tive stimuli eliciting increases and decreases, respectively (Bradley, Codispoti, Cuthbert, & Lang,
2001; Bradley, Moulder, & Lang, 2005).
In the theories outlined above, relying on the three-╉systems view (Lang, 1968), emotions are
equated with action, manifested in language expression, central and peripheral physiology, and/╉
or overt behavior. Whereas non-╉human animals commonly show fairly close correspondence
between preparation and behavior (e.g., Panksepp, 1998), the link between motivational engage-
ment and overt action is weaker in humans, putatively because of the development of cortical
control mechanisms that implement a regulatory function. Emotion regulation can thus be under-
stood as a differential correspondence between central and peripheral physiological preparation
and behavior: A smile without approach, a shudder without avoidance. The three-╉systems view
foregrounds publicly observable data and intervening variables derived from them without pro-
posing hypothetical constructs that characterize their relationship to emotion as a concept (for a
review of the relationship between intervening variables and hypothetical constructs, see Kozak &
Miller, 1982; MacCorquodale & Meehl, 1948). A theory of emotion would articulate hypothetical
constructs as well as the bridge principles that connect observable variables with the constructs.
How a theory constructs these relationships sets the stage for how we understand emotion regula-
tion and its dysregulation. Some examples are delineated in Table 5.1.
Although such bridge principles can be specified, and the overall psychophysics involved can be
further refined, this view provides little with which to construct necessary and sufficient criteria
for understanding emotion dysregulation or psychopathology. What makes a changed action set
adaptive as opposed to maladaptive? How much deviation from normality can confer functional
impairment via emotion dysregulation? The Bradley and Lang view does not have much to say
about emotion regulation, and its extension to subsume that construct is not obvious. Thus, the
“emotion is action” perspective and its vast empirical database occupy a critical though incom-
plete place in the RDoC framework.
Table 5.1 Left-most column: bridge principles that can be derived from the three-systems view.
Examples of emotion regulation and dysregulation in neighboring columns. “→” symbolizes “is” or
“which means that”, “¬” symbolizes negation.
prompt actions rather than as action dispositions and observable actions. In Gross’s view, “emo-
tion regulation requires the activation of a goal to up-or down-regulate either the magnitude or
duration of the emotional response” (Gross, Sheppes, & Urry, 2011, as cited in Gross, 2013, p. 359).
Here, goal activation holds the logical status of an unobservable psychological construct that serves
as the target of regulation, instead of observable psychophysiological action (or action preparation)
that is to be changed through regulatory behavior typical of the Bradley-Lang models. Gross’s view
of emotion, which combines four major views of mentalized phenomena contributing to emo-
tion (basic, appraisal, psychological constructionism, and social constructionism), emphasizes the
commonalities among the four views, that 1) emotions elicit loosely coordinated changes in feel-
ing states, physiology, and behavior (a problematic triad that mixes inferred and observed phe-
nomena), 2) emotions unfold over time, and 3) emotions are context-dependent (Gross, 2015a).
Gross’s initial conceptualization, a major contribution to this area of research, was the delineation
of emotion regulation as behavior classified along a time-unfolding emotion-generation process,
dubbed the process model (Gross, 1998; Kalisch, Wiech, Herrmann, & Dolan, 2006; Webb, Miles,
& Sheeran, 2012). The process model demarcates emotion generation as one that begins with a
situation, followed by the attendance to a stimulus, then to a cognition, and ends in an emotional
response that provides input and changes the situation (beginning the cycle over again). This model
provided a way to classify differing emotion regulatory behaviors by the time at which they were
58
elicited in the emotion-generation cycle. Specifically, emotions can be regulated by selecting one-
self into or out of a situation, known as situation selection strategies (e.g., when one chooses to
leave a noisy room while studying), changing the situation in some way, known as situation modi-
fication strategies (e.g., telling others to “stop all the commotion”), shifting one’s attention away
from an emotional stimulus, known as attentional allocation or attentional redeployment strate-
gies (e.g., putting on headphones or distracting oneself), changing one’s interpretations towards
an emotional stimulus to reduce the emotional impact, known as cognitive change or reappraisal
strategies (e.g., interpreting the midnight noise of studying as an integral part of a memorable
university experience), and changing one’s behaviors, known as response modulation (e.g., biting
one’s lip to avoid expressing contempt at the noisemakers). Further, emotion-regulatory behaviors
can be directed at the self, known as intrinsic emotion regulation, or directed at others, known as
extrinsic emotion regulation.
In what are now classic studies, Gross demonstrated that regulatory strategies that occur early
in such an emotion-generation process are more effective at downregulating indices of negative
emotion than are response-modulation strategies, a dichotomization he termed antecedent-
focused versus response-focused emotion regulation (Gross & Levenson, 1993). Critically, he also
defined successful emotion regulation by relating the outcome to the individual’s goals. He pos-
ited that regulation is successful if the resulting emotion meets the regulator’s goals, regardless
of social norms or long-term adaptive value (Gross, 1998; Gross & Thompson, 2007; Thompson
& Calkins, 1996). Gross was able to demonstrate that instructed cognitive reappraisal, an unob-
servable process, causes robust reductions in observable indicators of emotion (those featured
in the three-systems model) relative to conditions where participants were instructed to emote
as normal or to use response-focused expressive suppression (e.g., the resistance of expressing
visible emotion on the face; Gross & Levenson, 1993). Controlled comparisons have shown that
an instruction to change one’s interpretation reduces physiological responding and self-reported
negative affect and alters facial behavior toward an emotional stimulus. At the same time, it was
found that expressive suppression had no effect on psychophysiological or self-reported indica-
tors of negative emotional responding and some studies even showed prolongation of respond-
ing. Researchers then concluded that these strategies were maladaptive because it was presumed
that the individual’s goal was to reduce negative emotional responding. Following this reasoning,
empirical links have been found indicating negative predictive effects on important indices of
cognitive performance such as memory (Richards & Gross, 1999, 2000), social function (Butler
et al., 2003; Gross & John, 2003), mental health (Gross & Muñoz, 1995), and physical health
(DeSteno, Gross, & Kubzansky, 2013). Later work sought to validate this understanding of emo-
tion regulation neurobiologically, to demonstrate both its temporality and to identify the top-
down sources of cortical control (Goldin, McRae, Ramel, & Gross, 2008; Ochsner & Gross, 2005;
Thiruchselvam, Blechert, Sheppes, Rydstrom, & Gross, 2011). Findings generally indicate that
regions such as prefrontal cortex, orbital frontal cortex, and cingulate are active in paradigms of
negative emotion downregulation via instructed cognitive control and that cognitive reappraisal
activates these areas earlier than do expressive suppression strategies.
The process model view has since been extended by borrowing concepts from cybernetic control
(Carver & Scheier, 1982; Wiener, 1961). This updated view, dubbed the extended process model
(EPM; Gross, 2015a), achieved several things. Conceptually, it separated emotion generation from
emotion regulation, it defined emotion and emotion regulation in terms of valuations, it posited
and defined three explicit stages of the emotion regulation process (identification, selection, and
implementation), and it proposed two ways in which emotions may be dysregulated at each step
of the process (regulatory failure and misregulation). By using concepts from cybernetics, the
processes of both emotion generation and emotion regulation could be defined strictly through a
68
goal-instantiated information-to-action feedback loop. First, the information from the situational
context of the world (W; World) is perceived in a sensory array (P; Perception). Next, a discrepancy
calculation is made between the percept and the goal state. If this discrepancy is large enough that
it crosses some threshold, this information will be evaluated in the form of a “good for me/bad
for me” proposition (V; Valuation). This valuation will generate allostatic emotional actions, both
mental and physical, in an effort to reduce this discrepancy. Information is finally fed back to pro-
cess the need for continued emotive action or the termination of emotive action (A; Action) if the
goal state(s) is met. Taken together, these stages are called the World, Perception, Valuation, Action
(WPVA) cycle (Gross, 2015a). The conceptual separation between emotion generation and emo-
tion regulation here is one of first-order (a control system on a passive percept) vs. second-order
cybernetics (a control system imposed on the control system that is emotion; Von Foerster, 2003).
In other words, emotion generation involves a calculated valuation of percepts made relative to
goal states, and these valuations can be generated in a multitude of ways. Indeed, various models of
emotion explain the generation of valuations in different ways, for example as an “affect program”
from the basic view, an appraisal, or as a result of a psychological or social construction. Emotion
regulation, on the other hand, is a valuation of emotions themselves. In summary, emotion regula-
tion begins with the process of evaluating a valuation (Gross, 2014).
Emotion regulation involving an evaluation of a valuation is described not as one but as three
sequential WPVA cycles (see Figure 5.1). Specifically, these are 1) the emotion identification cycle,
2) the emotion regulation strategy selection cycle, and finally 3) the emotion regulation strategy
implementation cycle (Gross, 2014, 2015a, 2015b). These cycles and their components imply a
host of ways emotion regulation can go wrong. Gross posits two classes of such dysregulation.
The first class is emotion-regulation failure, which refers to the lack of appropriate emotion regu-
lation when it would serve one’s goals. The second class is emotion misregulation, the enacting
of regulatory behavior that is counterproductive to one’s goals (Gross, 2015a, 2015b). We further
observe that emotion-regulation failure or emotion misregulation can occur at either perception
or valuation stages in each cycle. For example, in the emotion identification cycle, perception fail-
ure is a failure to detect a counterproductive emotional display (e.g., Michael impulsively screams
in a fit of rage at a cashier while trying to return an item, leading him to be kicked out of the store
without receiving a refund), whereas valuation failure is a failure to understand that one’s emo-
tional display is counterproductive to one’s goals (e.g., Meghan decides to scream at a cashier, not
understanding that this behavior will not make the cashier more likely to help her). Misregulation
can be exemplified in the emotion identification cycle as well, where perception misregulation
might involve thinking that one has or will have panic symptoms (ostensibly and ironically to
Emotion Generation
W P V A
Emotion Regulation
W P V A W P V A W P V A
Identification Selection Implementation
Figure 5.1 The extended process model of emotion generation and regulation
Reproduced from James J. Gross, The Extended Process Model of Emotion Regulation: Elaborations, Applications,
and Future Directions, Psychological Inquiry, 26 (1), pp. 130–137, doi.org/10.1080/1047840X.2015.989751,
Copyright © 2015 Routledge, with permission.
78
The takeaway 87
avoid feeling panic) and valuation misregulation might involve a valuation that one’s heart rate
represents anxious feelings (a “bad-╉for-╉me” valuation) in a social evaluative situation, leading to
greater attention to one’s heart rate, which serves to further increase one’s anxiety. As the example
illustrates, the distinctions between perception and valuation, as well as regulation failure and
misregulation, will likely have mechanistic and conceptual overlap, as each will implicate the
other. Nonetheless, it is a useful nuance that fosters the construction of hypotheses regarding the
specific mechanistic implementations of emotion regulation.
Ochsner and Gross have worked to elaborate the neural implementations of emotion regulation
from the EPM viewpoint (Ochsner & Gross, 2014). This research has demonstrated that regions
including dorsal medial prefrontal cortex, rostral medial prefrontal cortex, ventral medial pre-
frontal cortex, ventral striatum, amygdala, and insula provide neural implementation of various
valuation systems. Regions such as dorsal anterior cingulate, dorsal posterior medial prefrontal
cortex, dorsolateral prefrontal cortex, ventrolateral prefrontal cortex, and inferior parietal lobe
implement various regulatory control systems (Ochsner & Gross, 2014). Acknowledging the mul-
tifaceted nature of valuation itself, they propose that valuation can range from stimulus-╉generated
core valuations (e.g., amygdala-╉implemented threat or ventral striatum-╉implemented reward),
context-╉derived valuations (e.g., ventral medial prefrontal cortex-╉implemented contextual under-
standing) and conceptual valuation (e.g., dorso-╉medial prefrontal cortex-╉implemented concep-
tual/╉categorical understanding). The insula notably plays a role in all valuation processes in that it
is posited to account for interoceptive awareness when calculating values in a way that resembles
the James-╉Lange view (Ochsner & Gross, 2014).
Summarily, in the EPM view, emotions and emotion regulation are conceptually separate and
maintain their logical status as unobserved hypothetical constructs. The valuation component of
the EPM incorporates private data. Therefore, this viewpoint does not lend itself to the construc-
tion of bridge principles between emotion or emotion regulation and empirical indices. Brain
regions important for emotion regulation are conceptualized as either control areas or valua-
tion areas. The valuation areas can themselves be sorted into regions central to core evaluation
(important for emotion generation) or central to contextual evaluation (important for appraisal
and meaning creation). Both psychological and neuroanatomical conceptualizations of emotion
regulation based on the EPM imply a taxonomy of dysregulation and possible sources of dys-
regulation in the brain (see section “Scientific Advancement of Emotion Regulation with RDoC-╉
Consistent Thinking” below).
The takeaway
The Bradley and Lang view, supported by a wealth of empirical data, allows for a bridging between
the hypothetical construct of emotion (or specific, more granular concepts demonstrating clear
relationships with emotion) and hallmark psychophysiological observables (e.g., hemodynamic
and electromagnetic neuroimaging, skin conductance, heart rate). It also readily complements
research in other areas of psychology such as motivation, attention, learning, and memory. While
this view allows for private data such as subjective awareness, it does not describe a role for them,
which some other theorists believe should be in a comprehensive theory of emotion and psycho-
pathology. The Gross and Ochsner EPM offers an elaborated, multiple-╉process model that includes
a taxonomy of emotion dysregulation, testable across multiple implementing neurobiological
mechanisms, yet remains highly speculative. They do not equate emotion with its indicators, but
they make many assumptions about private data that cannot yet be tested given limitations in the
articulation of the model to date. The EPM appears to assume a parity between unobservables and
observables (e.g., valuation causes mental and physical action) in a way that the Bradley and Lang
8
view does not. Arguably, the virtue of each of the two views is its weakness: Bradley and Lang are
more circumspect, so data and construct map well over but cover more limited terrain, whereas
Gross and Ochsner reach further conceptually and further from observable phenomena.
Units of Analysis
Domains Genes Molecules Cells Circuits Physiology Behavior Self -Report Paradigms
Negative Valence Systems
Constructs: e.g. 5-HTT (Hariri & e.g. Serotonin e.g. GABAergic cells e.g. anterior cingulate e.g. fear e.g. avoidance e.g. Behavioral e.g. Fear
e.g. Fear (Hartley & Phelps, Holmes, 2006) (Krakowski, 2003) (Capogna, 2014) cortex-amygdala potentiated startle (Schmader & Lickel, Inhibition Schedule Conditioning
2010) (Hung, Smith, & Taylor, (Lissek et al., 2008) 2006) (Carver & White, (Hermans, Craske,
2012) 1994) Mineka, & Lovibond,
2006)
Constructs: e.g. DRD2 (Peciña e.g. Dopamine e.g. dopaminergic e.g. nucleus e.g. postauricular e.g. approach e.g. Behavioral e.g. Appetitive
e.g. Approach Motivation et al., 2013) (Salgado-Pineda, neurons (Chinta & accumbens—ventral reflex (Benning, (Schmader & Lickel, Activation Conditioning (Shabel
(Wacker, Mueller, Pizzagalli, Delaveau, Blin, & Andersen, 2005) tegmentum Patrick, & Lang, 2006) Schedule (Carver & & Janak, 2009)
Hennig, & Stemmler, 2013) Nieoullon, 2005) (Der-Avakian & 2004) White, 1994)
Markou, 2012)
Cognitive Systems
Constructs: e.g. COMT (Drabant e.g. Glutamate, e.g. Pyramidal e.g. dorsolateral e.g. pupillometry e.g. distraction e.g. Emotion e.g. Reappraise/
e.g. Cognitive Control et al., 2006) GABA (Stan et al., cells (Helmeke, prefrontal cortex- (Silk et al., 2009) behaviors Regulation Watch—Negative vs.
(Ochsner, Silvers, & Buhle, 2014) Ovtscharoff, Poeggel, amygdala (Goldin (Thiruchselvam Questionnaire Neutral (Goldin et al.,
2012) & Braun, 2001) et al., 2008) et al., 2011) (Gross & John, 2008)
2003)
Constructs: e.g. OXTR (Kim e.g. Oxytocin e.g. Fusiform gyrus e.g. fusiform e.g. eye contact e.g. emotion e.g. Affect e.g. Dyadic
e.g. Social Communication et al., 2011) (Quirin, Kuhl, & neurons (Pizzagalli gyrus—amygdala (Adams Jr & Kleck, recognition Valuation Inventory conversation tasks
(Laurent & Powers, 2007) Düsing, 2011) et al., 2002) (Faivre, Charron, Roux, 2005) performance (Tsai, Knutson, & with one member of
Lehéricy, & Kouider, (Szanto et al., 2012) Fung, 2006) the dyad instructed
2012) to regulate (Richards,
Butler, & Gross,
2003)
Constructs: e.g. Apoe4 e.g. Amyloid e.g. Pineal cells e.g. hypothalamic- e.g. cortisol (Lam, e.g. sleep (Mauss, e.g. Self- e.g. Actigraphy
e.g. Arousal (Cuthbert, (Delano-Wood plaque deposition (Waider, Araragi, pituitary-adrenal Dickerson, Zoccola, Troy, & LeBourgeois, Assessment (Baum et al., 2014)
Schupp, Bradley, Birbaumer, et al., 2008) (Sturm et al., Gutknecht, & Lesch, gland axis (Laurent & & Zaldivar, 2009) 2013) Manikin Arousal
& Lang, 2000) 2013) 2011) Powers, 2007) Scale (Bradley &
Lang, 1994)
09
constructs, as well as consider new constructs as warranted. Indeed, NIMH leadership advocates
development of “hybrid” psychological-biological constructs (Kozak & Cuthbert, 2016). Perceived
gaps or paucities in certain cells could represent potential avenues of valuable research (Cuthbert
& Insel, 2013; National Institutes of Mental Health, 2014).
The RDoC matrix represents three efforts toward validity. The first is to provide descriptive
validity by answering questions about how largely psychological constructs are implemented bio-
logically (mechanistic). This is represented in the columns of genes, molecules, cells, and brain
circuitry and will involve research in genetics, endocrinology, immunology, neuroscience, etc.
The second is to increase our ability to validly explain neurobiological functions through a pre-
liminary consensus on the questions pertaining to why a biological system works the way it does
or for what reason a neurobiological structure is as it is. This consensus is represented by the rows
of domains and constructs, which will involve the efforts of psychology working in tandem with
neuroscience and other disciplines. The third effort addresses predictive validity by providing sci-
entific evidence that may answer what might happen should changes in a certain unit of analysis
occur. In the clinical care of mental illness, such answers may be most important for quality of
life, indexed most prominently in the columns of physiology, overt behavior, and self-report. This
research will involve a cross-fertilization of research from the fields of psychology, epidemiology,
and sociology.
As it pertains to emotion, emotion regulation, and emotion dysregulation, the RDoC matrix
comfortably accommodates the concepts presented by Bradley and Lang. Arousal exists as a con-
struct within the Arousal and Regulatory Systems domain, and motivational valence is repre-
sented in two domains (Negative Valence System and Positive Valence Systems). Related concepts
of attention and perception reside in the Cognitive Systems domain. The three systems of prepa-
ratory psychophysiology, overt behaviors related to approach and avoidance, and self-report are
represented in the physiology, behavior, and self-report columns respectively. The matrix also
accommodates the concepts of Gross’s process model:
• Situation selection and modification belongs in Positive Valence System Domain > Approach
Motivation > Action Selection/Preferential Decision Making.
• Attentional deployment belongs in Cognitive Systems > Attention and Perception.
• Cognitive appraisal/reappraisal belongs in Cognitive Systems > Perception, Language, and
Cognitive Control.
• Response modulation/suppression belongs in Cognitive Systems > Cognitive Control >
Response Selection; Inhibition/Suppression.
It is abundantly clear that even these concepts can be, and perhaps need to be, unpacked.
Cognitive reappraisal, for example, involves perception, language, and cognitive control (see
McRae, Ciesielski, & Gross, 2012, for such an analysis of cognitive reappraisal).
One of the characteristics that differentiates the RDoC from the DSM is that the RDoC constructs
are selected to be firmly grounded in research on neuroscience phenomena (e.g., Infantolino,
Crocker, Heller, Yee, & Miller, in press). To date, hemodynamic neuroimaging studies focused on
emotion-regulation strategies such as those developed by Gross (1998) have primarily focused on
fear conditioning (e.g., Milad, Rosenbaum, & Simon, 2014; Phelps, Delgado, Nearing, & LeDoux,
2004) and cognitive reappraisal (Banks, Eddy, Angstadt, Nathan, & Phan, 2007; Ochsner & Gross,
2008; Ochsner et al., 2012), although some work has examined emotional suppression (Goldin
et al., 2008). Fear conditioning paradigms commonly include phases of fear habituation, fear
acquisition, fear extinction, and fear extinction recall. These components of fear learning involve
both unique and shared neural circuitry. Subdivisions and subnuclei of the amygdala, as well as
the dorsal anterior cingulate, are considered central to fear acquisition (Milad et al., 2014). The
19
The takeaway 91
basolateral complex of the amygdala, hippocampus, and infralimbic region of the medial prefron-
tal cortex are thought to interact during fear extinction (Milad & Quirk, 2012). In terms of cogni-
tive reappraisal paradigms, a meta-analysis of 48 hemodynamic neuroimaging studies revealed
involvement of cognitive control regions, including dorsomedial prefrontal cortex, dorsolateral
prefrontal cortex, ventrolateral prefontal cortex, and posterior parietal lobe, as well as bilateral
amygdala (Buhle et al., 2014). Interestingly, this meta-analysis did not find evidence of differential
ventromedial prefrontal cortex activation during cognitive reappraisal, a region that had been
thought to be important for this process in previous studies (e.g. Diekhof, Geier, Falkai, & Gruber,
2011). Functional connectivity analyses using EEG, MEG, fMRI, PET, and optical imaging meth-
ods also provide valuable information regarding the relationships between brain regions during
emotion-regulation paradigms. Functional connectivity is assessed by examining the coactiva-
tion of neural regions; regions are said to be functionally connected if their activity increases or
decreases in tandem. These analyses have demonstrated significant positive correlations of ven-
tromedial prefrontal cortex and hippocampus with amygdala during fear extinction recall (Milad
et al., 2007), and dorsolateral, dorsal medial, anterior cingulate, and orbital cortices correlate with
amygdala during cognitive reappraisal (Banks et al., 2007).
For an investigation to be aligned with the RDoC framework, it should assess specific
psychopathology-related constructs (whether basic or clinical), preferably across multiple units
of analysis. For an investigation to make progress pertinent to the RDoC aim of constructing and
clarifying conceptual granulanda, the “anchor” unit of interest might be brain circuitry (Insel
et al., 2010; Insel & Cuthbert, 2015). This focus on brain circuits, rather than brain regions in iso-
lation, reflects an important shift in neuroscience toward viewing the brain more often as a highly
interconnected and dynamic organ.
The matrix is not yet structured to foreground the effects of the environment (e.g., parenting,
culture), development (e.g., stages, such as infancy, childhood, adolescence, adulthood, and old
age, relevant biological processes, such as puberty and senescence), and learning history. These
could be conceived as dimensions orthogonal to the matrix, thus related to all of its cells, and
often must be taken into consideration when making a determination about what is healthy versus
abnormal (National Institutes of Mental Health, 2012). One could imagine a two-dimensional
matrix for each cultural context and for each stage of development, both powerful forces that
shape one’s learning history. For example, developmentally, outward exuberance may not be dys-
regulatory for children too young to understand contexts where such displays are inappropriate
(e.g., a three-year-old laughing at a solemn funeral). Culturally speaking, exuberance may not
necessarily be a positively construed experience (Tsai et al., 2006) or even functional for the indi-
vidual (Tsai, Sun, Wang, & Lau, 2016) if one’s culture imposes limits upon positive emotional dis-
plays (Matsumoto, 1990). Therefore, one of the RDoC-relevant goals will be to reliably and validly
identify for whom, where, and at what stage to predict the development of emotion dysregulation
difficulties across the lifespan to help guide intervention and prevention.
Problematic functional configurations in the Negative Valence System might be labeled anxi-
ety, whereas problematic configurations in the Positive Valence System domain might be labeled
depression, and so on. The RDoC matrix itself presents no obstacle to this kind of categorical
classification. Indeed, complementation would be preferred, as it would be unwise to disregard
decades of DSM-based clinical research. However, the bulk of the research used to support diag-
nostic classification systems is limited to one unit of analysis: self (or clinician) report. As emo-
tion scientists know well, self-reports are ultimately unsatisfactory due to their dependence on
cultural norms and individual differences in disclosure (Bradley & Lang, 2006). Some would
even consider them flawed hypotheses about one’s own functioning (Kozak & Miller, 1982; Miller
& Kozak, 1993). By encouraging study and integration of multiple units of analysis, the RDoC
29
7000
"Emotion"
0
1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015
+ ”Genes” + ”Psychophysiology”
150 150 + ”Cells” 150 150 + ”Self-Report”
0 0 0 0
1976 1994 2012 1976 1994 2012 1976 1994 2012 1976 1994 2012
300 300 300 300
+ ”Behavior” + ”Paradigms”
150 + ”Molecules” 150 + ”Circuits” 150 150
0 0 0 0
1976 1994 2012 1976 1994 2012 1976 1994 2012 1976 1994 2012
59
(b) 2000
Since RDoC
"Emotion Regulation"
1000
0
1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015
0 0 0 0
1976 1994 2012 1976 1994 2012 1976 1994 2012 1976 1994 2012
2000 2000 2000 2000
0 0 0 0
1976 1994 2012 1976 1994 2012 1976 1994 2012 1976 1994 2012
Figure 5.2 (Continued)
69
(c) 300
Since RDoC
150 "Emotion
Dysregulation"
0
1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012 2015
0 0 0 0
1976 1994 2012 1976 1994 2012 1976 1994 2012 1976 1994 2012
300 300 300 300
0 0 0 0
1976 1994 2012 1976 1994 2012 1976 1994 2012 1976 1994 2012
Figure 5.2 New publications per year containing the keywords (a) “Emotion,” (b) “Emotion Regulation,” and (c) “Emotion Dysregulation” in combination
with words pertaining to each unit of analysis, curated by the NIH-funded UCLA RDoQ Tool as a predefined term set. Shaded area represents the years that
the RDoC initiative was implemented. Note that year-by-year numbers and figures do not represent cumulative publications.
© Michael Sun, 2016.
79
likely in part due to the heterogeneity inherent in this diagnosis (Bosker et al., 2011). Results
of candidate-gene research and genome-wide association studies may converge should the field
move toward defining emotion regulatory phenotypes from the RDoC perspective. For example,
research that selects individuals based on their scores on measures of positive valence may reveal
new genetic relationships as they relate to specifically defined constructs of dysregulation, such as
failure in reward learning. Future study of molecular and cellular units of analysis in the context
of the RDoC, not only diagnostic categories, will also surely build upon existing research. The role
of dopamine receptors in reward processing is one example of existing research that fits within the
RDoC framework because this process is not unique to a specific diagnostic category (e.g., Peciña
et al., 2013; Pizzagalli et al., 2008; Vrieze et al., 2013). The RDoC is well positioned to foster and
benefit from research on potential endophenotypes, which bridge gene and disease expression
(such as major depression). Research on endophenotypes pursues narrower relationships and
shorter, intermediate causal chains (Miller & Rockstroh, 2013; Miller et al., 2016) and can readily
accommodate specific roles for emotion dysregulation in mental illness. Endophenotypes can be
used to parse the genetics of emotion dysregulation into smaller, more tractable components. It
is presumed that such components would have simpler genetic architectures than a disorder itself
(Goldstein & Klein, 2014).
In investigations that seek to clarify psychopathology, the emphasis on microbiological or
behavioral units of analysis need not and should not distract from considerations of clinical
practice and understanding. A vision for the future of clinical research must be complemented
with an understanding of present needs in the field. We recommend that researchers embark-
ing on RDoC-congruent investigations of emotion dysregulation consider questions of applica-
tion, whether that be in patient conceptualization or clinical decision making. Clinical science
has traditionally focused on impaired function and subjective distress (Antony et al., 1994), and
replacing this with a reductionistic focus on a “gene/molecule/cell/circuit for psychopathology”
impoverishes rather than enriches the phenomenological understanding of psychiatric disorders
(Miller, 2010). Research on hybrid psychology-biology concepts with diverse degrees of granular-
ity may improve assessment in such a way that prediction of dysfunction and disease course could
be made earlier. Furthermore, empirical understanding at multiple levels can provide better cut
points and more finely tuned bridge principles that can help delineate function from dysfunction,
including healthy regulation from dysregulation. Holistic assessment of an individual can result
in precision clinical care on a personal level (Insel & Cuthbert, 2015). Finally, new treatments may
be developed through a combined use of pharmacology, behavior, and mediating technological
devices (Craske, Meuret, Ritz, Treanor, & Dour, in press; Cuthbert, 2014).
How has RDoC-inspired thinking already advanced clinical understanding and clinical prac-
tice? One example comes from the study of fear-based disorders. From an observational stand-
point both in the laboratory and in clinical practice (the same standpoint that brought us the
DSM), it was surmised that repeated exposure to conditional fear stimuli reduced fearful respond-
ing (Foa & Kozak, 1986). The extinction learning laboratory paradigm and its clinical analogue,
exposure therapy, were birthed from this observation, and the latter is regularly employed for
individuals with anxiety disorders (in which excessive fear responding is a central dysregulated
mechanism). It was believed that reduced fearful responding evidenced the erasure of fearful
associations between conditional and unconditional stimuli, and efforts were made to ensure
that a reduction in fear responding was observed in-session (van Minnen & Hagenaars, 2002).
However, efforts to understand emotional learning and memory across multiple disciplines led
investigators to conclude that the reduced response was actually due to the formation of new,
non-threat-associated memories of the conditional stimulus, contrary to the widely held view of
exposure therapy. These new inhibitory memories need to be consolidated over time (typically
89
over 24 hours). Evidence of short-╉term reduction in fearful responding (e.g., habituation) during
exposure therapy sessions is no longer viewed as essential to clinical progress. Indeed, it has been
found that short-╉term extinction does not predict long-╉term extinction learning (e.g., Brown,
LeBeau, Chat, & Craske, in press; Peters, Dieppa-╉Perea, Melendez, & Quirk, 2010). These findings
have prompted a revised Emotional Processing Theory (Rauch & Foa, 2006). This new theory has
the effect of clarifying how fear regulation occurs in nature (inhibitory learning as opposed to
habituation), as well as increasing therapeutic efficiency by saving a great deal of clinician and cli-
ent effort. Although these advances predate the RDoC proper, it is this type of empirical advance-
ment that the RDoC seeks to systematically reproduce more broadly for emotion regulation.
Domains Constructs
Negative Valence Acute Threat Potential Harm Responses Sustained Threat Frustrative Non-Reward Loss
Systems Responses Responses
Emotion generation to Emotion generation to Emotion regulatory Emotion generation to Emotion generation to loss
acute threat potential threat maintenance, stop, and frustration, Non-reward
switch to sustained threat Valuation
Trait emotion Emotion generation to reward Emotion regulatory Reward-Valuation Emotion generation and
generation toward acquisition maintenance, stop, switch regulation traits, effortfulness and
rewards to sustained reward automaticity of emotion
generation and emotion regulation
Cognitive Systems Attention Perception Declarative Memory Language Cognitive Control Working Memory
External sensory- Internal perception in all Stored representations that Appraisal and Reappraisal Emotion Regulation Selection, Holding
array level perception WPVA cycles, appraisal and influence perception Situation Selection, Situation representations
in all WPVA reappraisal Modification, Reappraisal, of perception and
cycles, attentional Suppression referent for valuation
redeployment processing
Systems for Social Affiliation and Social Communication Perception and Perception and
Processes Attachment Understanding of the Understanding of Others
Self
Social emotion Social emotion generation, Social emotion generation, Social emotion generation,
generation, Extrinsic Extrinsic emotion regulation Extrinsic emotion Extrinsic emotion regulation
emotion regulation regulation
Arousal and Arousal Circadian Rhythms Sleep and Wakefulness Consider: Default Mode
Regulatory Network
Systems
Note: Default Mode Network was a considered construct within the Arousal and Regulatory Systems but was determined to not yet be ready for inclusion due to a lack of sufficient evidence. Nonetheless, it
putatively serves an important role in the goal engagement required for emotion regulation, which is not adequately captured by other constructs.
01
Table 5.5 An example of a hybrid EPM-RDoC view of emotion regulation to exemplify RDoC-type thinking.
Rows—Domain: Emotion Columns—
Units of Analysis
Constructs Sub-Constructs
Generation Initial Initial Valuation Generative Action— Initial Perception Initial Valuation Generative Genes
Perception Cognition and Action—Cognition
Behavior and Behavior
Regulation Intrinsic Regulation Extrinsic Regulation
Identification Perception of Valuation of own Intrinsic Action – Perception of other’s Valuation of other’s Extrinsic Action – Molecules
own emotive emotive states Cognition and emotive states emotive states Cognition and
states Behavior to Identify Behavior to Identify
own emotion other’s emotion
Selection Intrinsic Intrinsic Valuation of Selective Action on Knowhow (Perception) Valuation of Selective Action on Circuits
Perception Situation Selection, the emotive self of using Situation using Situation the emotive other
of Situation Situation Modification, Selection, Situation Selection, Situation
Selection, Attentional Allocation, Modification, Modification,
Situation Cognitive Reappraisal, Attentional Allocation, Attentional Allocation,
Modification, and Response Cognitive Reappraisal, Cognitive Reappraisal, Cells
Attentional Modulation and Response and Response
Allocation, Modulation on others Modulation on
Cognitive others
Reappraisal,
and Response
Modulation
Implementation Contextual Contextual valuation Implemented Contextual knowhow Contextual valuation Implemented Physiology
knowhow of of emotion regulatory regulatory action on of implementing a of implementation regulatory action
implementing a appropriateness the self in context selected strategy on others in
selected strategy context
1
0
Maintenance Perceiving one’s Valuation of Action to Maintain Perceiving one’s online Valuation of Action to Maintain Behavior
online intrinsic maintaining one’s emotion self- extrinsic regulation as maintaining one’s extrinsic regulation
regulation as online intrinsic regulatory behavior one to maintain extrinsic regulation
one to maintain regulation
Stopping Perceiving one’s Valuation of stopping Action to Stop Perceiving one’s online Valuation of stopping Action to Stop the Self-Report
online intrinsic one’s online intrinsic emotion self- extrinsic regulation as one’s extrinsic extrinsic regulation
regulation as regulation regulatory behavior one to stop regulation
one to stop
Switching Perceiving one’s Valuation of switching Action to Switch to Perceiving one’s online Valuation of switching Action to Switch Paradigms
online intrinsic one’s online intrinsic another emotion self- extrinsic regulation as one’s extrinsic to another extrinsic
regulation as regulation regulatory behavior one to switch regulation regulatory behavior
one to switch
2
0
1
current RDoC framework. Time will tell which functionalism serves as a better explanation across
units of analysis and in their associations with one another.
It might be argued that emotion regulation, given its centrality in psychopathology, deserves
its own domain in the RDoC matrix. Indeed, this discussion did occur in the Cognitive Systems
domain workgroup (National Institute of Mental Health, 2011). As it is viewed currently, research
relevant to emotion regulation is scattered across the matrix. Research on maladaptively up-╉
regulated fear and anxiety falls primarily within the Negative Valence Systems domain, whereas
the lack of generated reward valuation in anhedonia and adaptive habit formation involves the
Positive Valence System domain. Top-╉down regulatory strategies involve the Cognitive Systems
domain, and their adaptive and maladaptive use in social contexts involves the Social Systems
domain. Finally goal engagement, a critical referent in emotion regulation, involves the Arousal
and Regulatory Systems domain. This distribution across the matrix of constructs related to
emotion regulation may fuel more confusion than seems necessary. It should be noted that, as
improvements in conceptual clarity accrue, we are likely to see a blurring of boundaries between
traditional psychological concepts such as cognition and emotion (Miller, 2010). One may wish
to adopt a hybrid conceptualization for this reason. Whether one decides to adopt the current
RDoC matrix or a hybrid matrix yet to be drafted, it should be noted that “the usefulness of any
approach will ultimately rest upon the degree to which it promotes an empirical understanding of
the emotions and their role in behavior” (Panksepp, 1982, p. 421).
Acknowledgements
We would like to thank Richard LeBeau, Anna S. Lau and members of the Anxiety and Depression
Research Center (ADRC) as well as the Culture Attention Emotion Science and Research
(CAESAR) lab for their helpful comments during the preparation of this chapter. Michael Sun
gratefully acknowledges the generous financial support of the Graduate Research Mentorship
award (with Michelle Craske) from the UCLA Graduate Division as well as a training fellowship
with the National Institute of Mental Health (NIMH) of the National Institutes of Health (NIH)
under award number T32-╉MH015750.
3
0
1
Acknowledgements 103
Meghan Vinograd gratefully acknowledges the generous financial support of the Graduate
Research Mentorship award (with Michelle Craske) from the UCLA Graduate Division as well as
the UCLA Depression Grand Challenge Research Fellowship.
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Part II
Emotion Regulation
and Child and Adolescent
Psychopathology
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Chapter 6
Diagnostic criteria
Attention Deficit Hyperactivity Disorder (ADHD) is considered one of the most pervasive disor-
ders of childhood (Castellanos & Tannock, 2002). ADHD frequently persists into adolescence and
adulthood and is consistently associated with a range of negative outcomes. The term ADHD was
first coined as part of the restructure and enhancement of the Diagnostic and Statistical Manual
of Mental Disorders (DSM) by the American Psychiatric Association (American Psychiatric
Association, 1980); prior to this, children with ADHD were diagnosed with brain dysfunction or
brain damage with hyperkinesia (Barkley, 1990).
The diagnostic criteria for ADHD has undergone several changes, but most notably, the DSM-╉
IV (American Psychiatric Association, 2000) has classified behavioural symptoms comprising
three major subtypes: Inattention (I), hyperactivity-╉impulsivity (HI), and Combined. Children
presenting with the inattentive subtype have difficulty with tasks that require sustained mental
effort, are more disorganized and are easily distracted and forgetful when compared to peers of
a similar age (Sergeant, Oosterlaan, & van der Meere, 1999). Children with the HI subtype were
characterized as more fidgety, restless and “squirmy” when compared to typically developing chil-
dren. The combined subtype is the most commonly diagnosed sub-╉type and involves six or more
symptoms of each of the inattention and hyperactivity subtypes (APA, 2000). Research has shown
children with ADHD, as compared to other children, also have difficulty inhibiting on-╉going
behavior (Oosterlaan, Logan, & Sergeant, 1998) and difficulty inhibiting immediate gratification
(Douglas & Parry, 1983). As with attention problems, these difficulties lead to serious problems in
home and school functioning.
The fifth revision of the DSM (DSM-╉5; American Psychiatric Association, 2013) characterized
ADHD as a neurodevelopmental disorder consisting of a pattern of inattention and/╉or hyperac-
tivity-╉impulsivity that affects every day functioning. It further specifies the severity of ADHD as
mild (involving minor impairments with few, if any, symptoms in excess of the six required for
diagnosis), moderate (impairment between mild and severe), and severe (marked impairment
and with several symptoms in excess of those necessary for a diagnosis). The DSM-╉5 suggests that
these symptoms should have persisted for at least six months, directly impacting social and aca-
demic/╉occupational activities and be present before the age of 12 years. Additionally, the DSM-╉5
allows for diagnosis in adolescents and adults, including types of behaviour and examples of how
the disorder could manifest itself in different age groups. The symptoms are expected to persist for
at least five months in individual above the age of 17, unlike six months for children and adoles-
cents; moreover, those aged 17 and older need to exhibit only five of the requisite symptoms, not
the six required for younger children.
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Prevalence
There is growing consensus that ADHD occurs in approximately 5% of school-╉aged children, a
prevalence rate that is seen across cultures (Esser, Schmidt, & Woerner, 1990; Polanczyk et al.
2007; Polanczyk et al. 2014). However, ADHD prevalence rates diverge widely as a result of age,
definition of disorder and assessment method. Distinctions based on definitions (e.g., clinical
classifications of ADHD versus scores on a behavior checklist) and more rigorous assessment cri-
teria lead to fewer cases of ADHD. For example, a review of 86 studies using the DSM-╉IV criteria
(American Psychiatric Association, 1994) indicated the prevalence of ADHD ranged from 5.9%
to 7.1% (Willcutt, 2012). ADHD diagnosis also seems to be influenced by parental practices and
beliefs. As reported by Asherson and colleagues (2012), in Asian countries such as Hong Kong
and Taiwan parental monitoring of child behavior is considered essential in reducing disruptive
behaviors and poor habits, thereby influencing diagnosis and access to treatment. Variations in
the prevalence rates of ADHD in different countries has raised a question to whether ADHD is
a universal syndrome affecting children worldwide regardless of race and society (Bauermeister
et al., 2010; Goetz et al., 2010; Polanczyk et al., 2007) or a cultural construct generally based on a
Western conceptualization (Asherson et al., 2012; Faraone et al., 2003; Jacobsen, 2002; Timimi &
Taylor, 2003).
Gender differences
ADHD is observed more often in boys than girls, with a male to female ratio approximating
three to one (Skounti, Philalithis, & Galanakis, 2007). Relatedly, girls have been found to have
lower levels of inattention, hyperactivity, and oppositional/╉defiant behaviour compared to boys.
Research shows that boys under the age of 13 years tend to be overt and display severe disruptive
behaviours in the classroom; whereas, girls appear to exhibit more cognitive and academic prob-
lems (Gaub & Carlson, 1997). In addition, females are less likely to be identified in samples due to
the manifestation of the disorder, as they are less likely to exhibit disruptive behaviors compared
to ADHD males, and are more likely to go unnoticed if they present inattentive behaviours (Gaub
& Carlson, 1997). Importantly, a large number of referral for ADHD males who exhibit disruptive
behaviours occur in school settings; therefore, females who similarly display disruptive behaviors,
may be ignored (Gaub & Carlson, 1997; Gershon & Gershon, 2002).
Psychosocial impairment
As mentioned previously, children with ADHD often suffer from academic and social impair-
ments. Academic deficits, school-╉related problems, and peer neglect tend to be most associated
with elevated symptoms of inattention; whereas, peer rejection and, to a lesser extent, accidental
injury are frequently linked with symptoms of hyperactivity or impulsivity (Willcutt et al., 2012).
Compounding the stress for a person with ADHD, family relationships are consistently strained
and lead to discord and negative interactions. In addition, attentional problems frequently have a
significant impact on rates of mother–╉child rejection; however for fathers, rejection seems to sig-
nificantly impact their children’s attention problems (Lifford, Harold, & Thapar, 2008). Moreover,
peer relationships are affected by peer rejection, neglect, or teasing of the individual with ADHD.
In its severe presentation, ADHD is markedly impairing, due to its deleterious impact on social,
familial, and scholastic/╉occupational functioning (Hinshaw & Melnick, 1995; Hoza et al., 2005).
Individuals with ADHD have significant difficulty regulating their initial thoughts, behav-
iors, and emotions during a given task, thereby impacting their ability to successfully manage
tasks and achieve their desired outcomes (Barkley, 2006). A main feature of ADHD is difficulty
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Comorbidity 115
with behavioral inhibition and self-╉regulation, with several models supporting this (Cleary &
Zimmerman, 2004). One such model primarily conceptualizes ADHD as an issue of behavioral
inhibition, which in turn, leads to a flawed concept of time awareness culminating in ineffective
time management (Barkley, 2006). This model closely links ADHD and its constructs to executive
function—╉a system that underlies the capacity for self-╉organisation and goal-╉directed actions;
thus, impairments in executive functioning result in behavioral disinhibition. Barkley claims that
the foundation for the key symptoms of ADHD (i.e., impulsivity, inattention, and hyperactivity) is
the result of the initial inability to diminish pre-╉potent responses to a given situation. Behavioral
inhibition allows individuals to halt an on-╉going response or response pattern; thus, creating a
delay and permitting self-╉directed action (Barkley, 2006). These self-╉directed actions are outlined
by core executive function processes, such as planning and working memory (Elliott, 2003); this
delay in time and executive functioning during normative functioning is what leads to effectual
and appropriate actions in addition to appropriate expression of emotions in relation to a task.
In contrast, for individuals with ADHD, difficulties inhibiting behavior and creating this delay
indicates they are often unable to prevent immediate responses to situations, such as answering
or talking out of turn, moderating emotional responses, controlling movements, or maintaining
attention and focusing on tasks with little immediate reward or positive consequence (Travell &
Visser, 2006).
Emotional impairments in children and adolescents with ADHD involve poor self-╉regulation
of emotion, excessive emotional expression, problems with anger and aggression, and greater
problems coping with frustration and empathy. Studies show that children with emotional and
behavioral difficulties are impulsively emotional and lack the ability to regulate their behavioral
responses to emotionally provoking events when compared to children without emotional and
behavioral difficulties (Cross, 2011).
Comorbidity
ADHD is highly comorbid with externalising disorders such as conduct disorder and opposi-
tional defiant disorder (ODD) (with comorbidity rates ranging from 43% to 93%) and internalis-
ing disorders (with comorbidity rates ranging from 13% to 51%) including anxiety and depression
(Jarrett & Ollendick, 2008). Moreover, children with ADHD are highly likely to develop ODD,
which involves difficulties with expressions of anger, hostility, frustration, and aggression toward
others, especially towards authority figures such as parents, alongside problems such as dis-
obedience. Boys with ADHD and comorbid ODD or conduct disorder in particular, have been
found to suffer from the impaired regulation of negative emotions (Melnick & Hinshaw, 2000).
Concordantly, approximately 45% of children with ADHD may also develop conduct disorder.
Furthermore within a subset of those with ADHD and conduct disorder the likelihood of child-
hood psychopathy such as callousness, lack of emotion and low empathy for others is increased
(Waschbusch, 2002).
Importantly, callous unemotional traits have been found to be prevalent in ADHD even after
controlling for conduct disorder (Musser et al., 2013). Marsh et al. (2013) compared ten to 17 year
olds with and without psychopathic traits on the subjective experiences of emotion during five
recent emotionally evocative life events. Their findings revealed that fewer children with psycho-
pathic traits reported the subjective experience of fear relative to other emotions. These results
suggest that comorbid psychopathy impairs fear learning, physiological responses to threats, and
the recognition of fear in others, as these children have difficulties expressing and displaying pro-╉
social emotions and behaviors, which is characterized by lower levels of empathy, a lack of a sense
of guilt or remorse, shallow or blunted affect, in conjunction with physiological under arousal
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(Kimonis et al., 2008). These callous unemotional traits are therefore, important when consider-
ing emotional arousal and regulation in ADHD. As but one example, Musser et al. (2013) tested
ADHD children with age appropriate levels of pro-╉social behaviors and those with low levels
of pro-╉social behaviors on affect based tasks measuring emotional suppression and arousal. The
results from this study showed that children with ADHD and low pro-╉social behaviours displayed
a reduced level of arousal and elevated emotion dysregulation, which highlights the significance
of physiological responses in ADHD and emotion regulation.
ADHD also has a negative effect on the emotional wellbeing of the affected child or adolescent,
including those at risk for major depression (Edbom et al., 2006). Research additionally shows
that 75% of children diagnosed with ADHD are likely to have mood disorders and are therefore,
at an increased risk of developing depression (Biederman et al. 2008). Furthermore youths with
ADHD show greater levels of depressive symptoms, compared to those without ADHD (Lee et al.,
2008). A recent study by Seymour et al. (2014) found that emotion regulation mediated symptoms
of depression in ADHD youth, such that young people with ADHD and comorbid depression
exhibited poor emotion regulation strategies. Seymour et al. argue that this could be as a result of
executive function deficits, in particular working memory. Specifically, those with impairments
in working memory and inhibition experience and express heightened emotions in response to
emotionally laden stimuli when compared to individuals with intact working memory; as work-
ing memory affects the ability to effectively appraise emotional stimuli and supress negative and
positive emotions.
Executive dysfunctions
Executive functions are a set of inter-╉related cognitive processes that allow for effective prob-
lem solving, and facilitate goal directed activities; these processes are comprized of inhibition,
working memory, attention shifting, planning, initiating tasks, detecting and correcting errors
(Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). Researchers indicate that self-╉regulatory
processes underlie cognitive, behavioral and emotional regulation (Berger, Kofman, Livneh, &
Henik, 2007; Posner & Rothbart, 1998). This suggests that executive functions are involved in the
self-╉regulation of emotions in goal directed situations (Zelazo & Cunningham, 2007).
Emotion regulation has been found to be consistently linked to inhibitory processes; for exam-
ple, a study of typically developing preschool children’s performance on an emotion regulation
task (i.e., responses to a disappointing gift) significantly correlated with responses on tasks inves-
tigating inhibitory processes (i.e., Simon Says) and suppression or slowing of responses (e.g., not
pulling a lever or drawing a line very slowly) (Carlson & Wang, 2007). Moreover, a study measur-
ing the performance of young adults during a Stroop task revealed that this measure of inhibitory
functions and conflict monitoring was linked with the ability to successfully manage negative
responses to unfamiliar and visually unappetizing food (Kieras, Tobin, Graziano, & Rothbart,
2005). Additionally, when asked to divide their attention by remembering an eight-╉digit number
during a task to challenge executive function processing capacity, individuals were increasingly
found to have difficulties modulating their negative responses. This is supported by Walcott and
Landau’s (2004) findings, in that emotion regulation was strongly associated with the speed of the
inhibition process using tasks such as the Stop Signal Reaction Time Task (SSRT).
Hoeksma, Oosterlan, and Schipper (2004) found that in children aged between ten and 13
anger variability over a number of days was strongly associated with outcomes on SSRT, which
measures the time needed to stop an inappropriate response. This is a further indication of behav-
ioral inhibition, as studies show that deficits in SSRT also reflect impairments in attentional and
cognitive processes (Alderson, Rapport, & Kofler, 2007). Rich et al. (2008) showed that children
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with severe mood disorder had problems with attentional orienting and initial attentional pro-
cessing; moreover, approximately 80% of their participants had comorbid ADHD. This suggests
that the underlying processes involved in ADHD are also related to attentional processes and
emotion regulation, supporting the view that executive function task difficulties are closely linked
to ADHD and emotion regulation (Skirrow, McLoughlin, Kuntsi, & Asherson, 2009).
As outlined earlier, children with ADHD consistently display deficits in most areas of executive
functions (Barkley, 2006). Research suggests that behavioral disinhibition is an important charac-
teristic of ADHD; Nigg (2001) suggests there are two distinct forms of impairments in inhibition
that can be applied to ADHD. Firstly, motivational inhibition automatically ceases an on-going
response that is usually caused by fear or anxiety as a result of a novel event. Secondly, execu-
tive inhibition involves processing of the deliberate suppression of a response for goal-directed
purposes. As proposed by Barkley’s (1997) behavioral disinhibition theory, children with ADHD
do not effectively respond to social circumstances, but rather display rules detached from the
emotional context of the situation. These children therefore, appear more dysregulated as they fail
to consider social cues and rules, thereby appearing more socially dysregulated. According to this
theory, the successful regulation of emotions would therefore, depend on successful behavioral
inhibition. This is supported by a study investigating behavioral disinhibition and its associations
to emotion regulation using a frustration-inducing task (Walcott & Landau, 2004). In this study,
boys with and without ADHD were explicitly given instruction to hide their emotional display
in the presence of a peer. Results determined that boys with ADHD failed to succeed on this
task, whereas, non-symptomatic boys were more effective at regulating their emotional displays
in response to contextual demands. Importantly, disinhibition scores were higher for boys with
ADHD than those without ADHD (Walcott & Landau, 2004).
The findings discussed above are generally supported by imaging data investigating executive
processes and ADHD, whereby the frontal regions of the brain are associated with inhibitory con-
trol and emotional processing (Posner et al., 2011). Thus, children with ADHD are shown to have
increased activation in prefrontal regions, relative to healthy controls on an emotional process-
ing task; these findings were specific to emotional processing even after controlling for cognitive
processes. Essentially, this indicates that normal function in the prefrontal regions are impaired
in ADHD, however, they may also mediate or facilitate affective responses i.e., negatively valenced
words such as “kill” drew increased attention than neutral words such as “month;” similarly posi-
tive words could induce self-reflection to a greater extent than neutral words (Posner et al., 2011).
In relation to emotion regulation, Shaw et al. (2014) proposed a top-down regulatory pro-
cess and bottom-up mechanistic theory to explain the processes affecting emotion regulation in
ADHD. According to a bottom-up psychological mechanism, the attention systems identify emo-
tionally significant stimuli and exert control—an aspect that is thought to be impaired in ADHD.
In contrast, in healthy individuals, affectively salient stimuli receive appropriate sensory coding
and early detection, whilst this effect is significantly reduced in ADHD as a result of heightened
emotions (i.e., the over perception of negative stimuli). Concordantly, the accurate identification
of emotions in human faces is associated with well-regulated behavior; thus, misperception could
be caused as a result of emotion dysregulation. Furthermore, aversion to delayed rewards is an
indication of impulsivity; this is mediated in the limbic regions of the brain, which are also respon-
sible for emotion processing; thus, it is probable that these brain regions may also be involved in
emotion regulation (Musser et al., 2013; Shaw et al., 2014).
In relation to top-down regulatory processes, the importance of the autonomic nervous system
is paramount, as it recognizes emotional valence and task demands, particularly when the stimuli
are negative rather than positive. This is difficult for those with ADHD because they lack physi-
ological indicators of regulation. Thus, the inability to focus on a goal or allocate appropriate levels
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of attention to a task means that individuals with ADHD have difficulties managing emotions or
focusing on emotional stimuli. For example, when completing an emotional Stroop task, the per-
formance of adolescents with ADHD is severely impaired when compared to healthy counterparts
(Posner et al., 2011).
Neural mechanisms
ADHD is a neurodegenerative disorder with most models highlighting deficits in the frontal lobe
networks. In particular the prefrontal cortex (PFC) region has been consistently found to mediate
cognitive control processes, including decision-╉making and emotion regulation, in particular the
orbitofrontal cortex, dorsomedial prefrontal cortex, anterior cingulate gyrus, dorsolateral pre-
frontal cortex and ventrolateral prefrontal cortex (Phillips, Ladouceur & Drevets, 2008). Shaw
et al. (2014) claim that for individuals with ADHD, the prefrontal regions, including the ventro-
lateral, orbitofrontal and medial prefrontal cortices are impaired. Plessen and colleagues (2009)
suggest that deficits in the connections between the amygdala and orbitofrontal cortex may lead to
behavioral disinhibition. The orbitofrontal cortex is strongly connected with the amygdala, thala-
mus and multiple cortical regions, thus, it is an important region involved in emotion regulation
processes. In addition, the amygdala plays a crucial role as it is involved in processing emotion
and emotional behavior.
The majority of studies have shown amygdala hyperactivation in ADHD, during both the
subliminal perception of fearful expressions and while subjects rated their fear of neutral faces
(Malisza et al., 2011). These findings are similar to behavioral measures of delay aversion, dur-
ing which amygdala hyperactivation was observed for the processing of delayed rewards (Plichta
et al., 2009). The anticipation (and receipt) of rewards causes reduced ventral striatum responsive-
ness in ADHD, thus contributing to aversion delay. This is supported by dysfunction in a neural
network composed of the amygdala, ventral striatum, and orbitofrontal cortex, which mediates
emotional stimuli, and is implicated in emotion regulation. Therefore, Shaw et al. (2014) have
argued that emotion dysregulation in ADHD implicates dysfunction in the amygdala, ventral
striatum and orbitofrontal cortex. Relatedly, lesion studies have shown that the orbitofrontal
region, in particular, is important for the generation of emotional states and emotion regulation
(Ochsner & Gross, 2004). Thus, neural theory predicts (Shaw et al., 2014) deficits in these regions
are strongly associated with symptoms of both ADHD and emotion dysregulation.
Emotion dysregulation
One of the earlier models for emotional dysregulation (ED) (Cicchetti, Ackerman, & Izard,
1995) posited that regulating emotion requires certain control mechanisms involving structure
or a strategy that will allow for co-╉ordination and actions. Cicchetti and colleagues (1995) out-
lined four of these aspects: Firstly, control concerns the cause of felt emotion, involving cogni-
tive and affective mechanisms. Secondly, control structures mediate the output of this emotional
system, whereby earlier mechanisms of cognitive and affective processes are reflected in expres-
sion. Thirdly, control structures coordinate expression and inhibit responses based on context.
Finally, this control structure deviates for those with externalising and internalising problems, as
these individuals tend to suffer from weak or absent control structures. As such, individuals with
ADHD are thought to have problems moderating or suppressing the emotional reactions they
experience, leading to impulsive and severe emotional reactions toward events when compared
to non-╉ADHD individuals of a similar age. Emotion dysregulation therefore, results from a lack
of knowledge concerning affective behavior or difficulty in modulating emotional responses to
social situations or environmental demands (Saarni, 1999).
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Development 119
Impairments in emotional control are closely associated with hyperactive and impulsive symp-
toms, and likely arise from the poor inhibitory capacity involved in ADHD (Barkley, Murphy,
& Fisher, 2008). Observational studies show that children with ADHD display heightened emo-
tional reaction and frustrations compared to their non-╉ADHD peers; this is further supported by
parent reports of increased levels of sadness, anger and guilt. Importantly, these youth have dif-
ficulty self-╉regulating these negative emotions (Berlin, Bohlin, Nyberg, & Janols, 2004; Braaten &
Rosen, 2000; Melnick & Hinshaw, 2000). Moreover, as irritability is an aspect of reactive aggres-
sion and emotional outbursts, it is considered one of the main outcomes of emotion dysregula-
tion in ADHD (Leibenluft, 2011). In fact, a study examining ADHD children with and without
irritability found increased rates of ODD and depression/╉dysthymia in children with irritable
mood and ADHD (Ambrosini, Bennet, & Elia, 2013).
A recent meta-╉analysis by Shaw et al. (2014) revealed a consistent increase in aggressive
behavior in ADHD compared to non-╉ADHD samples. Their results suggest a strong association
between aggression and hyperactivity-╉impulsivity rather than between aggression and inatten-
tion. Emotion dysregulation was further reflected in frustration inducing situations in ADHD.
In addition, children with ADHD were more likely to express negative affect and have emotional
outbursts when compared with non-╉ADHD participants during challenging tasks. Based on their
meta-╉analysis Shaw et al. (2014) described three distinct features of ADHD and emotion dysregu-
lation. The first feature suggests that at its core, emotion dysregulation is a main characteristic
of ADHD and its symptoms of hyperactivity, impulsivity and inattention, are reflective of defi-
cits in executive functions. The second feature considers ADHD and emotion dysregulation as
a unique entity, formed as a result of distinct neurocognitive features and the clinical outcomes
for those with the combination of ADHD and emotion dysregulation. The third feature refers
to the fact that symptoms of ADHD and emotion dysregulation overlap and are underlined by
dissociable neurocognitive deficits such as impairments in executive function, which impacts
decision-╉making and emotional control. This model is supported by correlations observed for
deficits in emotional processes, for example in emotion recognition and frustration tolerance
(Banaschewski et al., 2012); however it is important to note that not all those with ADHD display
impaired levels of emotion dysregulation
Results from longitudinal studies reveal that ADHD symptoms and emotion dysregulation
difficulties emerge in early childhood and continue into adulthood (Biederman et al., 2012).
Skirrow, McLoughlin, Kuntsi, and Asherson (2009) argue that these symptoms of emotional
dysregulation significantly differ from mood instability, as mood instability is used to describe
volatile, irritable and changeable mood with a hot temper and low frustration tolerance in
the absence of underlying deficits. Emotion dysregulation however, is believed to be an active
modification or alteration of on-╉going emotional responses. These responses are associated to
emotions linked with the environment and therefore, part of emotional patterns. Therefore,
those with emotion dysregulation do not usually suffer from mood instability, as mood insta-
bility arises from existing processes that lead to deviant emotional responses independent of
regulatory processes.
Development
Research shows a strong association between ADHD and emotion dysregulation (Sjöwall, Roth,
Lindqvist, & Thorell, 2012). Stringaris and Goodman’s (2009) study examining 5,326 youth
found mood lability (i.e., poorly controlled shifts in emotion) in 38% of children with ADHD.
Parent reports of the Child Behaviour Checklist revealed that adolescents with mood and aggres-
sion problems also tended to suffer from attention difficulties and were more likely to suffer from
0
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1
emotion dysregulation among those likely to have ADHD (Althoff et al., 2006). Shaw et al. (2014)
noted that clinic-╉based studies in young people with ADHD conveyed similar levels of emotion
dysregulation, ranging between 24% and 50%.
Longitudinal research of children with ADHD spanning into adulthood has rarely consid-
ered emotion dysregulation, but rather has focused on outcomes from the DSM-╉IV disruptive
and antisocial disorders (Klein et al., 2012). Stringaris, Maughan, and Goodman (2010) con-
ducted a longitudinal study of 7,140 children and found that temperamental emotionality in
three-╉year-╉olds predicted co-╉morbid ADHD with internalising disorders by the age of seven.
Another longitudinal study by Sanson, Smart, Prior, and Oberklaid (1993) showed that infants
who developed hyperactive symptoms alone did not differ in their temperament from typical
infants; whereas, children who developed ADHD and aggressive traits were prominently unco-
operative and irritable from infancy. Therefore, a difficult temperament with significant nega-
tive emotionality has been linked with later ADHD combined with emotion dysregulation.
Nonetheless, environmental factors such as parental criticism and hostility were associated
with the development of conduct problems in children with ADHD, and with the development
of childhood ADHD in pre-╉schoolers with behavioral problems. Shaw et al. (2014) claims that
poor parental emotion regulation is reflected in high levels of hostility, thereby contributing to
the development of emotional dysregulation in children with ADHD.
TREATMENT 121
Clinical implications
Empirical findings demonstrate physiological and observable behaviors consistent with ED in
children with ADHD (Musser et al., 2011; Musser, Galloway-╉Long, Frick, & Nigg, 2013; Seymour
et al., 2012; Walcott & Landau, 2004). These include demoralization, learned helplessness, low
self-╉esteem, fear and anxiety, increased frustration and occupational challenges. Previous stud-
ies have found ADHD boys to be socially inflexible, emotionally intense with poor attention and
concentration levels (Sanson, Smart, Prior, & Oberklaid, 1993). Using an unsolvable puzzle task
to elicit aggression, boys with ADHD who were considered highly aggressive were further found
to be more emotionally reactive and less effective at emotion regulation than boys with low lev-
els of aggression and without ADHD (Hinshaw & Melnick, 1995). This suggests that aggression
rather than ADHD is responsible for this level of emotional response. Additional manifestations
of emotion dysregulation involve over-╉reactivity to positive and negative emotions (Martel &
Nigg, 2006), lack of emotional control (Erhardt & Hinshaw, 1994; Saunders & Chambers, 1996);
and impatience which most likely leads to peer perceptions of youth with ADHD as easily excited,
disruptive, or intrusive in their social interactions (Landau & Moore, 1991). Children with inat-
tentive presentations of ADHD show emotion dysregulation enhanced by emotional intensity and
display heightened emotions (Wheeler, Maedgen & Carlson, 2000).
Negative emotionality however is also a characteristic of ODD which includes loss of temper, as
the child gets easily angry and resentful (Barkley et al., 2010). Negative emotionality is similar to
emotional dysregulation, however it is a risk-╉factor for ED (Belsky, Friedman, & Hsieh, 2001) and
is considered a risk factor for developing ODD in children with ADHD (Martel & Nigg, 2006).
Children and adolescents with ADHD are therefore more likely to experience impairments in
social relationships, as they exhibit aggressive behaviors and consistent rule breaking unlike typi-
cally developing peers (Buhrmester, Whalen, Henker, MacDonald, & Hinshaw, 1992).
Treatment
Treatments for ADHD involve a broad range of options including behavioral therapy, psycho-
therapeutic approaches and pharmacotherapy; the aim of treatment is to treat the disorder as early
and as effectively as possible. When considering non-╉pharmacological treatments, studies show
that parent and family education is important, along with effective parent training in behavioral
management involving teachers to improve classroom behaviors. These treatments indicate that
with appropriate behavior modification training and special education placement, outcomes for
children with ADHD can be greatly improved (Thompson et al., 2004). In addition, treatment
programs have shown that the management of adolescents with ADHD can be effective; these
include parent and teacher training in behavioral management, particularly contingency man-
agement methods applied in classrooms and similar settings, such as summer camp (Antshel &
Barkley, 2008). However, Barkley (2006) argues that interventions for behavioral management in
children with ADHD are most effective when inappropriate behaviors are targeted in the child’s
natural environment, as it occurs. Subsequently, Barkley suggests it is important to assist the
child/╉individual in understanding suitable behavior which is contextually expected.
Most psychosocial treatment programs involve a multimodal treatment plan part of which
includes medication (Jensen et al., 2001). The Multimodal Treatment Study of Children with
ADHD investigated long term outcomes of interventions, including medication and behavior
modification in combination and alone. The results showed that medication alone and medica-
tion with behavior modification was superior to behavior modification alone or standard com-
munity care (MTA Cooperative Group, 1999). Apart from decreasing levels of ADHD symptoms,
21
these two intervention strategies improved aggressive behavior, social skills, academic achieve-
ment, and parent-╉child relationships. Stimulant medications such as methylphenidate have been
found to be effective in improving academic outcomes and emotional wellbeing. In addition, a
study evaluating the effectiveness of multimodal psychosocial treatment of children with ADHD
being treated with methylphenidate reported a consistent pattern of improvement in academic
achievement and emotional status, particularly self-╉esteem and ratings of depression (Hechtman
et al., 2004). Non-╉stimulant medications, such as atomoxetine have also been found to reduce core
ADHD symptoms, improve social interactions and quality of life in children and adolescents with
ADHD (Cheng et al., 2007; Wilens et al., 2006).
In relation to psychological intervention, Cognitive Behavioural Therapy (CBT) has been
shown to benefit individuals with ADHD by helping them to understand and categorize the emo-
tions they experience accurately. Importantly, CBT has been found to help with labeling emotions
correctly and coping with intense negative reactions (Mongia & Hechtman, 2012). Moreover,
these skills can be developed alongside mindfulness training (Mongia & Hechtman, 2012), which
promotes present centered focused awareness of emotions (Farb et al., 2007). Additionally, inter-
ventions aiming to treat avoidance behavior and mood disturbances in ADHD may also improve
emotion regulation by enhancing motivation and providing individuals with strategies to cope
with daily life (Mongia & Hechtman, 2012).
Considering emotion dysregulation in ADHD treatment has been challenging, primarily
this is due to the fact that studies have measured emotional changes as a secondary outcome
(Shaw et al., 2014). However, one of the few studies measuring the attributes of stimulants on
emotional expression found improvement in emotional dysregulation, parallel to improve-
ments observed in hyperactivity and impulsivity (Mccracken et al., 2003). According to Manos
et al.’s (2011) literature review, emotional lability and irritability reduced by 3% in ADHD as
a result of medication alone. Stimulants have also been found to improve emotion recogni-
tion, whilst concurrently improving performance (Conzelmann et al., 2011). These findings
are supported by neural activities, as medicated adolescents have been found to have reduced
activity in the prefrontal regions, similar to healthy controls, contrasted by increased reactiv-
ity found in ADHD participants not taking medication. ADHD adolescents taking medica-
tion were found to have better performance on emotional processing tasks when compared to
ADHD adolescents without medication. Shaw et al. (2014) suggest that stimulant treatment
of the core symptoms of ADHD also leads towards improvement in emotion dysregulation.
Additionally, behaviour modification combined with medication is effective at reducing exter-
nalising and internalising symptoms, which are linked with emotion dysregulation (Stringaris
& Goodman, 2009).
Conclusions
ADHD is one of the most commonly occurring psychiatric disorders of childhood (Spencer,
Biederman, & Mick, 2007). Moreover, it frequently persists into adolescence and adulthood and is
associated with multiple functional impairments. Research has revealed that externalizing behav-
ioral problems and social impairment are associated with emotion dysregulation in children
with ADHD (Wheeler, Maedgen & Carlson, 2000; Melnick & Hinshaw, 2000; Parker, Majeski, &
Collin, 2004). Emotion dysregulation is strongly linked to inhibitory deficit, which may manifest
into socially inappropriate behavioral responses to extreme emotional expression and the inability
to self-╉regulate (Barkley, 2006). This then suggests the individual finds it difficult to self-╉soothe
during enhanced emotional experiences, focus on the task at hand, and to organize thoughts
to achieve goal driven behavior (Lynn, Carroll, Houghton, & Cobham, 2013). The association
3
2
1
Conclusions 123
between emotion dysregulation and ADHD has been mainly explored in children; therefore, gen-
eralizability across developmental stages remains largely unaddressed. Moreover, ADHD is highly
comorbid with the internalising/╉externalizing disorders which significantly impact emotion dys-
regulation, yet very few studies have considered the effect of subtype or comorbidity on emotion
dysregulation (Wheeler, Maedgen & Carlson, 2000; Melnick & Hinshaw, 2000).
In summary, emotion dysregulation affects approximately 25–╉╉45% of children and between
30–╉70% of adults with ADHD. It represents a major source of impairment and presages a poor
clinical outcome (Shaw et al., 2014). Emotion dysregulation in ADHD may be caused through
deficits at multiple levels, ranging from abnormal early orientation to emotional stimuli to deficits
in cognitive processes, in particular working memory and response inhibition. Although these
deficits may contribute to emotion dysregulation they alone do not explain its presence in ADHD,
as the underlying mechanism is likely complex, and is influenced by impairments in neural net-
works in the prefrontal cortex and executive functioning processes.
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Chapter 7
Emotion Regulation
and Conduct Disorder: The Role
of Callous-╉Unemotional Traits
Nicholas D. Thomson, Luna C. M. Centifanti,
& Elizabeth A. Lemerise
Conduct disorder
Although all children disobey adults at times, children with conduct disorder (CD) persistently
break the rules, engage in norm-╉breaking behavior, defy adults and authority figures across situa-
tions, and repeatedly and seriously violate the rights of others (American Psychological Association
[APA], 2013). CD was first introduced as a psychiatric diagnosis in the second edition of the
American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders (DSM).
Since this time the diagnosis of CD has become more refined (Kimonis, Frick, & McMahon, 2014).
There are four types of symptoms that define CD: 1) aggression towards people and animals (e.g.,
fighting, bullying); 2) destruction of property (e.g., fire setting, vandalism); 3) deceitfulness, or
theft (e.g., conning, shoplifting); and 4) serious violations of rules (e.g., truancy, running away
from home [APA, 2013]). CD is one of the most prevalent mental health concerns for children and
adolescents and is considered one of the most challenging childhood disorders to treat (Dadds &
Fraser, 2003). To further complicate matters, children with CD are often viewed as “bad” rather
than having a mental illness because their symptoms result in the violation of the rights of oth-
ers (e.g., hostility, aggression, cruelty). Further, conduct problems represent a large cost to society
(Welsh et al., 2008). Although CD is considered a behavioral disorder, differences in emotion (dys)
regulation might identify subgroups of youth with CD. Some children with CD may exhibit irrita-
bility and mood swings resulting in aggressive responding; whereas, other children with CD may be
emotionally disconnected from others so they callously hurt others. This emotional heterogeneity
may explain why some children with CD fail to be bothered by the effects of their behavior on other
people, whereas others experience anxiety over their negative behavior (Pardini & Frick, 2013).
In this chapter, we will discuss the evidence for considering how children with CD manage their
emotions because subgroups of children with CD may show different developmental trajectories
based on having strong or poor emotion regulation abilities. We will also discuss the implications
for clinical practice in managing CD based on this heterogeneity.
Based on the severity and number of symptoms displayed, CD can be classified from “mild,”
such that the youth displays few symptoms and/╉or causes minor harm (e.g., lying, truancy), to
“severe,” such that the youth displays many more symptoms than required for a diagnosis and
considerable harm to others is caused (e.g., forced sex, use of a weapon). Severity of CD has
been found to affect the persistence of the disorder, with youths in the moderate to severe scale
of CD more likely to retain CD symptoms into their adolescence (Cohen, Cohen, & Brook,
1993) and suffers from educational problems (Kim-╉Cohen et al., 2005). Although the number of
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children who display early and pervasive antisocial behavior is small in number (5% [Hinshaw
& Lee, 2003]), they account for almost half the crime in the United States (Loeber, Burke, Lahey,
Winters, & Zera, 2000).
In the DSM-╉5 (APA, 2013), heterogeneity in CD diagnosis is recognized, such that persis-
tence of antisocial behavior beyond childhood is characteristic of a subgroup of those with CD.
Currently, the diagnosis takes into account the age at which the symptoms onset, because early
onset of behavioral problems typically relates to lifetime-╉persistence of these behaviors (Moffitt,
1993). Childhood-╉onset, which is defined as onset before the age of ten years, has been associated
with greater cognitive impairment, mental health concerns, and more harmful, violent behavior
than adolescent-╉onset CD (onset after the age of ten years) (Johnson, Kemp, Heard, Lennings,
& Hickie, 2015). Heterogeneity in CD is in line with the dual taxonomy of offending posited by
Moffitt (1993). Moffitt theorized that those who have an onset of offending during adolescence
(adolescent-╉limited offenders) tend to cease their delinquency by early adulthood, whereas those
with childhood-╉onset (lifecourse-╉persistent offenders) continue their antisocial behavior into
adulthood (Moffitt, 1993).
A test of Moffitt’s (1993) taxonomic predictions revealed four antisocial behavior trajectories
roughly in line with Moffitt: 1) lifecourse-╉persistent, 2) adolescence-╉limited, 3) childhood-╉limited,
4) and low (Odgers et al., 2008). There was empirical evidence for the developmental trajectories
of antisocial behavior which coincided most with the designations of CD: lifecourse-╉persistent
and adolescent-╉onset antisocial trajectories coincided with childhood-╉and adolescent-╉onset
CD. However, the outcomes related to the trajectories differed for the adolescent-╉onset group
(Odgers et al., 2008). Some individuals in the adolescent-╉onset trajectory continued to show anti-
social behavior into adulthood. Also, a trajectory not originally posited by Moffitt was identi-
fied: A childhood-╉limited trajectory. People on this trajectory of antisocial behavior desisted past
childhood. However, of importance to psychopathology, they only showed minor problems with
smoking, managing finances, and internalizing behavior problems (e.g., anxiety and depression).
Thus, there are some who present with early conduct problems but who grow out of them, only
seeming to be left with the remains of their poor behavior management choices. Thus, it could be
that other factors like emotion or behavior management could be useful in delineating heteroge-
neity within CD.
Yet, in line with childhood-╉onset CD diagnoses, research finds that children with early-╉onset of
CD typically have a prior diagnosis of Oppositional Defiant Disorder (ODD). ODD is considered
a precursor to and milder variant of CD (Loney & Lima, 2003). Longitudinal samples have shown
that 80% (Loeber, Green, Keenan, & Lahey, 1995) of children with CD had a former diagnosis of
ODD, and about 90% of clinically referred children with CD diagnosis meet the criteria for ODD
(Faraone, Biederman, Keenan, & Tsuang, 1991). CD and ODD can co-╉occur, and a comorbid
diagnosis of CD with ODD can be given (APA, 2013). In research, the term “conduct problems”
(CP) is often used to jointly describe children with severe behavioral problems, or a diagnosis of
CD or ODD (Kimonis, Frick et al., 2014).
Prevalence and course
Conduct disorder is one of the most prevalent disorders for children and adolescents (Kessler
et al., 2012; Lindhiem, Bennett, Hipwell, & Pardini, 2015), but the negative impact is not
limited to these early years and is associated with lifelong adjustment, mental health, legal,
social, occupational, and physical health problems (Jones, 2013; Odgers et al., 2008). Based
on study samples, the prevalence of CD is estimated to be between 2% and 15% (APA, 2013;
Egger & Angold; Kim-╉Cohen et al., 2005) with more cases evident of adolescent-╉onset than
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childhood-onset (Nock, Kazdin, Hiripi, & Kessler, 2006; Perou et al., 2013). Overall, boys are
twice as likely as girls to receive a CD diagnosis (4.6% versus 2.2% with current CD diagno-
sis [Perou et al., 2013]). However, gender differences are greater early in childhood. At the
age of five years, boys are three to five times more likely to be diagnosed with CD than girls
(Kim-C ohen et al., 2005). Emerging into mid-adolescence, gender differences tend to reduce
significantly with female CD prevalence peaking at the age of 16 years (Esser, Schmidt, &
Woerner, 1990; McGee et al., 1990). For adolescent girls, CD is the second most common
psychiatric diagnosis with a prevalence rate of about 10% in community samples (Dalwani
et al., 2015; Pajer et al., 2008) and 36% in detention center samples (Washburn et al., 2007).
Although research on CD tends to focus on male samples, there is evidence supporting simi-
larities between males and females in biological (Fairchild et al., 2014) and psychosocial vul-
nerabilities (Bardone et al., 1998; Pajer, 1998).
Moffit’s (1993, 2006) dual taxonomy of conduct problems identifies two groups of youth based
on the timing of onset of behavioral problems. The developmental typology suggests that con-
duct problems developing in early childhood lead to “life-course-persistent” antisocial behavior,
whereas antisocial behavior that begins in adolescence is limited to the teenage years (Moffitt &
Caspi, 2001). Prior research suggests that children who develop CD during childhood differ in
the underlying mechanisms compared to youths who develop CD during adolescence. Evidence
suggests that children with childhood-onset are exposed to family, social, and inherited neurode-
velopmental risk factors more than youths with adolescent-onset of CD (Moffitt & Caspi, 2001;
Odgers et al., 2008). By the age of 32, adults with a history of childhood-onset of CD show greater
perpetration of violence, and more mental and physical health problems (Odgers et al., 2008). The
different trajectories based on age of onset are attributed to causal mechanisms in the child’s envi-
ronment as well as biological factors that seem to distinguish the two groups. Childhood-onset
has been associated with poorer neurological functioning (e.g., self-control, memory and verbal
abilities), which in turn, negatively impacts the successful navigation of social relationships, man-
agement of emotions, and the ability to control behaviors (Johnson et al., 2015; Moffitt, 2006;
Pardini & Frick, 2013). The child is more likely to experience childhood maltreatment (Johnson
et al., 2015), poorer parenting strategies (i.e., harsh and inconsistent discipline), and greater
family-level conflict, poverty, mental health problems (Odgers et al., 2008) and parental history
of antisocial behavior (McCabe, Hough, Wood, & Yeh, 2001). Whereas, youths with adolescent-
onset CD are less likely to have a childhood history of ADHD or ODD, have neurological deficits,
and have less severe family dysfunction and aggression and a greater remission rate of antisocial
behavior into adulthood (Moffitt, Caspi, Dickson, Silva, & Stanton, 1996). Prior research supports
the dual taxonomic trajectory of antisocial behavior; thus, the DSM-5 categorization of age of
onset is an important factor. However, there is considerable evidence showing etiological hetero-
geneity within the childhood-onset group based on emotionality (Frick & Viding, 2009; Pardini
& Frick, 2013).
Further heterogeneity in CD has recently been identified based on callous-unemotional (CU)
traits. Research has identified a subgroup of youth with CD and callous unemotional (CU)
traits, although the term used in the DSM is Limited Prosocial Emotions (LPE; APA, 2013). To
meet diagnostic criteria for LPE, the youth must display two of the following four character-
istics: a lack of remorse or guilt, a callous lack of empathy, shallow or deficient affect, or lack
of concern about performance (Blair, Leibenluft, & Pine, 2014). Thus, children with LPE are
emotionally cold and experience little concern over the effects that their problem behaviors
may cause (see Munoz & Frick, 2012). Children with CU traits have a lack of concern for the
welfare of others; they often act cruelly to others with the intention to cause physical or emo-
tional harm in order to achieve a goal (e.g., exerting dominance [Pardini & Byrd, 2012]). This
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group of children has a lack of emotionality (Essau, Sasagawa, & Frick, 2006) making them
fearless perpetrators of antisocial behavior without consideration of the consequences of their
actions (Fanti, Panayiotou, Lazarou, Michael, & Georgiou, 2015). Emotional deficits such as low
empathy and guilt are suggested to play an integral role in the atypical development of moral
values for children with CU traits (Frick, Ray, Thornton, & Kahn, 2014). Although children
with conduct problems continue to show behavioral problems throughout childhood, children
with conduct problems (CP) and CU traits continue to show the greatest levels of conduct prob-
lems, delinquency, and police contacts (Frick, Stickle, Dandreaux, Farrell, & Kimonis, 2005).
Compared to children with CD-╉only, children with CD + CU have been described as having
different etiological mechanisms (i.e., social, genetic, behavioral, and cognitive vulnerabilities
[Kimonis, Centifanti, Allen, & Frick, 2014; Sebastian et al., 2015]), and are hypoactive in their
emotional responses (Frick & Viding, 2009; Sebastian et al., 2015). Evidence from twin stud-
ies suggests that children with CU traits and conduct problems are more likely to have inher-
ited contributing factors, whereas conduct problems in children with low levels of CU traits
are explained mostly by environmental vulnerabilities (Viding, Blair, Moffitt, & Plomin, 2005;
Viding, Jones, Frick, Moffitt, & Plomin, 2008).
Therefore, prior research with community samples and clinic-╉referred samples has found that
children and adolescents with CD and LPE (CD + LPE) are characteristically different from youth
with only CD (CD-╉only) in terms of long-╉term outcomes. When compared to youth with CD-╉
only, youth with CD + LPE are more likely to display severe and persistent psychopathology (Rowe
et al., 2010), get involved in criminal activities at a younger age (Pechorro, Jiménez, Hidalgo, &
Nunes, 2015), have greater levels of externalizing behaviors (e.g., aggression, delinquency, psy-
chopathic traits [Colins & Andershed, 2015]), and are more likely to develop antisocial personal-
ity disorder symptoms in adulthood (McMahon, Witkiewitz, & Kotler, 2010).
practice of correctly labeling children’s emotions and coach their children on coping strategies
and problem-╉solving have children who display better emotional competence (emotion aware-
ness/╉understanding and emotion regulation [Gottman, Katz, & Hooven, 1997; Laible & Panfile,
2009; Thompson, 2006]). For example, mothers who remark appropriately about their child’s
mental states appear to “scaffold” a richness in children’s understanding of emotions (Centifanti,
Meins, & Fernyhough, 2015). Further, mothers’ appropriate verbal comments about their infant’s
mental states and desires led to lower levels of CU traits at age ten years through a greater emotion
understanding at age four years (Centifanti, et al., 2016). However, caregivers’ hostile responses
to their children’s emotions, including anger, tend to increase children’s arousal, interfering with
learning about emotions and with the regulation of emotions, raising risks for children’s aggres-
sive and other problem behaviors (Lemerise & Dodge, 2008). Moreover, the stresses associated
with poverty (a well-╉known risk factor for aggressive behavior and CD) interfere with children’s
regulatory development as well as with the supportive parenting that might buffer children from
these stressors (Blair & Raver, 2015).
With language development, children soon learn that they can communicate their needs more
effectively using their words. However, Thompson (1994) theorized that emotions continue to
serve in social signaling, defensive motivations, and in communication of one’s needs, but also
serve to maintain affiliational ties. Indeed, nonhuman primates rely on expressions of threat to
inhibit agonistic behavior from other primates (see Izard, 1991). Thus, emotions can communi-
cate in addition to other forms of communication. Human infants respond to pain with crying,
seemingly to summon their caregiver’s attention, as infants lack the ability to defend themselves.
By 19 months, however, children respond to pain with anger (after a short period of crying),
which might serve to inhibit any perpetrator. This developmental change in their emotional
expression may, arguably, be due to many other factors related to the regulation of emotion and
the emerging theory of mind (which both depend on cognitive processes [Lemerise & Dodge,
1993; Meltzoff, 2002]).
An example of the biological and environmental interplay can be seen in longitudinal studies.
The parasympathetic nervous system facilitates a reduction in heart rate and increases respira-
tory sinus arrhythmia (RSA). When operating effectively, this helps facilitate emotion regula-
tion (Beauchaine, 2015; Hinnant, Erath, & El-╉Sheikh, 2015). Lower resting RSA and less RSA
withdrawal (during a threatening or challenging event) has been associated with poor emotion
regulation, executive control, adjustment problems, and greater levels of parent-╉child aggression
(Beauchaine, 2015; Whitson & El-╉Sheikh, 2003). In a recent study, children whose parents used
harsher parenting strategies had reductions over time in their RSA withdrawal to stress, suggest-
ing that children in a hostile home environment are more likely to suffer from long-╉term physi-
ological alterations which affect their ability to regulate their emotions (Hinnant et al., 2015). In
support of the emotion dysregulation subgroup, CD-╉only children have demonstrated a hyper-
sensitivity to fear, and poor behavioral inhibition (Fanti, Panayiotou, Kyranides, & Avraamides,
2015). Children with poor emotion regulation tend to have elevated levels of hyper-╉vigilance to
threat cues and attributions of hostile intent. Children with higher levels of hostile attributional
bias misinterpret ambiguous social cues as hostile intent which results in the child responding
reactively (Dodge et al., 2015). To further exacerbate matters, engaging in aggressive behavior
inevitably places the child in hostile social situations, which will likely increase the child’s ten-
dency to attribute hostile intent from peers (Dodge et al., 2015). Children with CD-╉only indeed
show increased heightened emotional reactivity. Because of the emotional instability, a tendency
to misinterpret benign intents as hostile intents, and hypersensitivity to fear, this subgroup of chil-
dren uses reactive (i.e., in response to provocation) aggression as a result of poor emotion regula-
tion (de Wied, van Boxtel, Matthys, & Meeus, 2012; Frick, Cornell, Barry, Bodin, & Dane, 2003).
There are some factors that might distinguish CD-╉only groups from CD + CU groups, making
the former more amenable to intervention. Children with CD-╉only are more receptive to pun-
ishment (Fanti, Panayiotou, Lazarou, et al., 2015) and affectively empathetic and sympathetic to
others (de Wied et al., 2012; Frick et al., 2003; Frick & Morris, 2004). In contrast, CD + CU chil-
dren are punishment insensitive, lack emotionality, and consider deviant strategies (e.g., revenge,
blaming others, aggression [Pardini, 2011; Stickle, Kirkpatrick, & Brush, 2009]) as acceptable
methods to achieve a goal (Frick et al., 2014). The juxtaposition of CD + CU and CD-╉only in
childhood-╉onset illustrates distinguishing features that could affect treatment outcome, hence the
importance of distinguishing childhood-╉onset subgroups.
Recent research supports the principle of equifinality, whereby different developmental mecha-
nisms (e.g., hyper and hyposensitivity to fear) may lead to the same outcome of antisocial behav-
ior (Fanti, Panayiotou, Kyranides, et al., 2015). However, the way in which a child perpetrates
antisocial behavior may be indicative of the developmental pathway he\she has taken. As with
the two subtypes of childhood-╉onset of CD, emotionality and emotion dysregulation play integral
roles in how aggressive behavior in children is understood.
Childhood aggression
CU traits have been suggested to moderate antisocial behavior for youth with conduct problems
(Helseth, Waschbusch, King, & Willoughby, 2015), including aggression subtypes that differ in
emotionality and emotion regulation. Proactive aggression occurs without provocation and is
typically motivated by intentional purpose (e.g., social dominance, physical goal). By comparison,
reactive aggression occurs in response to a perceived provocation or threat (Dodge & Coie, 1987).
Proactive aggression is characterized as cold-╉blooded, whereas reactive aggression is fueled by
anger or frustration (Dodge, 1991; Teten Tharp et al., 2011). Theoretically, children with CU traits
are more likely to be proactively aggressive, yet, empirically, children with CU traits tend to show
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high levels of both reactive and proactive aggression (Centifanti, Fanti, Thomson, Demetriou, &
Anastassiou-╉Hadjicharalambous, 2015; Muñoz et al., 2008). For instance, detained adolescents
(13–╉18 years) who reported being high on both reactive and proactive aggression (forming a
“mixed” aggressor group) had higher levels of CU traits, and lower levels of physiological reactivity
when provoked (Muñoz et al., 2008). The mixed group were also more aggressive in a behavioral
task when they experienced no provocation from an opponent (Muñoz et al., 2008). Therefore,
youth with CU traits may respond aggressively in all provocation situations (without provocation,
or in response to low or high provocation), but they seem to have less of an emotional response.
Cravens-╉Brown, & Bretveld, 2003]). Aspinwall (1998) reviewed evidence that people in a nega-
tive mood orient more quickly to negative information, but their resources are tied up in regu-
lating their negative emotions; thus, they are unable to fully process the negative information.
Alternatively, attentional systems may become dysregulated by intense emotional arousal, pre-
cluding an adequate processing of relevant cues (Thompson & Calkins, 1996). Aspinwall’s (1998)
conclusion may explain why Schippell et al. (2003) found that reactive aggressors showed selective
attention and suppression of social threat words. A large stress reaction results in an internal-╉
focus (Thompson & Calkins, 1996), diverting attention away from the stimulus and precluding
adequate processing. In the reactive-╉aggressive child, this diversion of attention may serve to pre-
vent further emotional negativity that typically threatens their self-╉image (Schippell et al., 2003).
In fact, aggressive children have been shown to overestimate their likeability with their peers
(Rudolph & Clark, 2001). Hypervigilance to threat cues may serve to aid in their suppression and
in the protection of esteem or may simply reflect the selection of mood-╉congruent information
(Lemerise & Arsenio, 2000; Schippell et al., 2003).
Cognitive competence is essential for successful development of behavioral regulation (Olson,
Bates, Sandy, & Schilling, 2002) or inhibitory control. A lower verbal intelligence quotient may
lead to a generation of fewer alternatives when generating responses to a situation and a rapid
accessing of aggressive responses, which could lead to aggressive behavior (Dodge & Pettit, 2003;
Lemerise & Arsenio, 2000). Children who are more impulsively aggressive evidence intellec-
tual deficits, particularly verbal deficits (Arsenio et al., 2009; Babcock, Tharp, Sharp, Heppner,
& Stanford, 2014; Loney, Frick, Ellis, & McCoy, 1998). One study found that children classified
as rejected-╉reactive aggressive were better able to choose a constructive response, when given
response options rather than free choice (Wood & Gross, 2002). The generation and subsequent
selection of an aggressive response may result from deficits in inhibitory control and/╉or planning.
Emotional competence involves being able to control one’s expressivity as well as to express
emotions flexibly and appropriately within the situation (see Lemerise & Arsenio, 2000). In addi-
tion, competence is shown by being able to sensitively respond to others’ emotional cues and
behavioral cues, which are important in providing feedback for the child’s behavior. Of impor-
tance, emotional cues are displayed by the child and by others as the encounter proceeds, which
allow the child to adjust his or her response in-╉line with the current environmental demands
(Lemerise & Arsenio, 2000). During situations of high arousal, this delicate interchange may dis-
integrate. Emotional cues may be missed or misinterpreted, whereby a peer’s positive affective
desire to share a toy may be misconstrued as an angry demand. The result is possibly an angry
reaction or resistance on the part of the reactive-╉aggressive child.
The outcome of these perceptual and interpretive processes is an emotional and behavioral
response. Differences in the expression of emotion have been found to distinguish the two sub-
types of aggression (Hubbard et al., 2002). During a competitive game, a dysregulation of angry
or hostile emotions seemed to characterize reactive but not proactive aggression (Hubbard et al.,
2002). Strong emotional reactions to stressful situations can impede attempts to regulate behav-
ior as well as cognitive attempts to regulate emotion (Lemerise & Arsenio, 2000; Thompson &
Calkins, 1996). All of the deficits discussed thus far increase the likelihood of aggressive behavior
(Crick & Dodge, 1994).
“instrumental” is used in describing this type of aggression (Dodge et al., 1997; Raine, Fung,
Portnoy, Choy, & Spring, 2014). Proactive aggressors have been shown to prefer instrumental and
dominance goals over relational goals (de Castro et al., 2005; e.g., Salmivalli, Ojanen, Haanpää,
& Peets, 2005), and to evaluate aggressive responses more positively in terms of their effective-
ness and one’s emotional reactions and self-╉efficacy (Arsenio et al.; Dodge et al., 1997). Their
preference for instrumental goals over relational goals biases response selection toward aggressive
responses (see Harper, Lemerise, & Caverly, 2010).
Those who use proactive aggression tend to show higher levels of aggression and blunted emo-
tion or emotion that is inconsistent with their behavioral displays (Bobadilla, Wampler, & Taylor,
2012; Hubbard et al., 2002). This is similar to the low emotionality related to CU traits. As sug-
gested above, those who experience distress, such as anxiety and fear, may be more easily social-
ized (Eisenberg et al., 1997; Izard, 1991). Children who were emotionally reactive and more prone
to negative emotion were also high in conscience development (Kochanska, 1991). High reactivity
to transgressions may facilitate the affective and affiliative component of conscience development,
but it also may hinder the enactment of guilt-╉related behavior (such as reparation attempts and
confession [Kochanska et al., 1994]). Nonetheless, this pattern of responding was found to be
more characteristic of girls than of boys (Kochanska et al., 1994). Eisenberg et al. (1997) found
that, although both boys’ and girls’ negative emotionality positively relates to behavior problems,
only boys’ anxiety (expressed in the laboratory) was negatively related to behavior problems.
Thus, boys’ low anxiety might be more germane to the development of a cold, unfeeling type of
aggression.
In sum, reactive aggressive children appear to suffer more from information-╉processing errors,
which result in hostile-╉attributional bias, making their behavior amenable to interventions that
focus on regulating their emotional arousal. For example, the Coping Power Program (Lochman,
1992; Lochman & Wells, 2004) specifically focuses on helping the aggressive child to deal with
his/╉her intense anger arising from provocation. It also targets biases that often result in reactive
aggression, such as viewing others’ actions as originating from hostile intentions. Using cognitive-╉
behavioral techniques, these programs target faulty information processing deficits that can lead
to reactive aggression (Boxer & Frick, 2008). The verbal deficits, emotional reactivity, and impul-
sivity that accompany reactive aggression may underlie information processing errors, as well
as also underlying their unsuccessful attempts to regulate their behavior. Admittedly, proactive
aggressive children also have social-╉cognitive biases in prejudicially perceiving positive outcomes
for behaving badly. However, their emotional deficits predispose them to fail to develop complex
cognitive and emotional processes, such as understanding and identifying emotions in others
(specifically, negative emotions) and responding sensitively to them. Complex emotions such as
guilt may fail to develop as a result. Thus, they require different types of treatments, such as inter-
ventions that target the multiple contexts in which children function.
Treatment
Youths who engage in serious antisocial behavior are more likely to experience psychosocial, aca-
demic, and occupational challenges (Frick & Dickens, 2006). The negative influence is not exclu-
sive to the youths’ wellbeing but extends to the community, with extensive economic and social
burden as well as the physical and emotional cost to victims. Therefore, the impact that interven-
tions have is not isolated to the individual or the family involved, but they positively affect the
greater community and society. However, high-╉risk individuals and families (with severe exter-
nalizing behaviors) are considered extremely difficult to treat due to the strength and stability of
personality characteristics (Moffitt, 1993) and exacerbation by the (cross)generational reach of
9
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1
antisocial behavior (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999). Although there are
a variety of interventions that have demonstrated effectiveness in children and adolescents with
severe antisocial behavior, the remainder of this chapter will focus on three empirically efficacious
interventions designed for youth with conduct problems: Multisystemic Therapy, Functional
Family Therapy, and The Incredible Years.
Multisystemic therapy
Multisystemic Therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham,
2009) is a family-╉focused home-╉and agency-╉based intervention designed to treat adolescents
with severe antisocial behavioral problems. As shown in Figure 7.1, MST considers that antisocial
behavior is attributed from multiple social domains including, peers, family, school, and the com-
munity. As the name implies, MST is truly integrative of therapeutic practices, drawing on the use
of cognitive–╉behavioral approaches, behavior therapies, parent training, and family therapies. In
order to address the multiple social domains that affect the child, MST functions as an intensive
therapy tailored to the unique needs of the family and child, and builds on the assistance and
involvement from multiple sources (e.g., teachers, parents, extended family). Based on the func-
tion of social ecology, the MST practitioner delivers the intervention and assessments within the
child’s day-╉to-╉day environment where the maladaptive behavior occurs naturally (e.g., at home,
school), which adds to the ecological validity of MST.
Peers
Reduced antisocial
MST Improved family
School behavior and improved
functioning
functioning
Community
four years post-╉MST, adolescents had a reduction in violent crime and drug use (Henggeler,
Clingempeel, Brondino, & Pickrel, 2002). Positive longitudinal results have been found with ado-
lescent sexual offenders who have received MST. When compared to youth receiving commu-
nity services, adolescents who received MST had decreased behavioral problems and symptoms,
decreased sexual and other criminal offending, and improved social relations and academic per-
formance nine years after treatment (Borduin, Schaeffer, & Heiblum, 2009). Based on the high
intensity design of MST, there is strong empirical support for its use in adolescents with conduct
disorder and for treating severe behavioral problems (Brestan & Eyberg, 2010; Curtis, Ronan, &
Borduin, 2004; Henggeler & Sheidow, 2012).
(40%), client-╉centered treatment group (59%), and the eclectic-╉dynamic family program group
(63% [Klein, Alexander, & Parsons, 1977]). Overall, there is a wealth of empirical support for the
use of FFT in youth with severe behavioral and offending problems.
Incredible Years
Although research has shown the positive effect that interventions have for teens with CD, com-
pared to early interventions (during childhood) the effectiveness is less reliable (Pardini & Frick,
2013). Therefore, early intervention and prevention during childhood is considered the opti-
mum period for preventing the trajectory to severe antisocial behavior. The Incredible Years (IY;
Webster-╉Stratton, 1984, 2011) is a well-╉validated set of three programs designed for children,
parents, and teachers (Webster-╉Stratton, Reid, & Hammond, 2004; Webster-╉Stratton, 2016). The
aim of the interlocking series of programs is to prevent, reduce, and treat behavioral problems
and promote social and emotional stability through instruction. The parent training is designed
to target high-╉risk families as well as those families with children with behavior problems. The
parent training programs are age adjusted (toddlers [one to three years], preschoolers [three to
five years], and school-╉age [six to 12 years]) to deliver developmentally appropriate strategies
for increasing child prosocial attitudes and emotional wellbeing, while reducing and preventing
behavior problems (Webster-╉Stratton, 2016). The teacher training program is a six-╉day workshop
designed for educators and school counselors of pupils ages three to ten years. Teachers are taught
classroom management strategies, and how to encourage children’s prosocial behavior and reduce
problematic classroom behavior (e.g., aggression, hostile interpersonal relations). The child pro-
gram promotes friendship, emotion regulation and literacy, and perspective taking for children
ages three to eight years. Children are assessed on one of three “levels” for the most developmen-
tally appropriate class. IY is based on well-╉established behavioral principles, which in applica-
tion are simple and comprehensive to the user, making it a reliable and replicable intervention
(Webster-╉Stratton, Jamila Reid, & Stoolmiller, 2008). IY applies these teaching principles concur-
rently across a variety of environments, supporting prosocial behaviors in “real-╉world” settings,
which essentially covers all areas in which the child socializes (Boxer & Frick, 2008). Programs
such as IY, that apply positive modifications to the child’s environment (e.g., parenting behaviors),
are reliably shown to be effective methods of improving childhood behavioral outcomes (Gridley,
Hutchings, & Baker-╉Henningham, 2015).
The parents who participated in the program showed significant improvements compared to the
control group. Parents reported using less harsh and inconsistent discipline and more positive
parenting strategies (e.g., praise, appropriate discipline), and were observed using fewer critical
statements to their child (Posthumus et al., 2012). IY has been shown to aid mothers who were
recently released from prison, with parent-╉and teacher-╉report of improvements in child behavior
(Menting, de Castro, Wijngaards-╉de Meij, & Matthys, 2014). A meta-╉analysis including 50 studies
(see Menting et al., 2013) found that children who entered the program with more severe behav-
ior problems reported the greatest improvements such that prosocial behavior had increased and
oppositional behavior decreased immediately after the intervention, for observations, teacher and
parent ratings.
Children who come from homes with a family history of externalizing behaviors have been
suggested to have a genetic risk as well as an environmental risk for showing antisocial behav-
ior cross-╉generationally (Silberg, Maes, & Eaves, 2012). These children are more likely to have
chronic behavior problems in childhood and develop antisocial personality disorder in adulthood
(Lahey et al., 1988). A recent study (see Presnall, Webster-╉Stratton, & Constantino, 2014) assessed
the effectiveness of the IY program for children (three to eight years) with CD, with and without
a family history of externalizing behaviors (e.g., Antisocial Personality Disorder). Although chil-
dren from families with histories of externalizing behaviors had more severe conduct disorder
symptoms upon entry into the program, both groups benefitted from the intervention showing
a reduction in externalizing behavior (Presnall et al., 2014). Overall, IY has been shown to have
excellent utility in diverse samples, including those who come from homes which pose the great-
est risk for developing severe behavioral problems, which is why IY is considered by the National
Institute of Justice as an effective form of prevention and treatment for children with conduct
problems.
Conclusion
The cost of conduct problems is extensive, causing emotional and physical damage to victims, and
causing financial and community resource burdens. To add to the challenge, these children are
viewed by society as “bad” children rather than children suffering from a mental illness. Further,
treatment is notoriously difficult in this population, especially due to the etiological and devel-
opmental heterogeneity within the disorder. Despite all these setbacks, effective intervention
programs have begun to accumulate evidenced in support of improving behavior for children
with conduct disorder, even in the most challenging subgroups. These interventions offer sig-
nificant life improvement for children and families, and substantial cost-╉savings to society when
compared to children not receiving adequate interventions (Bonin, Stevens, Beecham, Byford,
& Parsonage, 2011). Although intervention programs tend to focus on outcome measures (e.g.,
aggression), further improvement in treatment outcomes can be accomplished by understanding
that conduct disorder is multifaceted and subgroups can be differentiated based on etiological and
developmental differences. Thus, we should aim to tailor treatment and family interventions to
specific subgroups of children with conduct disorder.
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Chapter 8
Emotion Regulation
and Anxiety: Developmental
Psychopathology and Treatment
Dagmar Kr. Hannesdóttir & Thomas H. Ollendick
Anxiety
Some years ago, Barlow (1991) put forth the notion that anxiety was a disorder of emotion and
was characterized by problems in regulating those emotions. In doing so, he noted that emotions
themselves were not maladaptive or problematic in and of themselves but rather that the tim-
ing and intensity of these emotions could be problematic. Furthermore, it has long been known
that individuals differ in the ways in which they appraise their emotions (Gross & John, 1995;
1998). Subsequently, these appraisals contribute to whether emotions are perceived as aversive or
nonaversive and whether the person attempts to avoid, escape or embrace them. If the emotion is
perceived as aversive and undesirable, the individual is more likely to attempt to regulate the emo-
tion than if the emotion is viewed as pleasant and desirable. Unfortunately, all attempts to regulate
aversive emotions are not effective—╉some attempts, in fact, lead to undesirable effects and their
exacerbation. Given these relations, it is no surprise that emotion regulation and its associated
deficiencies are intimately associated with the anxiety disorders and have been examined exten-
sively over the years (e.g., Amstadter, 2008; Davidson, 1998; Kring & Werner, 2004).
In this chapter, we will first briefly review the anxiety disorders of childhood and adolescence,
examining the role of emotion regulation in the onset, maintenance and expression of these dis-
orders, and then highlighting evidence-╉based interventions for these disorders that incorporate
emotion and its regulation. In doing so, we hope to illustrate the complexity of these disorders and
to illustrate the promise of emotion-╉based interventions.
Disorder Due to Another Medical Condition) are included. Obsessive-Compulsive Disorder and
Posttraumatic Stress Disorder, previously included in the Anxiety Disorders, are now placed in
separate diagnostic categories, Obsessive-Compulsive and Related Disorders and Trauma-and
Stressor-Related Disorders, respectively.
Based on the DSM-IV-TR (2000) criteria (as well as those put forth in DSM-5) the anxiety
disorders diagnosable in childhood and adolescence have several features in common, includ-
ing: 1) Persistent and excessive anxious arousal, and 2) symptoms that cause clinically significant
distress or impairment in social, academic, and other important areas of functioning. The dif-
ferent disorders vary primarily according to the stimuli eliciting anxiety in these disorders. In
addition, although anxiety disorders are among the most commonly diagnosed disorders of child-
hood, prevalence rates vary by disorder. Each of the disorders is briefly described.
Significant anxiety regarding separation from home or individuals to whom the child is attached
is the hallmark of Separation Anxiety Disorder (SAD). Children must show at least three of eight
symptoms, with onset of these symptoms usually before age 18 years, and they must have the
symptoms for at least four weeks to receive a diagnosis of SAD. Associated features include: per-
sistent reluctance to attend school, remain alone, or go to sleep without a major attachment figure
nearby, as well as nightmares involving the theme of separation and the presence of a number of
physical complaints when separation occurs or is anticipated. The prevalence of SAD is reported
to be between 1–4%, with rates decreasing as children get older (Brückl et al., 2007; Canino et al.,
2004; Egger & Angold, 2006; Merikangas, He, Burstein, et al., 2010).
Social Anxiety Disorder (SOC), previously referred to as Social Phobia, is characterized by
excessive and persistent (typically lasting for six months or more) fear and avoidance of social
situations or situations where scrutiny could lead to embarrassment. Children with SOC may not
be aware that their fears are unreasonable and/or excessive and may express their distress through
crying, tantrums, freezing, clinging, or shrinking from social situations with unfamiliar people.
The feared stimuli (i.e., social situations) with SOC are typically avoided or endured with intense
distress that may take the form of a panic attack in some cases. To be diagnosed with SOC, a child
needs to demonstrate age-appropriate social relationships with familiar people and to display
avoidance in interactions involving peers as well as adults. Prevalence rates for SOC are typically
reported between 1–3% but also vary by age with increasing rates seen in adolescents (Canino
et al., 2004; Egger & Angold, 2006; Essau, Conradt, & Petermann, 2000; Roberts, Roberts, & Xing,
2007; Wittchen, Nelson, & Lachner, 1998).
Often considered similar to SOC in its focus on socialization and interpersonal relationships
(Muris & Ollendick, 2015), Selective Mutism (SM) is diagnosed when a child refuses to speak in
specific social situations (e.g., school, community, clinic) despite the ability to do so. Such refusal
to speak must occur for at least one month with interference occurring in educational/occupa-
tional, achievement or social communication domains. However, SM is not diagnosed when
symptoms occur only within the first month of school or because of language/communication
issues. Associated features include social concerns, shyness, or other anxiety symptoms and the
prevalence of SM is thought to be quite small (i.e., <1%; Egger & Angold, 2006).
Once referred to as Overanxious Disorder, Generalized Anxiety Disorder (GAD) is character-
ized by excessive anxiety and worry about several different domains in the child’s life. The worry
experienced by a child with GAD is often reported to be uncontrollable and occurs more days
than not, typically for the past six months. Children must also exhibit at least one of the following
six physical/somatic symptoms: 1) Restlessness or feeling keyed up or on edge; 2) easily fatigued;
3) difficulty concentrating or mind going blank; 4) irritability; 5) muscle tension; and 6) sleep
disturbance. The worries reported by children with GAD are similar to the worries of children
without GAD and vary primarily in terms of their frequency, intensity and duration. Some of the
more common worries reported by children concern evaluation by others, perfectionism, health
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of significant others, and catastrophic events. Prevalence rates have been reported to vary widely
1–4% (Canino et al., 2004; Egger & Angold, 2006; Lavigne, LeBailly, Hopkins, Gouze, & Binns,
2009; Merikangas, He, Burstein, et al., 2010; Wittchen, Zhao, Kessler, & Eaton, 1994).
Specific Phobias (SP) are excessive and persistent (typically lasting 6 months or longer) fears
of explicit objects or situations, which are typically avoided or endured with intense anxiety or
distress. Exposure or anticipation of exposure to the feared stimulus results in extreme anxiety
including panic attacks in some cases. Children may not be cognizant of the unreasonable or
excessive nature of their fears and may express their fear by crying, throwing a tantrum, freez-
ing, or clinging. At a clinical level, phobias tend to be involuntary, inappropriate, and limiting
to a child’s quality of life (Anderson, 1994; Essau et al., 2000). Specific phobias can be speci-
fied as falling into one of the following subtypes: Animal (e.g., snakes, spiders, dogs), Natural
Environment (e.g., storms, heights, water), Blood-Injection-Injury (e.g., seeing blood, getting an
injection, receiving an injury), Situational (e.g., tunnels, flying, enclosed places), or Other (e.g.,
choking, loud sounds, costumed characters). Prevalence rates vary by child age and gender but are
typically reported to range from 2–6% (Burstein et al., 2012; Egger & Angold, 2006; Essau et al.,
2000; Wittchen et al., 1998).
Panic Disorder (PD) and Agoraphobia (AG) are each diagnosed separately in DSM-5.
The hallmark symptom of panic disorder is the recurrence of panic attacks, which are acute
and extreme feelings of anxiety that occur unexpectedly and are followed by one month or
more of persistent concern about having another attack, worry about the consequences of
the attack, or a change in behavior related to the attack. Agoraphobia is characterized by
excessive anxiety resulting from situations in which escape or avoidance may be inhibited
or in which help may not be available if panic symptoms were to occur. Panic Disorder and
Agoraphobia are among the less commonly diagnosed anxiety disorders during childhood,
with prevalence rates of about 1–3% increasing into adolescence and adulthood (Canino
et al., 2004; Doerfler, Connor, Volungis, & Toscano, 2007; Essau et al., 2000; Merikangas, He,
Brody et al., 2010; Ollendick, Birmaher, & Mattis, 2004; Roberts et al., 2007; Wells et al., 2006;
Wittchen et al., 1998).
Although the stimuli that elicit anxiety and fear in these disorders differ, the disorders all share
commonalities in the expression of anxiety. Fundamentally, anxiety is an emotional state asso-
ciated with heightened physiological arousal and behavioral avoidance that is triggered by the
perception of real or imagined threat. At times, these perceptions can be distorted and the threat
is exaggerated well beyond the real threat imposed by the stimulus. As Barlow (1991) noted, how-
ever, this emotion can be adaptive and can lead to constructive attempts to handle the threat and
to prepare the organism for adaptive change and growth; however, at other times, the emotion is
intense, frequent, and durable as in an anxiety or phobic disorder and it becomes less adaptive
and leads to a host of problems, including academic, behavioral, and social difficulties (Grills-
Taquechel & Ollendick, 2012).
The etiology of the Anxiety Disorders is complex and not straightforward. Equifinality (i.e.,
multiple pathways to any one outcome; Cicchetti & Toth, 1991) is the most succinct way to
describe the etiology of anxiety and its disorders in children. Indeed, fears and anxieties in chil-
dren have been described as multiply determined if not over-determined (Marks, 1987; Ollendick,
1979; Weems & Stickle, 2005). Contemporary etiological models reflect this heterogeneity with
consideration of various influences that cut across personal-social-ecological systems and typi-
cally include biological, developmental, psychological, social, and environmental components
(e.g., Grills-Taquechel & Ollendick, 2012; Hirshfeld-Becker, Micco, Simoes, & Henin, 2008;
Vasey & Dadds, 2001). Biological contributions have been well documented in familial, twin,
and genetic research studies, as have various connections with early developmental behaviors
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(e.g., temperament, attachment) and child dispositional characteristics (e.g., anxiety sensitiv-
ity, cognitive biases, and emotion regulation difficulties). Family influences, beyond genetics,
have also received a great deal of research attention in the past several decades. Research in this
domain has generally concentrated on anxious parenting behaviors and child-╉rearing practices.
For example, several investigators have drawn upon Rachman’s (1977) influential work denoting
three common pathways for fear acquisition and suggested parenting practices that may result in
heightened child anxiety. Indeed, using a variety of paradigms (e.g., cross-╉sectional, longitudinal,
observational, experimental), researchers have demonstrated the influences of parental model-
ing of anxious behaviors, conveying anxiety-╉provoking information, and reinforcing anxious
behaviors displayed by their children (cf, Beidel & Turner, 1998; Fisak & Grills-╉Taquechel, 2007;
Grills-╉Taquechel & Ollendick, 2012; Muris, van Zwol, Huijding, & Mayer, 2010), as well as for
parent-╉rearing behaviors characterized by rejection, control, and overprotection (cf., DiBartolo &
Helt, 2007; Ollendick & Benoit, 2012; Rapee, 1997).
Importantly, however, there is no single or direct cause of anxiety disorders in children and ado-
lescents. As noted by Thompson (2001, p. 160), “the action is in the interaction” among multiple
internal and external influences that contribute to their onset and expression. For example, tem-
peramental vulnerability as shown in behavioral inhibition may not determine alone the develop-
ment of an anxiety disorder but in combination with other influences it may play an important
role (Ollendick & Benoit, 2012). Temperamental inhibition may serve to sensitize young children
to anxiety-╉producing stimuli in a manner not seen in children who are not behaviorally inhibited.
So, too, anxiety sensitivity, emotion regulation difficulties, and parenting practices may function
in similar ways—╉they can heighten the aversive response to the feared stimuli and contribute to
an accumulation of risk over time (Thompson, 2001).
Such a conceptualization of how children develop anxiety disorders sheds light on how children
with a biological disposition to experience anxious feelings easily and who avoid situations that
elicit intense emotions might develop anxiety disorders through a dynamic interplay between
parental reactions, feedback from the environment and their own biased cognitions and expecta-
tions of how the world works for them. However, as noted, the process is not a straightforward
one; difficulties with emotion regulation, like other risk factors, can set the stage for the onset of
anxiety disorders but do not directly cause them.
In the next sections, research is reviewed on emotion regulation and the role it plays in the
development and maintenance of anxiety disorders in children and adolescents and how emerg-
ing knowledge on emotion regulation might improve and increase the effectiveness of cognitive-╉
behavioral treatment (CBT) for anxiety. Recent findings on emotion knowledge and emotion
regulation strategies among children with anxiety are reviewed and discussed in light of new
trends in treatment development, such as emotion-╉focused CBT (e.g., Suveg, Kendall, Comer, &
Robin, 2006), so that current treatment programs can become more effective for a larger group of
children. In addition, the role of parents in modeling emotion regulation skills for anxious youths
are discussed in terms of developmental psychopathology and the implications for treatment pro-
grams currently in use are evaluated.
depression) in general and how they are perceived and handled, such as anxious feelings, sad-
ness, and anger alike. Collective evidence suggests that children with internalizing disorders
seem to have problems managing negative emotions in general (Trosper, Buzzella, Bennett, &
Ehrenreich, 2009), not just emotions relating to their specific problems and the nature of their
disorder.
A few studies have also shown that this pattern of increased reactivity in infancy and early
childhood is predictive of physiological reactivity and emotion regulation difficulties in later
childhood. For instance, McManis and colleagues demonstrated a link between high reactiv-
ity to stress in infancy and right frontal asymmetry activation patterns among these children at
the age of ten to 12 years while performing a stressful speech task (McManis, Kagan, Snidman,
& Woodward, 2002). Similar findings were obtained in another study where right frontal EEG
activation patterns at approximately four years of age predicted increased heart rate and slower
cardiovascular recovery after a stressful speech task at age nine in a small sample of non-╉anxious
children (Hannesdottir, Doxie, Bell, Ollendick, & Wolfe, 2010). Concurrent studies on anxious
youths have also shown this pattern of cortical activation patterns emerging when anxious chil-
dren are faced with stressful situations. Hum and colleagues found that children with anxiety
showed heightened attention and arousal in response to a task with various emotion faces (both
positive and negative) while the non-╉anxious control group showed differential patterns of activa-
tion dependent on whether the faces were angry, sad, or happy (Hum, Manassis, & Lewis, 2013).
These results indicated that children with anxiety experienced heightened reactivity and were
engaged in a process of emotion regulation simply by being shown faces of people; irrespective of
what emotions those faces were showing.
Overall, the studies that have examined physiological reactivity, cerebral activation patterns and
emotion regulation among children with anxiety support the notion that these children experi-
ence heightened arousal easily and have a lower sympathetic activation threshold compared to
less anxious children (cf., Beauchaine, 2015). In addition, these children may need to put more
effort into regulating such intense emotions and into recovering from them, while not being able
to allocate their cognitive resources elsewhere at the same time. This may in turn limit their abil-
ity to perform well in a particular situation (e.g., a socially anxious child speaking in front of
the class) or to think rationally to reduce catastrophic beliefs in the situation (e.g., a separation
anxious child convincing herself that her mother is simply running late and has not been in a car
accident). Thus, strong physiological reactivity to anxiety provoking situations and considerable
emotion regulation efforts in such situations may play a large role in maintaining anxiety disor-
ders among children and reinforce avoidance and escape behaviors.
parent while the child is still relatively young (about birth to five years of age) and the parent is
able to control and select situations for the child. However, when children become more indepen-
dent and enter the school system the parent has less and less control over which situations their
children will find themselves in and then anxiety may become more debilitating for them and
more distress will be evident in their daily lives.
Numerous studies have shown that parents of anxious children tend to do exactly this. For
example, parents of anxious children have been found to be more overinvolved and intrusive,
allowing avoidance of uncomfortable situations and less encouraging of autonomy than parents
of non-anxious children (e.g., Barrett, Rapee, Dadds, & Ryan, 1996; Hudson, Comer, & Kendall,
2008; Hudson & Rapee, 2001; Hurrell, Hudson, & Schniering, 2015). Studies on emotion social-
ization have also shown that parents of anxious children, especially mothers, tend to show greater
intrusiveness even when simply discussing previously experienced emotionally arousing negative
situations (anxiety or anger) in a structured interaction task as opposed to parents of non-anxious
children or when discussing happy events and positive emotions (Hudson et al., 2008). In addi-
tion, the way children with anxiety interpret ambiguous situations as threatening may impact
subsequent conversations and discussions with parents (Chorpita, Albano, & Barlow, 1996).
Therefore, children who develop anxiety disorders may have had fewer opportunities to prac-
tice discussing and experiencing negative emotions and figuring out ways to manage their emo-
tions since their parents have often been too quick to assist them in avoiding or escaping negative
emotion situations or taking over the situation themselves. When the parent takes over the situ-
ation or removes the child from a mildly threatening or embarrassing situation (e.g., the child is
asked their name at a family party but cannot utter a single word due to shyness), the child learns
indirectly that 1) “this was in fact a dangerous situation since my parent felt the need to rescue
me,” and 2) “I cannot take care of it myself and I need to be rescued from such situations.”
In one recent study, Suveg, Morelen, Brewer, and Thomassin (2010) explored behavioral inhi-
bition (a temperament characteristic associated with anxiety, as seen earlier in the chapter) and
family emotional environment (restricted expressiveness, as seen earlier in the chapter) and their
associations with anxiety in a sample of late adolescents. They also examined whether emotion
regulation mediated these relationships. They argued, as above, that emotional reactivity as seen
in behaviorally inhibited youths would lead these youths to be “keyed up” or “wired,” making
emotional regulation more difficult and anxiety more probable. Similarly, they argued that the
family emotional environment would influence emotion dysregulation through a failure to appro-
priately socialize the emotion understanding and regulation skills necessary for adaptive func-
tioning, also resulting in increased anxiety. Basically, consistent with their hypotheses, they found
that a measure of emotion regulation fully mediated the relationship between behavioral inhibi-
tion and anxiety and partially mediated the relationship between family emotional environment
and anxiety. Thus, these risk factors, in tandem, were related to anxiety but mostly through their
effects on emotion regulation.
In sum, children with anxiety have less knowledge of emotion and emotion regulation strate-
gies, have fewer ways of solving problems in emotionally arousing situations, show higher emo-
tional reactivity, and have a more difficult time calming down. In addition, because the child’s
anxious behavior often elicits overprotective behavior from the parent (Rapee, Lau, & Kennedy,
2010), parents of anxious children are more likely to accept their avoidance behavior, be overly
intrusive, and encourage less autonomy and expression of emotions compared to parents of chil-
dren without anxiety. Therefore, it is important when reviewing the role of emotion regulation in
child anxiety and its implications for treatment that treatment components focusing on emotion
and emotion regulation are included in programs for child anxiety reduction and that their par-
ents are included to some extent in the treatment of their children.
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in child anxiety were evidenced as were improvements in parents’ own self-╉regulation skills and
reductions in parental accommodation of the child’s anxiety (Lebowitz, Omer, Hermes, & Scahill,
2014). Again, however, only six of the ten children were designated as treatment responders—╉a
rate remarkably similar to the other emotion-╉based interventions and the standard evidence-╉
based treatments.
Furthermore, following these studies, it will be important to compare the relative efficacy of
parent-╉based interventions such as the Supportive Parenting for Anxious Childhood Emotions
(SPACE) program (Lebowitz & Omer, 2013; Lebowitz et al., 2014) to the more child-╉focused
interventions such as Emotion Focused CBT (ECBT; Suveg et al., 2006; Suveg, Davis, & Jones,
2015) and the UP-╉Y; (Ehrenreich-╉May & Bilek, 2012; Trosper et al., 2009). In doing so, it will be
important to examine moderators of change in these distinctly different approaches (see Maric,
Prins, & Ollendick, 2015). For which families does a more parent-╉focused intervention work
better? It certainly seems plausible that the SPACE program might be more appropriate and
thus more effective in families in which the parents accommodate their child’s emotional dis-
plays and show poor emotion regulation strategies themselves. After all, the program is specifi-
cally designed to alter parent behavior, which is then hypothesized to result in changes in their
child’s anxiety. So, too, of course might the UP-╉Y and EBCT programs work best for children
and adolescents who themselves display emotion regulations difficulties. In one of our recent
trials (Ollendick et al., 2015), for example, only about one third of the anxious children exhib-
ited emotion regulation difficulties. For these children adding an emotion regulation compo-
nent makes good sense; for the other two thirds it might not. We might also consider whether
emotion regulation training would benefit some subgroups of children with anxiety disorders
more so than others. For example, since there is considerable overlap in symptomatology for
children with anxiety/╉worry and depression (Cummings, Caporino, & Kendall, 2014), emo-
tion understanding and regulation training might benefit this group of children with comor-
bid symptoms more in terms of learning how to manage and withstand negative emotions in
daily life. In the final analysis and consistent with a developmental psychopathology framework
(Cicchetti & Rogosch, 1996; Lease & Ollendick, 2000), multiple pathways to anxiety disorders
exist and it will be important to tailor our interventions to the specific pathways involved for
any one child with an anxiety disorder.
Thus, although much has been accomplished, continued progress is needed before we fully
understand the parameters and underlying causes of emotion dysregulation in anxious youths
and to develop, evaluate, and eventually disseminate evidence-╉based treatments for them.
Thanks to the pioneering work of Barlow (1991) some 25 years ago, we are moving in the
right direction and the next generation of research holds considerable promise for reaching
our goal.
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Chapter 9
Depression
In this chapter we describe the main features of depression in children and adolescents in terms
of symptomatology, epidemiology and risk factors. One way of viewing depression is as an imbal-
ance of positive and negative affect systems. We take a broad view of emotional regulation as
comprising responses to, interpretations of and control of emotional material affecting the bal-
ance between positive and negative affect and can, therefore, influence a person’s thoughts and
beliefs about themselves and the world around them. We describe cognitive behavioral therapy
and behavioral activation as psychological interventions primarily aimed to alter negative and
positive affect systems respectively.
above). Depressive disorder is usually defined by clinical interview and there are fairly rigorous
quantitative and qualitative criteria for operationalizing or defining each symptom. For instance,
in order to meet the criteria for depressed mood, the low mood must be present most of the time
and nearly every day for at least two weeks (i.e., the “quantity” is high) and the low mood should
be qualitatively different from the ordinary ups and downs of mood; for instance, it should be
present to a degree that is definitely abnormal for the particular individual and should be rela-
tively unaffected by external factors. The symptoms must also cause significant distress or impair-
ment in social, educational or other important areas of functioning. The diagnostic criteria for
depression include symptoms of both increased negative affect as well as decreased positive affect.
Symptoms like low mood and irritability index, high levels of negative affect and symptoms like
loss of interest or pleasure index low levels of positive affect and both are indicative of a depres-
sive mood state. One way of viewing depression is as an imbalance between negative and positive
affect systems (Insel et al., 2010).
There is good evidence to support the validity of viewing depression as a continuous dimension
of symptoms. For instance, when depressive symptoms are present but fall short of meeting the
diagnostic threshold, they are still impairing (Angold, Costello, Farmer, Burns, & Erkanli, 1999;
Pickles et al., 2001), increase the risk of later depressive disorder (Pine, Cohen, Cohen, & Brook,
1999) and are associated with a range of poor outcomes similar in severity to that of the diagnosis
of MDD (Wesselhoeft, Sorensen, Heiervang, & Bilenberg, 2013). Depressive disorder and depres-
sive symptoms are associated with a range of adverse short-╉term and long-╉term outcomes includ-
ing deliberate self-╉harm, educational failure and future depressive episodes (Angold et al., 1999;
Pickles et al., 2001; Riglin, Petrides, Frederickson, & Rice, 2014; Skegg, 2005). Thus, high sub-╉
threshold symptoms indicate an increased probability of developing MDD and are also associated
with functional impairment. The usual approach to defining severity of depression is to sum the
number of symptoms endorsed; however, it is also accepted that particular symptoms may only
be present at higher levels of severity and that certain symptoms, such as suicidality, may be of
particular concern (National Institute for Health and Clinical Excellence, 2005). It is worth noting
that there are different methods used to define depressive symptoms including semi-╉structured
interviews, structured interviews and self or parent reported questionnaires. The threshold for
endorsing symptoms differs according to the method used, with the most conservative estimates
of the prevalence (i.e., lower estimates) provided by semi-╉structured interview.
Depression in young people is under-╉recognized; studies across the world show that only a
small minority of children and adolescents meeting diagnostic criteria for depressive disorder
receive any kind of intervention from a health professional (Paula et al., 2014; Sayal, Yates, Spears,
& Stallard, 2014; Zhong et al., 2013). This low rate of access to services is also true of individuals
with known risk factors for depression such as the offspring of depressed parents (Potter et al.,
2012) and young people with previous depressive episodes (Brenner et al., 2015). Various features
may contribute to difficulties in identifying depression in this age group, including the presen-
tation of depression (where mood may be irritable rather than depressed or low mood may be
fluctuating), as well as the presence of other difficulties such as academic impairment, which may
mask the underlying problem.
Risk factors
It is generally accepted that depression has a complex, multi-╉factorial aetiology. This means there
are multiple causal risk factors involved acting in concert with protective factors in complex ways.
These risk and protective factors are varied (e.g., cognitive, biological, contextual) and both genes
and environment are likely to contribute. In this section, we discuss factors that may be useful for
identifying groups at high risk of developing depression. We also include a brief discussion about
what is known about genetic and environmental risk factors. As mentioned earlier, high levels
of sub-╉threshold depressive symptoms increase risk for episodes of MDD. Other important risk
factors for depression in young people are depressive disorder in a parent and exposure to stress-
ful life events. Children of depressed parents are around three times more likely to be diagnosed
with MDD compared to the children of healthy control groups (Rice, Harold, & Thapar, 2002).
Nevertheless, familial risk is not depression-╉specific and there is familial clustering of other types
of psychopathology, such as antisocial behavior (Harrington et al., 1997) and anxiety (Rende,
Warner, Wickramarante, & Weissman, 1999; Warner, Weissman, Mufson, & Wickramaratne,
1999; Weissman, Warner, Wickramaratne, Moreau, & Olfson, 1997).
Stressful life events are important in the onset of depressive disorder and 60% of adolescents
with depression experience an acutely disappointing life event in the month prior to the onset of
depression (National Institute for Health and Clinical Excellence, 2005). Stressful events involving
the loss of a significant relationship due to death or separation and acutely disappointing events,
such as failing an exam, appear to be especially important in precipitating depression. Stressful life
events may be particularly important in the first onset of depression, as opposed to recurrences
(Kendler, Thornton, & Gardner, 2000; Monroe, Rohde, Seeley, & Lewinsohn, 1999). Depressed
young people may also “evoke” or “create” stress in their lives because of the way they behave, for
instance, losing a friend following an argument (Hammen, 1991). There is evidence that exposure
to social stress increases around adolescence (Rice, Harold, & Thapar, 2003). Girls appear particu-
larly sensitive to depressive symptoms following social stress (Rudolph, 2002). Consistent with
their important role in the development of depression, sub-╉threshold symptoms, family history of
depression in a parent and exposure to stressful events have all been used as criteria for the selec-
tion of individuals to receive therapeutic intervention, with the aim of reducing symptomatology
(i.e., selective or indicated prevention programs; Horowitz & Garber, 2006; Stice, Shaw, Bohon,
Marti, & Rohde, 2009).
Twin studies show that depressive symptoms and disorder in adolescence are influenced by
genetic factors to a moderate degree (Rice, 2010). It is unclear exactly what is inherited, but it
seems likely that part of the heritable effect is indirect. For instance, genes may operate indirectly
via influences on behavior or personality traits that affect exposure to stress. Interestingly, a num-
ber of twin studies show that depressive symptoms in childhood are not influenced by genetic
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factors but environmental influences predominate (Eaves et al., 1997; Rice et al., 2002; Scourfield
et al., 2003; Thapar & McGuffin, 1994). Longitudinal studies also suggest that childhood and
adolescent depression may differ in rates of continuity into adult life, with childhood depression
showing low rates of continuity with depression in adulthood and adolescent depression showing
higher rates of continuity with depression in adulthood (Harrington et al., 1991). There are dif-
ferences in the prevalence, sex ratio of cases, rates of continuity and aetiology of childhood and
adolescent onset depressive symptoms and disorder. Evidence, to date, suggests that adolescent
depression can be viewed as an early onset form of the adult disorder (Thapar, Collishaw, Pine, &
Thapar, 2012); whether this is the case for childhood onset depression is less clear and it may be
that childhood onset depression is different.
In summary, depression can be viewed both categorically and continuously. There are differ-
ences between depression in childhood and adolescence. Depression in a parent, stressful life
events and sub-╉threshold symptoms are important risk factors for MDD. Depression involves
symptoms that reflect an excess of negative affect, such as low mood and irritability and a dearth
of positive affect, such as a loss of interest.
(Lopez-╉Duran et al., 2013) but a different pattern of results where shown in a study of high-╉risk
girls, where they appeared less sensitive to sad stimuli (Joormann et al., 2010). Studies of remit-
ted, depressed adolescents (Maalouf et al., 2011) and a longitudinal study examining the affective
processing of depressed adolescents, prior to the onset of depression (Kilford et al., 2015), showed
that any observed affective bias appeared to be state dependent and was not observed in remitted
adolescents. Collectively, these results do not suggest a clear pattern of attentional bias for emo-
tional information in depressed children and adolescents.
Studies that have reported a preference for happy stimuli in depressed cases have suggested that
some depressed young people may use this as a rudimentary form of emotion regulation (Cohn
& Tronick, 1983). Thus, allocation of attention away from a negative stimulus (such as a sad face)
and towards a happy one may serve to reduce emotional distress. There is evidence that this may
occur in infants of depressed mothers and the use of this strategy is related to the infant’s own
affect (Cohn & Tronick, 1983; Termine & Izard, 1988).
In summary, there is inconsistent evidence for negative affective bias as measured by atten-
tional tasks in depressed children and adolescents. This contrasts with the pattern of results for
depressed adults and illustrates the importance of considering developmental differences. Results
of one longitudinal study suggested that sad and happy material may differentially interrupt task
performance in depressed and healthy individuals and that it may be important to consider the
role of cognitive control of emotional material (Kilford et al., 2015). We deal with the control of
emotional material later in this chapter.
depressed children and young people (Hipwell, Sapotichne, Klostermann, Battista, & Keenan,
2011; Rawal & Rice, 2012a). This pattern of response distinguishes children with depression, not
only from healthy controls, but also from children with other psychiatric disorders (Rawal & Rice,
2012a). Interestingly, there is evidence that over-╉general memory for negative cue words specifi-
cally predicts later depression (Rawal & Rice, 2012a) and distinguishes high-╉risk from low-╉risk
children (Woody, Burkhouse, & Gibb, 2015). It is important to note that the valence (i.e,. happy
or sad) effect is observed for the type of word used as a cue to prompt the recall of a memory
rather that the valence of the autobiographical memory itself. One longitudinal study reported
that currently depressed adolescents were more over-╉general than healthy and psychiatric control
groups for both positive and negative cue words, but that the predictive influence of OGM on
later depressive symptoms and disorder was only observed for negative cue words (Rawal & Rice,
2012a). This provides indirect evidence that, OGM may be a process that begins initially with
negative material (i.e., prior to a depressive episode) but becomes generalized to other material
with time (i.e., once a depressive episode has begun) (Williams, 1996). Thus, OGM may indi-
rectly measure a type of emotion regulation strategy where specific details of the personal past are
avoided in order to reduce distress (Crane et al., 2014; Williams, 1996). Such a strategy is unlikely
to be adaptive in the long-╉term. Over-╉general autobiographical memory may also interfere with
using memory for other, more effective, forms of emotion regulation.
Recalling positive autobiographical memories has been shown to be an effective strategy to
repair low mood. This phenomenon has also been shown in experimental research, where acti-
vating the neural substrate of a positive memory reduces depressive symptoms (Ramirez et al.,
2015). It seems likely that the inability to recall specific details of the personal past will affect a
person’s ability to use positive memories as a form of emotion regulation (Dalgleish & Werner-╉
Seidler, 2014). There is an indication that depressed individuals are less effective in using the recall
of positive events as a strategy to repair sad mood (Joormann, Siemer, & Gotlib, 2007). It is not
exactly clear why this might be; however, it is possible that recalling memories that lack detail and
vividness may fail to have the desired mood-╉repair effect. Indeed, one study showed that adults
with remitted MDD recalled less vivid positive memories than healthy controls (Werner-╉Seidler
& Moulds, 2011). An intervention study found that training in positive imagery improved symp-
toms of anhedonia in currently depressed adults (Blackwell et al., 2015). A preventive, universal
intervention that reduced depressive symptoms in healthy adolescents also included a session
based on recalling positive autobiographical memories (Rice et al., 2015).
In summary, evidence suggests that recalling low levels of positive information is associ-
ated with the onset of depressive symptoms over time. There is reason to believe that recalling
positive autobiographical memories is an effective emotion regulation strategy. Studies of adults
suggest this effective mood repair strategy goes awry in depression. Further research is required
to test if this finding also applies to children and adolescents with depression. Another feature
of autobiographical memory that is important in depression occurring in young people is the
level of specificity that is recalled. Difficulties in recalling specific details of the personal past is
likely to interfere with the ability to use happy memories as an effective mood repair strategy.
Collectively, results illustrate the importance of positive memories in regulating and repairing
low mood.
research most often uses behavioral tasks involving rewards, such as winning points or money;
although, tasks involving other sorts of reward, including social reward are beginning to be devel-
oped and used. Lowered reward responsiveness may be involved in the maintenance of depressive
symptoms, as it may lead to diminished engagement in pleasurable activities and reduced motiva-
tion to pursue outcomes that are usually enjoyable, such as social events, interpersonal relation-
ships and activities like exercise (Depue & Iacono, 1989; Forbes & Dahl, 2005; Lewinsohn, 1975).
Consistent with this idea, lowered reward-responsiveness, as measured by fMRI, and behavioral
tasks are correlated with affect in every-day life (Forbes et al., 2009) and engagement in positive
daily activities, such as exercise and extra-curricular activities (Rawal et al., 2013b). Several stud-
ies have shown that depressed young people “play it safe” and bet less of their points compared to
healthy individuals and psychiatric controls when the chances of winning are very high (Forbes,
Shaw, & Dahl, 2007; Guyer et al., 2006; Rawal et al., 2013b). This pattern of reward decision mak-
ing has also been shown to predict depressive symptoms and new onset depressive disorder over
time when controlling for prior symptom severity (Rawal et al., 2013b). Similarly, lowered activa-
tion in the ventral striatum, a brain area involved in reward processing, has been found to predict
the symptom of anhedonia/loss of interest over time (Stringaris et al., 2015).
Thus, MDD in children and adolescents appears to be characterized by a reduced expectation
of future reward, a diminished ability to change behavior according to the likelihood of a reward
and alterations in the functioning of the brain’s reward circuit (Pizzagalli, 2014; Stringaris et al.,
2015). Reduced sensitivity to reward is thought to be a factor underlying the symptoms of depres-
sion that index low positive affect, such as anhedonia/loss of interest and social withdrawal. These
sorts of symptoms may be particularly important markers of severity and prognosis. For instance,
anhedonia has been reported to predict severity and relapse in treatment resistant adolescent
depression (McMakin et al., 2012). Family studies have suggested that reductions in the capacity
for positive affect may distinguish children at low and high familial risk for depression (Olino
et al., 2011). Kovacs & Lopez-Duran (2010) posit that an attenuated capacity for positive affect
(which may stem in part from blunted reward sensitivity) is likely to interfere with the ability of
young people to engage in effective mood repair strategies such as doing something fun, doing an
enjoyable, distracting activity or focusing on happy memories. An intervention involving training
in reward decision making and strategies to enhance positive affect reduced adolescent depressive
symptoms; the change in reward decision making appeared to explain the reduction in symptoms
(Rice et al., 2015). Thus, the lack of a normative positive bias, as indicated by reduced sensitivity
to reward, may also impair effective emotion regulation strategies.
In line with the idea that depressed young people fail to show a normative positive bias are
studies of probability judgements. It is widely established that healthy individuals show an opti-
mism bias where they judge negative events as more likely to happen to others than to themselves
(Sharot, 2011). Depressed children and adolescents made more balanced judgements and (cor-
rectly) judged these events as equally likely to occur to themselves as to another person (Dalgleish
et al., 1997). This effect appeared to be mood-dependent as it was not observed in a recovered
depressed group (Dalgleish et al., 1998).
In summary, there is good evidence that decision making, when there is the potential for
reward, is impaired in individuals with depression and those at increased risk of developing
depression. There is also good evidence that the neural correlates of reward processing are affected
in depression and recent evidence also shows that this predicts depression over time (Stringaris
et al., 2015) consistent with previous longitudinal behavioral studies (Forbes et al., 2007; Rawal
et al., 2013b). Depressed and vulnerable young people appear not to expect future reward and are
inflexible in modifying their behavior according to the likelihood of obtaining a reward (Rawal
et al., 2014). It is possible that low expectations of future reward, as well as lower capacity for
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positive affect, may interfere with young people’s ability to engage in effective emotion regulation
strategies, particularly those that involve up-╉regulating positive affect.
Reduced executive functioning capacities might interfere with retrieving specific autobiograph-
ical memories, which may serve as an important resource when coping with negative or stressful
events. Difficulties in retrieving specific autobiographical memories (i.e., overgeneral autobio-
graphical memory; [OGM]) have been shown to characterize currently depressed children and
adults (Kuyken, Howell, & Dalgleish, 2006; Park, Goodyer, & Teasdale, 2002; Vrielynck, Deplus,
& Philippot, 2007; Williams et al., 2007). Longitudinal studies also demonstrate that overgeneral
autobiographical memory increases the risk for developing depression (Hipwell et al., 2011; Rawal
& Rice, 2012a). Several theorists suggest that impairment in retrieving specific autobiographical
memories may be at least partially due to reduced executive functions (Conway & Pleydell-╉Pearce,
2000; Hertel & Hardin, 1990; Williams et al., 2007; Zacks & Hasher, 1994). Studies conducted
with adults and children give support to the role of executive functioning in the retrieval of spe-
cific autobiographical memories (Picard, Reffuveille, Eustache, & Piolino, 2009; Raes, Verstraeten,
Bijttebier, Vasey, & Dalgleish, 2010; Rawal & Rice, 2012b; Williams et al., 2007). This may inter-
fere with the ability to use autobiographical memory as a form of emotion regulation strategy as
described above.
Finally, it is possible that executive functioning could affect how individuals respond to preven-
tive or therapeutic interventions. It has been suggested that psychological interventions used for
depression, including Cognitive Behavioral Therapy(CBT), encourage the patient to exercise cog-
nitive control over thoughts and emotional responses. These strategies attempt to change how the
person relates and responds to their thoughts by generating alternative interpretations, switch-
ing between thoughts and interpretations or examining thoughts from a distanced perspective
(Brewin, 2006; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Siegle et al., 2007). While such inter-
ventions may improve executive functioning by practicing these skills, it is also possible that those
with executive functioning difficulties might find these tasks challenging.
In summary, depressed children and adolescents show a range of difficulties in processing emo-
tional material that may compromise their ability to use effective emotion regulation techniques.
These difficulties include biases for negative information, an absence of bias for positive informa-
tion and difficulties in exerting control over emotional material. The best evidence of emotion
regulation difficulties predicting the onset of depressive disorder and symptoms comes from low
levels of bias for positive information. Later we review the interventions that are used to amelio-
rate depression in young people and relate these to the emotion regulation difficulties described
previously.
Finally, we discuss psychological approaches to reducing and preventing symptoms in young people
without depressive disorder.
CBT focuses on altering dysfunctional styles of thinking and behavior through challenging
negative thoughts and beliefs. CBT programs encourage and support young people in identifying
and evaluating negative thoughts and cognitive distortions with the aim of encouraging more
balanced, less negative, more reflective beliefs about the self, the world and the future. CBT is,
therefore, aiming to target the negative feelings, thoughts and beliefs that are common in depres-
sion. CBT also encourages individuals to exert greater executive control over automatic emotional
reactions (Siegle et al., 2007). It is possible that young children, or those whose meta-cognitive
skills (i.e., the ability to think about thoughts) are not well developed and may struggle with this
aspect of CBT.
A number of CBT-based programs have been used in preventive interventions. Preventive inter-
ventions can be delivered to high-risk groups, including those with known risk factors for a disor-
der or those with high symptoms that fall below the traditional diagnostic (selective or indicated
prevention). Preventive interventions can also be delivered to all members of a group, regardless
of symptoms (universal prevention). CBT programs appear to be effective in preventing depres-
sive symptoms and disorder in those at high-risk (Garber et al., 2009; Horowitz & Garber, 2006;
Merry, McDowell, Hetrick, Bir, & Muller, 2004; Stice et al., 2009). In particular, the Coping with
Adolescent Stress program has been shown to be effective (Clarke et al., 1995; Garber et al., 2009).
In contrast, CBT-based programs do not appear to be effective in universal prevention programs
with a very large randomized controlled trial finding no benefit (Stallard et al., 2012).
In our review of the emotion regulation difficulties seen in depression in children and ado-
lescents, we have identified low levels of positive affect as important in predicting the onset of
depression and in interfering with adaptive styles of emotion regulation. To that end, it is also
worth considering behavioral activation and the more behavioral elements of CBT that are rec-
ommended for interventions with depressed young people. Behavioral activation involves activ-
ity monitoring and scheduling and aims to encourage individuals to engage in interesting and
pleasurable activities (Dichter et al., 2009). Meta-analysis has indicated that behavioral activa-
tion is effective in reducing symptoms in depressed adults and is as effective as CBT or antide-
pressant treatment (Cuijpers, van Straten, & Warmerdam, 2007). Activity scheduling may be the
“active” element of behavioral activation packages as this alone is effective in reducing depression
in adults (Cuijpers et al., 2007; Jacobson et al., 1996). An appealing aspect of behavioral activation
is that it may be simpler for individuals to understand and for therapists to deliver then cognitive
behavioral therapy. A preliminary trial suggested that behavioral activation may be efficacious in
depressed adolescents (McCauley et al., 2015). Behavioral activation has been shown to alter the
responding of brain areas involved in reward processing (Dichter et al., 2009).
We developed TRY (see later), which incorporated CBT and behavioral activation and focused
on enhancing reward-processing and tested it as a classroom-based universal prevention program
(Rice et al., 2015). TRY aimed to enhance reward-processing through activities such as illustrating
the use of rewarding experiences to lift mood and evaluating potential risk and rewards involved
in day-to-day decision making. We also measured reward-decision making with a behavioral
task pre and post intervention and compared TRY to two other psychological therapies (cogni-
tive behavioral therapy and mindfulness based cognitive therapy) as well as a comparison group.
TRY was the only intervention associated with a reduction in depressive symptoms at follow-
up. Reward-seeking increased following TRY. In the TRY program, which focused on increas-
ing sensitivity to rewarding activities, reward seeking increased; this increase was associated
with decreased depressive symptoms. There is, therefore, preliminary evidence that behavioral
3
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the nature of the scaffold, which in CBT with children may be varied according to the child’s
interests and needs.
A central tenet of CBT for depression is psychoeducation and, therefore, there is a need for
therapy to support children’s learning about internal processes linked with cognitive and emo-
tional aspects of functioning. There has been substantial research that has looked at the teaching
approaches most associated with effective learning (see Hattie, 2009). There are clear indications
that, in order for children to grasp new ideas, information needs to link with pre-╉existing under-
standings and be presented in a variety of ways, using multi-╉media to reinforce concepts where
possible (Mayer, 2005). Spaced or distributed practice (i.e., short, multiple practice sessions inter-
spersed with other activities) is important for efficient learning and is much more effective than
practicing a new skill less frequently, but for longer periods (Walker, Greenwood, Hart, & Carta,
1994). The implication of this is that, for example, shorter daily practice is preferable to more
extended weekly practice. Some children may have difficulty with the abstract nature of CBT and
discussion of concepts that are not in the “here and now.” Therefore, another important adaptation
of CBT for children and young people is to present concrete examples in parallel with abstract
concepts, to ensure transfer (Gentner, Rattermann, & Forbus, 1993). This may involve video, role-╉
play, use of stories, model characters, pictures and so on. CBT for children and young people
needs to provide engaging, stimulating activities that are developmentally appropriate and align
with current interests (Fuggle, Dunsmuir, & Curry, 2012).
CBT for children generally combines behavioral and cognitive components (Weisz & Kazdin,
2010), although the degree to which each component is effective, is contestable (Weisz, McCarty,
& Valeri, 2006). Similarly, both cognitive and behavioral methods are central to CBT with adults
for depression, although the extent to which outcomes are influenced by the balance of these
two components is uncertain (Gortner, Gollan, Dobson, & Jacobson, 1998). CBT for children;
therefore, needs to be adapted to ensure that session content is accessible and addresses the level
of metacognitive and executive functioning of the individual. This will require careful planning,
adaptation and simplification of methods, and for many children, an emphasis on more concrete,
behavioral components. As mentioned earlier, one common technique that has been success-
fully integrated within small scale adolescent interventions for depression with positive out-
comes is behavioral activation (BA) (Ritschel, Ramirez, Jones, & Craighead, 2011). BA involves
the young person monitoring and recording daily activity and then exploring the relationship
between mood and activity levels. Social factors are also taken into account due to their impact
on emotional state.
to encourage the use of happy autobiographical memories and engagement in enjoyable activi-
ties, including social activities as emotion regulation strategies. TRY was developed for delivery
to universal populations of young people aged 14–15 years, attending co-educational mainstream
schools. It consists of eight 60-minute sessions, designed to be delivered on a weekly basis by a
facilitator during Personal Social and Health Education (PSHE) lessons. The session-by-session
outline of the TRY program is detailed below:
1 . Introduction; psychoeducation about stress and depression; rationale for the TRY program
2. Goal setting; introduction to the modified CBT model
3. Identifying rewarding experiences and happy memories
4.
Identifying and evaluating thoughts
5.
Decision making with regard to rewarding experiences and the impact on mood
6.
Evaluation of positive experience and how this informs future decision making and practicing
the TRY decision making process
7 . The role of social support and managing conflict
8. Review of TRY program and personal goals
Additional information and multi-media resources used in the TRY intervention can be accessed
at http://www.ucl.ac.uk/educational-psychology/try.html.
It is important to recognize that in order to deliver universal therapeutic interventions in schools,
facilitators require a range of competencies. These include interpersonal skills, such as sensitivity
and the ability to consult and negotiate with school staff (Kratochwill, Elliott, & Callan-Stoiber,
2002; Zins & Erchul, 2002), as well as the ability to develop and maintain good relationships with
young people (Shirk, Karver, & Brown, 2011). Facilitators also need to be appropriately trained,
experienced and knowledgeable about the intervention and have good group management skills
(Lendrum, Humphrey, Kalambouka, & Wigelsworth, 2009), factors all positively related to better
pupil outcomes (Humphrey et al., 2008).
To ensure appropriate standards of TRY program delivery, facilitators were all qualified educa-
tional psychologists, regularly providing services to schools, who had received additional train-
ing in CBT who had attended a one-day training session in TRY implementation. In addition,
and consistent with recommendations from the British Association of Behavioural and Cognitive
Psychotherapies (BABCP), the Health and Care Professions Council (HCPC) standards of con-
duct, performance and ethics (2012), the British Psychological Society (BPS) Code of Ethics and
Conduct (2009), facilitators of the TRY intervention attended scheduled, two hour group supervi-
sion meetings with an experienced CBT trainer three times during the eight week intervention.
Supervision frameworks were based on several models of CBT supervision (Liese & Alford, 1998;
Liese & Beck, 1997; Pretorius, 2006), within a structured, practical format and incorporating a
didactic function to ensure consistency in the delivery of the intervention, and to share experi-
ences of managing group dynamics and school personnel.
As reported earlier, in a preliminary study, TRY was associated with a reduction in symptoms
of depression and an increase in reward-seeking and was more effective than standard CBT and
mindfulness based CBT (Rice et al., 2015). There is, therefore, preliminary evidence that this
intervention, incorporating CBT and behavioral activation and focusing on enhancing reward-
processing, may be an effective, accessible intervention that can be delivered in universal settings.
Although psychological therapies are the intervention of choice for treating and preventing
depression in children and young people, there is no single “gold-standard” intervention package
or approach. Basic research on emotion regulation has informed the development of interven-
tion programs. It may be useful to consider the balance of both positive and negative affect when
seeking to reduce depressive symptomatology and the impact of symptoms in children and young
people.
6
8
1
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Chapter 10
Eating disorders
Eating disorders in children and adolescents differ from those in adults in prevalence of clinical
syndromes and in the psychopathology of disorders. Bulimia nervosa and binge eating disorder
have a later age of onset than anorexia nervosa and Avoidant/╉Restrictive Food Intake Disorder
(ARFID), which are the more common childhood problems. However, very little is known about
ARFID and its treatment. Thus, this chapter will focus on anorexia nervosa and describe a new
approach to emotion regulation in its management in adolescents. The diagnostic clinical features
of common eating disorders (American Psychiatric Association, 2013) are listed in Box 10.1.
Anorexia nervosa occurs in around one in 400 adolescent girls. In pre-╉pubertal children eat-
ing disorders are less common and have a different sex distribution where almost a quarter of
presentations manifest in boys (Madden, Morris, Zurynski, Kohn, & Elliot, 2009). ARFID is also
common in children and boys; however, it is unclear if ARFID, or at least a proportion of ARFID
cases of early onset, are a predecessor for anorexia nervosa or other eating disorders, or whether it
is a distinct eating disorder with longitudinal studies needed to elucidate this. In children it often
presents with significant weight loss in the context of somatic concerns such as nausea and full-
ness, and in adults with a specific anxiety related to eating.
In addition to differences in sex distribution, eating disorders of early onset also appear to
have a greater responsivity to treatment and, in clinical samples, better long term outcomes
than when onset presents in adulthood (Hay, 2015). A a strong body of research supports the
efficacy of treatment in young people with eating disorders (See for example, Forsberg & Lock,
2015). The causes of eating disorders in children and adolescents are similar to those in adults;
these include a family history of eating, mood and substance abuse disorders as well as obesity.
Exposure to “anorexogenic” environments such as classical ballet and high levels of criticism
and parental expectations are often associated with the onset and maintenance of disorders
(Hay et al., 2014; Hay & Claudino, in press; Zipfel, Giel, Bulik, Hay, & Schmidt, 2015). The
pathway into an eating disorder is a complex interplay of biological/╉genetic, psychological vul-
nerabilities and societal factors (Mitchison & Hay, 2014) and recent research has pointed to
the importance of gene-╉environment interactions and the role of epigenetics (Campbell, Mill,
Uher, & Schmidt, 2011).
Bulimia nervosa
Recurrent binge eating-╉uncontrolled overeating
Use of extreme measures to control their weight—╉purging/╉non-╉purging
Overvalued ideas of body weight/╉shape on self-╉view
Normal weight or over weight
1973). This construct, defined as alexithymia, has been consistently reported by clinicians and
demonstrated by researchers with rates as high 77.1% in individuals with anorexia nervosa com-
pared to 6.7% in healthy matched controls. In addition, rates of comorbid depression and anxiety
in anorexia nervosa are high (Hatch, Madden et al. 2010).
Recent models of anorexia nervosa are increasingly emphasising the role of maladaptive
emotion regulation strategies and difficulties with emotion identification as key precursors to
the development and maintenance of anorexia nervosa (Haynos & Fruzzetti, 2011; Oldershaw,
Lavendar, Sallis, Stahl, & Schmidt, 2015; Lavendar, et al., 2015). There is a small but growing body
of evidence indicating that people suffering from anorexia nervosa show a greater use of maladap-
tive emotion regulation strategies, such as avoidance, emotion suppression, inhibition, repression,
rumination and self-╉destructive behaviors (Haynos & Fruzzetti, 2011). Furthermore, people strug-
gling with anorexia nervosa use fewer adaptive strategies compared to healthy controls (Haynos &
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Fruzzetti, 2011; Oldershaw, et al., 2015). This is important because less adaptive emotion regula-
tion strategies are suggested to result in more overall emotional problems whilst contributing to
psychological co-╉morbidity (Haynos & Fruzzetti, 2011)—╉a factor now recognized as a barrier to
family based treatment (FBT) outcomes (Lock, Courtourier, Bryson, & Agras, 2006). Preliminary
findings suggest emotion regulation difficulties may persist following weight restoration (Haynos,
Roberto, Martinez, Attia, & Fruzzetti, 2014). Furthermore, they can moderate against treatment
efficacy, contributing to the maintenance of anorexia nervosa (Racine & Wildes, 2015), with poor
emotion regulation techniques related to relapse (Federici & Kaplan, 2008).
Evidence-╉based treatments
The first treatments developed for eating disorders were for anorexia nervosa. Early trials
included adults as well as adolescents. The seminal study of psychological therapies were those
of Russell, Szmukler, Dare, and Eisler (1987) and Eisler, Dare, Russell, Szmukler, le Grange, and
Dodge (1997). This was a post weight-╉restoration outpatient psychotherapy trial where indi-
vidual therapy was compared to family therapy. While there were no differences in outcomes
between the two treatment arms, secondary analysis revealed better outcomes with family ther-
apy in participants who had an eating disorder for less than three years and were under the age
of 18. Although predominantly a trial of anorexia nervosa, this study also included participants
with bulimia nervosa. Two further trials have looked at treatment interventions in study samples
of adults and adolescents (Crisp, Norton, et al. 1991; Ball and Mitchell 2004), while there have
been nine randomized controlled trials that have specifically studied the efficacy of psychologi-
cal therapies for children and adolescents with anorexia nervosa which have included weight
restoration in aims and outcomes.
There have been five randomized control trials of manualized family based therapies with a
predominant behavioral focus, as in FBT. The first of these was by Robin et al., (1999). This was
a small non-╉blind trial with unclear allocation concealment and thus, had a high risk of bias.
Thirty-╉seven participants were randomized to either a families systems therapies or to an ego-╉
orientated individual therapy. Those in the family therapy arm had significantly greater weight
gain at the end of treatment and at a one-╉year follow up. Similarly, the second (Eisler et al. 2000;
Eisler, Simic, Russell, & Dare, 2007) also had risk of bias in that there was unclear allocation,
concealment and blinding. In this study, forty participants were randomized to either family
based treatment, conjointly or individualized therapy where the parents were seen separately
from the child with anorexia nervosa. Similarly in this study, there were no differences between
the groups in outcomes at any point up to a five-╉year follow up with the exception that where
there were maternal criticism participants showed significantly higher levels of improvement
when therapy was separated.
Three trials that controlled for bias with adequate allocation concealment that involved inde-
pendent or blind outcome assessments were conducted by Lock, Agras, Bryson and Kraemer
(2005), Lock et al. (2010) and Agras et al. (2014). In Lock et al. (2005), 86 participants were ran-
domized to either ten sessions over six months or 20 sessions over 12 months of FBT. Although
there were no between group differences, the longer treatment led to greater improvements in
people with higher levels of obsessive compulsive symptoms and those with non-╉intact families.
Agras et al. (2014) compared FBT with systemic family therapy in 164 participants. There were
no differences in weight or other primary outcomes. However, there was earlier weight regain
and fewer hospitalizations in participants who were treated with family based treatment. On the
other hand, systemic family therapy led to better outcomes with those who had higher levels of
obsessive compulsive symptoms. Finally, Lock et al. (2010) randomized 121 participants to FBT
91
or individual, adolescent focused controlled psychotherapy. This singular study reported higher
remission rates and greater weight gain at both end of treatment and a one-year follow up in those
randomized to family treatment.
Other studies done in the treatment of children and adolescents include research by Geist,
Heinmaa, Stephens, Davis, and Katzman (2000) who randomized participants to family therapy
where the families were seen for eight sessions with the patient, the patients parents and siblings
or to a family group psycho-education arm where groups of families were seen in a workshop
design for eight sessions. In this study of 25 participants, there were no significant differences
between groups. This study also had risk of bias, as there was no blinding. Another study by
Gowers et al. (2007) compared a specialist outpatient, manualized cognitive behavioral thearapy
treatment intervention with separate parental counselling and non-manualized supportive and
family care. This study found no differences between groups. Godart et al. (2006), in a high quality
randomized control trial, compared a non-manualized psychodynamic systemic family therapy
to usual specialist care in 60 adolescent participants. This trial reported significantly improved
weight-gain and other outcomes in those who received the additional family therapy.
These trials of FBT have formed the basis for the leading evidence based therapy in chil-
dren and adolescents with anorexia nervosa. It is notable that the majority was conducted with
female participants and that only two found significant improvements in primary outcomes.
It is also important to note that although there were minimal differences in symptomatic out-
comes, family based treatment in the trial by Agras et al. (2014) was associated with lower
financial costs and hospitalization rates. When compared with other non-family based treat-
ments, FBT also demonstrated improved remission rates at follow-up (Courtourier, et al., 2010
Forsberg & Lock, 2015). It has to be acknowledged however, that although FBT and other fam-
ily therapies have strong evidence for treatment of children and adolescents with anorexia ner-
vosa (Zipfel et al., 2015) their efficacy for adolescents with bulimia nervosa is less established
with mixed or inconsistent findings. In addition, there have been no trials in ARFID or binge
eating disorder (Hay et al., 2014).
As previously highlighted, FBT has become established as the leading treatment for adolescents
with anorexia nervosa. The treatment has been manualized (Lock & Le Grange, 2015) and dis-
seminated internationally. The treatment includes three phases. Phase I focuses on empowering
parents to manage all anorexia nervosa related behavior until the adolescent is weight restored.
Following a period of weight maintenance, Phase II focuses on working with the adolescent to
return to an appropriate level of control over food and eating. Phase III then focuses on life cycle
events that may have been interrupted by the eating disorder.
Research indicates that FBT is effective for anywhere from approximately 30–60% of young
people struggling with anorexia nervosa at the end of treatment, with these findings improved
upon at follow-up (Forsberg & Lock, 2015). While this data is encouraging, particularly when
compared to poor response rates to adult treatments (Bulik, Berkman, Brownley, Sedway, & Lohr,
2007), it is now clear that FBT is not effective for a substantial minority of young people who con-
tinue to struggle or do not complete treatment. Furthermore, remission is often defined within
the literature as reaching a specified weight range, which does not always correspond with full
psychological recovery. Given a lack of effective alternative treatments, this leaves a substantial
proportion of adolescents with anorexia nervosa at high risk of becoming chronically unwell.
Research is beginning to investigate possible factors associated with poor treatment responses
or drop out in FBT. Initial findings have identified a range of family factors related to emotional
expression and management that are associated with poorer outcomes or dropout. These include
high expressed emotion, family conflict and criticism (Eisler, Simic, Russell & Dare, 2007; Lock,
Coutourier, Bryson, & Agras, 2006; Russell, Szmukler, Dare, & Eisler; Le Grange, Eisler, Dare,
02
& Russell, 1992), with parental warmth being related to good outcomes (Le Grange, Hoste,
Lock, & Bryson, 2011). These findings are important, as Phase I of FBT can be very stressful and
emotionally challenging for all family members as parents actively and consistently challenge
the symptoms of anorexia nervosa. Accordingly, this often results in young people and families
being faced with extremely distressing events on a regular basis with, potentially, reduced emo-
tion regulation capacities. The treatment often requires this to be repeated consistently for many
weeks to months.
Several individual factors have also been identified that are associated with poorer outcomes in
FBT. Recent findings suggest that adolescents with more severe eating disorder psychopathology
and those struggling with co-╉morbid Axis I and/╉or emerging Axis II psychological difficulties
have a greater likelihood of dropout and may require a longer duration of treatment (Forsberg
& Lock, 2015). This is important, as co-╉morbidity rates in anorexia nervosa remain high, with
more than 50% experiencing a co-╉morbid anxiety disorder (Kaye, Bulik, Thornton, Barbarich,
& Masters 2004) and between 50 and 70% and experiencing a major mood disorder (Godart,
et al., 2006).
Central to this, is teaching young people how to identify the early signs of their distress and
the importance of intervening early in distress management. Creating “distress thermometers,”
where participants map the physical, psychological and emotional changes that occur as their
distress increases from zero out of ten (no distress) to ten out of ten (high distress), is part of this.
Following this, young people then match strategies with differing levels of distress intensity. As
distress becomes exponentially harder to manage the more it intensifies, staff focus on and sup-
port young people to intervene early in their distress management. Young people are encouraged
to involve family and other support as needed.
Additionally, patients’ beliefs about their capacity to effectively manage emotions are chal-
lenged. Many young people in the program have strong beliefs that they do not possess adequate
skills to effectively and adaptively modulate emotional experiences—╉a common experience in
anorexia nervosa (Lavender, et al., 2015). Situations where young people effectively manage dis-
tress are identified and amplified by staff with young people supported to identify and label their
own skills to help increase self-╉efficacy.
Beyond food and eating, behavioral/╉experiential opportunities to manage distress are also
encouraged, planned for and debriefed. Young people are encouraged to practice managing many
distressing situations, particularly those related to adolescent development e.g., turning to par-
ents when distressed (practicing openness) and attending social events that might be anxiety-╉
provoking. Young people are also encouraged to tolerate changes to their body occurring with
weight gain.
Case example
The case of Emma outlined below is a combination of several patients and their families who
have completed the day program. The case is used for two purposes; firstly, to give an example
of the way emotion regulation interventions can enhance standard family based treatments and
secondly, to illustrate the importance of not only providing young people with a forum to learn
skills, but also highlighting the importance of ensuring there are the appropriate structures and
therapeutic processes working in tandem to facilitate skill implementation.
Emma
Emma first presented with anorexia nervosa when she was 16-╉years-╉old. She weighed 41kg, was
156 cm tall and presented with medical complications of her weight loss including bradycardia
(low heart rate) and hypothermia (low temperature). She resided with her mother, Leanne. Her
father had been living in a separate house since the acrimonious breakdown of her parents’ mar-
riage 18 months prior her 19 year-╉old brother had moved out of the family home at the comple-
tion of high school. Emma had an eight-╉month history of food restriction and compulsive exercise
resulting in a 7kg weight loss. She reported a six-╉month history of amenorrhea.
Emma described experiencing significant mood difficulties for the previous nine to twelve
months, with reduced sleep, increased social isolation and anhedonia. Emma had been engag-
ing in deliberate self-╉harm of superficial cutting on her wrists and hip up to twice a week for the
previous three months. She described passive suicidal ideation, denying any active plans or will
to commit suicide. Her presentation occurred in the context of ongoing, severe bullying at school
and her grandmother passing away nine months prior with bowel cancer. Emma also described
experiencing separation anxiety from her mother, Leanne, up until early primary school.
Emma was admitted to an inpatient paediatric ward for medical stabilisation and psychologi-
cal containment. Following her discharge FBT was provided by a clinical psychologist. After nine
months of treatment Emma’s weight had slowly been reducing and family conflict continued to
escalate. This had resulted in several occurrences of Emma running away from home during
meals and physically intimidating her parents by threatening to hit them and on two occasions
assaulting them.
At this point the day program was offered to Emma and her family to contain Emma’s weight
loss, stop the escalation of dangerous behavior, provide skills training to Emma around emotion
regulation and increase systemic empathy and understanding. The aim of the admission to day
program was to break the vicious cycle of Emma’s experience of parental invalidation resulting in
Emma’s emotional distress and behavioral escalation.
Over the course of her admission in the day program, emotion regulation and distress tolerance
were key treatment interventions for Emma. Emma’s goal was to find ways of not becoming so
angry that she needed to run away during meals or become threatening to her mother; something
that made her feel very guilty. The daily adolescent group provided the most direct method of
equipping Emma with the specific knowledge and skills around how to regulate her emotions.
Box 10.2 outlines the selected skills Emma was taught in the group. Emma initially struggled with
participating in group, often saying very little or saying she had tried everything and it did not
help. While this was challenging to staff initially, through validation, encouragement and genuine
interest in her difficulties staff were able to engage Emma in the process of group discussions, even
though content remained difficult to engage with.
In tandem with skills group, the day program context provided an opportunity for staff to
prompt the early identification of signs of distress, the communication of difficult emotions and
the appropriate use of skills in different contexts throughout the day, such as during difficult meals
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behavioural experiments
Distraction ◆ Group discussion around the difference between skilful
distraction and unhelpful avoidance
Generation of a list of distraction techniques and pairing with
◆
or following stressful events. By ensuring group sessions involved practical elements, in vivo tasks
or experiments and homework tasks, the environment ensured Emma experimented with skills,
albeit begrudgingly. This slowly allowed her to experience some mild benefits from skill imple-
mentation, which then allowed her to generalize them from their use on the program to life out-
side of the program. Staff consistency in their relationship with Emma facilitated a safe space for
her to feel accepted, despite frequent emotional outbursts. This allowed her to feel more comfort-
able in trying new things and reduced feeling of shame or embarrassment.
Importantly, other therapeutic aspects of the program, which were not directly related to emo-
tion regulation skill development, were seen as key to helping Emma improve her ability to regu-
late her emotions. Family and multi-family sessions provided an opportunity for Emma to involve
Leanne in emotion regulation skill development and planning could be done with the therapist
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as to how Leanne could best support Emma with skill use. Additionally, with Leanne spending
less time providing meals for Emma, this enabled her to plan more specifically around the meals
she was supervising. This allowed her to feel more prepared and confident, leaving her more
able to tune into Emma’s needs, reduce criticism and provide much needed validation during the
meals. Similarly, multi-╉family groups and meals were also beneficial for Emma as they provided
repeated opportunity for staff to model and coach Leanne on how to support Emma with consis-
tent warmth and firmness, as well as skill use and implementation.
Effective skill implementation only really began to result in noticeable changes for Emma four
to five weeks after she commenced treatment. Through the process of staff using a firm but kind
approach, with consistent boundaries and communication across all activities, Emma settled
enough to attempt learnt techniques. She described finding it helpful being “checked-╉in” with
frequently and said it provided the opportunity to test out expressing her more difficult emotions.
She also said the experience of interacting with staff in multiple therapeutic context (e.g. meals,
groups, family therapy) was beneficial. She said this exposure to staff across settings, as well as
staff being able to engage in adolescent appropriate conversations, use humour, model appropriate
eating, and tolerate high affect allowed Emma to feel able to accept and engage in the program. It
was then through this connection that Emma described feeling able to experiment with alternate
ways of managing her emotions and tolerating feelings of worthlessness and hopelessness.
Emma was discharged from the day program after completing 11 weeks. She was discharged
within her healthy weight range after having gained four kilograms. While she continued to feel
distressed around meals and many eating disorder behaviors persisted, she and her family said
they felt much better equipped to continue to make gains in outpatient treatment. Both Emma
and Leanne said that it was the combination of Emma learning new ways to regulate her emotions
with Leanne being able to validate, understand and provide support around skill use that made
them feel less stuck and able to move forward in treatment.
Summary
A growing body of literature indicates FBT is an effective treatment for adolescents with anorexia
nervosa. Nevertheless, FBT is not effective for everyone, with a significant minority continuing to
respond poorly to even the best available treatments. Given the role emotion regulation difficul-
ties are hypothesized to play in the development and maintenance of anorexia nervosa, modifica-
tions to FBT that target emotion dysregulation are emerging. The case of Emma highlights a few
key factors to consider when designing and implementing emotion regulation focused adjuncts
or modifications to treatment. It highlights the importance of matching skills training with a
consistent program structure and a positive group milieu. It is through the combination of these
three factors that progress in treatment is hypothesized to occur. In the case of Emma, without
the structure or milieu, skills training was unlikely to have been meaningfully attempted poten-
tially adding to her feelings of hopelessness and helplessness. It was through the combination of
all three elements that psychoeducation was delivered in a format and environment that allowed
Emma to make meaningful treatment gains.
This approach to improving emotional regulation in adolescents with anorexia nervosa is in
the early stages of assessment and further investigation and controlled trials are needed. Further
research is also indicated to investigate the best approach to young people with other eating
disorders including bulimia nervosa and binge eating disorder where individuals may have con-
comitant problems with impulsivity and emotion regulation. There is a small body of research
supporting the efficacy of a modified individual outpatient form of dialectical behavior ther-
apy in adults with bulimia nervosa or binge eating disorder (Safer, Telch & Agras 2001; Safer
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Summary 207
Robinson, & Jo, 2010) and trials are now being run in adolescents. Although research is promis-
ing, it is in the early stages and further investigation is required involving large-╉scale unbiased
studies. However, it is important to note, treatment outcomes have high success rates (20–╉60%)
when eating disorders are treated in childhood and adolescence; which is imperative, as adult
anorexia nervosa is one of the most challenging psychiatric illnesses to treat effectively with one
of the highest morbidity rates.
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Chapter 11
Prevalence of substance use
Data on the prevalence of substance use among adolescents is available from several US national
studies. The Monitoring the Future (MTF) project has been conducted annually since 1975
(Johnston et al., 2015). This project is a repeated series of cross-╉sectional school-╉based surveys,
with the same set of questions given every year to comparable age groups. Trends for prevalence
of tobacco, alcohol, and marijuana use delineated in the MTF survey have also been observed in
other national surveys with different sampling and data collection methods, such as the Youth
Risk Behavior Surveillance Study (Frieden et al., 2014) and the National Survey on Drug Use and
Health (Center for Behavioral Health Statistics, 2015).
The 2014 MTF survey included about 41,600 students who were in eighth, tenth, or twelfth
grade in public or private secondary schools across different areas of the United States. In this
survey, the lifetime prevalence for any alcohol use was 27%, 49% and 66% for eighth, tenth, and
twelvth graders, respectively. Rates of alcohol use within the past 30 days, an index of regular use,
were 9%, 24% and 37% for these same age groups. Hence, the prevalence of alcohol use was shown
to be substantial, particularly in later adolescence. Consistent with other surveys, the MTF study
has found marijuana to be the most widely used illicit drug over the 40-╉year history of the survey
(Johnston et al., 2015). In the 2014 survey, the prevalence for ever-╉use of marijuana or hashish
ranged from 12% to 35% among eighth to twelfth graders, and the prevalence of use during the
past 30 days was 6%, 17%, and 21% for these same age groups. Thus, it is observed that usage rates
increase steadily by age for all substances. The study also provided information regarding differ-
ing patterns of use with regards to gender, ethnicity, and socioeconomic status; however, detailed
discussion of this data is beyond the scope of the present chapter.
With regard to secular trends, the absolute level of cigarette use has declined steadily over the
last decade. The most recent MTF survey found that cigarette use among adolescents is now at
the lowest level recorded in the history of the survey (30-╉day prevalence of 4%, 7%, and 14% for
eighth, tenth, and twlveth graders, respectively). Although MTF data on adolescents shows rates
of marijuana use that have remained stable in recent years, Hasin et al. (2015) noted that the rate
of marijuana use in the U.S. adult population has doubled in the past ten years. MTF data have
shown a steady decline in perceived risk of marijuana use among adolescents, and because of
policy changes in some U.S. states, rates of teenage use are being watched with concern.
study revealed the most-╉reported illegal drugs used were marijuana, cocaine, and illicit prescrip-
tion drugs (Swendsen et al., 2012). These investigators reported a lifetime prevalence of 6% for
alcohol abuse/╉dependence, 7% for illicit drug abuse/╉dependence, and 11% for any substance use
disorder. Thus, consistent with Kilpatrick et al. (2000), there was an appreciable prevalence of
substance use disorder observed in the adolescent population.
The National Survey on Drug Use and Health (NSDUH) is an annual survey of the US
population and most recently has used DSM-╉IV criteria with a 12-╉month time frame. Data
for the 2014 survey for adolescents aged 12–╉17 years (Center for Behavioral Health Statistics,
2015) showed that 2.7% of the sample had an alcohol abuse diagnosis, 2.7% had a marijuana
abuse diagnosis, and 3.5% had an illicit drug abuse diagnosis (including marijuana but also
cocaine, heroin, inhalants, and non-╉prescribed prescription drugs). Overall, 5.0% of the ado-
lescent population was indicated as having any kind of substance use disorder. NSDUH data
have shown declines in rates of disorder from 2002 to 2012, though most rates have been stable
for 2013 and 2014.
Across studies, a higher prevalence of SUD was found for adolescent boys when compared to
adolescent girls of the same age demographic. All studies saw an increase in SUD prevalence with
age, particularly between the ages of 14–╉17. Overall, lower rates of substance abuse and depen-
dence were found in minority ethnic groups compared to Caucasians (Kilpatrick et al., 2000,
Merikangas et al., 2010). Although rates of substance use disorders among adolescents are not
as high as for depression and anxiety disorders, studies have shown a significant comorbidity of
SUDs and other psychopathological conditions (Cheetham et al., 2010).
There has been debate in the clinical literature about diagnosing SUD in adolescence. There
are two primary concerns regarding the appropriateness of SUD criteria to younger adolescents.
Firstly, younger adolescents generally have less opportunity to use substances due to parental
monitoring and restricted access; hence, use may be less frequent and more sporadic, which
substantially reduces the likelihood of symptoms such as withdrawal and of use interfering with
social role obligations (Kaminer & Winters, 2015). Moreover, the hazardous-╉use criteria often
reflect drinking and driving, which younger adolescents typically are precluded from (Winters,
2013). Finally, several criteria require fairly sophisticated executive functions and self-╉awareness,
such that individuals need to identify and set use limits; and impaired control is then inferred by
failure to meet these limits. However, the cognitive development of children and younger adoles-
cents reflects a period of heightened reward-╉seeking and socio-╉emotional functioning prior to the
maturation of executive control functions (Steinberg, 2008). Hence among adolescents, substance
use may be severely dysregulated in the sense that they do not have high control over it, yet they
are not using more than “intended” nor displaying failed efforts to “cut down or control” use
(Chung & Martin, 2005). Thus the standard diagnostic criteria could miss patterns of substance
use in children and adolescents that are of clinical relevance.
Second, even modest substance use by children and adolescents is highly likely to cause con-
flict with parents, educators, and law enforcement. This may be particularly pronounced with
female adolescents, who are more likely to report drinking despite interpersonal problems than
their older peers (Harford, Grant, Yi, & Chen, 2005). Furthermore, children and adolescents are
in the midst of a period of shifting peer groups, struggles with emotional and behavioral regula-
tion, and transitions in their involvement in school and recreational activities; and some have
yet to develop long-╉term commitments to educational and occupational pursuits. Thus, there is
the risk that experimental, essentially normative, substance use during this dynamic period may
be mislabeled as an SUD (Winters, 2013). Indeed, many individuals mature out of risky sub-
stance use patterns in young adulthood (Jochman, Fromme, & Scheier, 2010; Reich, Cummings,
Greenbaum, Moltisanti, & Goldman, 2015); for example, the frequency of binge drinking tends
to decline in the mid-╉20s (Reich et al., 2015). Although substance use frequency may decline,
some research suggests that observed declines in SUD with age reflect decreases in new cases and
lower risk of relapse rather than developmental changes in the persistence of SUD once estab-
lished (Verges et al., 2013). In other words, transition in and out of problematic substance use is
common (Compton, Dawson, Conway, Brodsky, & Grant, 2013), but the risk of developing new
problematic patterns of use tends to decline with age. In summary, diagnosis and recognition of
substance-╉related problems in youth requires a balanced consideration of the potential increased
vulnerability of the developing brain to substances (Spear, 2010), the potential for diagnostic cri-
teria to underestimate the severity of the problem (Kaminer & Winters, 2015), and conversely a
need to recognize that there is a certain amount of age-╉appropriate drug experimentation that
may not warrant costs associated with diagnosis and intervention (Winters, 2013).
that substance disorder develops because of elevated negative affect. However, it is also possible
that both substance use and affective disorder are attributable to an underlying, transdiagnostic
vulnerability factor (dysregulation of behavior and emotion being a plausible candidate) and/╉
or that the biological and social disruptions occasioned by substance abuse themselves produce
negative affect (Koob & Le Moal, 2008; Swendsen & Le Moal, 2011). A credible body of theory
also points to deficiencies in positive affect as an important but understudied influence on the
development of disorder (Gilbert, 2012). Low positive affect may occur because of a dispositional
deficiency in the ability to experience positive mood (reward deficiency syndrome or hedonic
capacity: Audrain-╉McGovern et al., 2012; Yacubian & Buchel, 2009) or because of lack of access to
alternative reinforcers (Audrain-╉McGovern et al., 2010).
Reactivity (Angerability)
When I have a problem at school or at home:
I get mad at people.
I yell and scream at someone.
Anger Control
When I am angry or upset:
I stay calm and “keep my cool” when I’m feeling mad.
I try to calmly deal with what is making me mad.
Soothability
I can easily calm down when I am excited or “wound up.”
If I get upset or distressed, I can recover quickly.
Sadness Control
When I am feeling sad or down:
I can control my sadness and carry on with things.
I stay calm and don’t let sad things get to me.
Distress Tolerance
I can’t handle feeling distressed or upset. (Disagree)
When I feel distressed or upset, I must do something about it immediately. (Disagree)
Affective Lability
My moods change a lot from day to day.
I shift back and forth from feeling calm to feeling tense and “jittery.”
Rumination
I often find myself thinking about things that have made me angry.
I get angry thinking about things that have happened in the past.
Sources: Oliver & Simons, 2004; Simons & Gaher, 2005; Wills et al., 2006, 2011, 2013.
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some individuals even more reactive to stress (Andersen & Teicher, 2009). Other things equal,
persons who are more reactive to stress are at an increased risk for substance abuse and other
disorders (Siegel, 2010, 2015; Sinha, 2008).
Soothability, an additional key element related to substance abuse, is defined as the ability to
reduce aversive arousal states through one’s own efforts. Khantzian (1990) originally noted that
clients with drug use disorder experienced difficulty soothing or calming themselves when they
were in stress-provoking situations. Khantzian (1990) suggested, in his self-medication model,
that this was a basic process in perpetuating drug consumption because persons with low
soothability turned to drugs for more immediate relief. Effective implementation of self-soothing
produces lowered arousal, which makes it easier to pursue effortful, active coping efforts and has
the additional benefit of not alienating supporters through lashing out in anger. Soothability, as
a general attribute, may involve several of the specific strategies outlined above (e.g., attentional
focusing, distraction, reappraisal). Research has demonstrated that measures of soothability are
positively correlated with other indices of emotional control ability and are inversely related to
substance use in early adolescence (Wills et al., 2006).
Distress tolerance is another key element that is intricately tied to risk for substance use disor-
der. The ability to reflect on feeling states and engage in adaptive coping responses may depend,
in part, on an individual’s ability to tolerate distress. In this regard, distress tolerance may be
considered a meta-emotion construct that incorporates the perceived ability to withstand dis-
tress; appraisal of distress; efforts to stop distress; and the tendency to become absorbed by dis-
tress (Simons & Gaher, 2005). Low tolerance for distress has been linked to substance use (Leyro,
Bernstein, Vujanovic, McLeish, & Zvolensky, 2011; Wray, Simons, Dvorak, & Gaher, 2012), to
other indicators of dysregulated affect, such as deliberate self harm (Arens, Gaher, Simons, &
Dvorak, 2014), and to psychopathology syndromes linked to dysregulated affect such as posttrau-
matic stress disorder and borderline personality disorder (Gaher, Hofman, Simons, & Hunsaker,
2013; Vujanovic, Marshall-Berenz, & Zvolensky, 2011). In addition, reduced ability to differen-
tiate, label, and understand the source of emotion states (i.e., alexithymia) has been inversely
associated with distress tolerance (Gaher et al., 2013). Both low distress tolerance and deficits in
emotional awareness have been associated with poor behavioral control, especially when nega-
tively aroused (Emery, Simons, Clarke, & Gaher, 2014; Gaher et al., 2013; Shishido, Gaher, &
Simons, 2013). Thus, the lack of understanding of emotional states and the inability to tolerate or
accept aversive feeling states may increase the likelihood of incurring substance-related problems
(Buckner, Keough, & Schmidt, 2007; Emery et al., 2014; Shishido et al., 2013), whilst also inter-
fering with engagagement in substance use treatment (Daughters et al., 2005). Taken together,
the findings suggest that the clarity of emotional experience and the ability to mindfully accept
emotions are indicative of adaptive emotion regulation. In contrast, poor tolerance for distress
and limited awareness of emotional experience (e.g., poor differentiation, poor labeling or under-
standing) promote impulsive responding, efforts to suppress emotion, and maladaptive substance
use outcomes.
An additional factor that impacts substance use disorder is affective variability. In recent years,
there has been increased understanding of the importance of the dynamic time course of emo-
tion in studies of emotion regulation (Ebner-Priemer, Eid, Kleindienst, Stabenow, & Trull, 2009;
Fairbairn & Sayette, 2013; Simons, Wills, & Neal, 2014). Affective lability refers to the speed, fre-
quency, and range of changes in affective states (Oliver & Simons, 2004). Studies on borderline
personality disorder and depression have highlighted the importance of instability of affect, over
and above mean levels, in contributing to pathology (Jahng et al., 2011). Similarly, research on
substance use problems has indicated significant effects of affective variability, often over and
above mean affect level, such that individuals who are more variable in mood show more alcohol
7
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and marijuana related problems and tobacco use (Dvorak & Simons, 2008; Mohr, Arpin, &
McCabe, 2015; Simons & Carey, 2006; Simons et al., 2014; Weinstein & Mermelstein, 2013a).
In respect to emotion regulation strategies for reducing affective variability, research indicates
that the source (e.g., bottom-╉up vs. top-╉down) as well as the intensity of emotions influences the
selection and effectiveness of emotion regulation strategies (McRae, Misra, Prasad, Pereira, &
Gross, 2012; Sheppes et al., 2014). In this regard, cognitive strategies, such as reappraisal, appear
to be more effective for emotions that are, in part, the result of cognitive evaluations (McRae et
al., 2012). Cognitive reappraisal is more often utilized when individuals are experiencing rela-
tively low-╉intensity emotions. In contrast, when emotions are of high intensity, strategies such as
distraction, which minimizes emotional processing, are efficacious (Sheppes et al., 2014). Taken
together, these results suggest that individuals who experience intense, unpredictable shifts in
emotion may be predisposed towards relying on regulatory strategies that minimize awareness
and processing of the emotional stimuli, making substance use an attractive option. This view
is consistent with Khantzian’s (1990) hypothesis that the negative consequences experienced by
individuals with a drug use disorder are less salient than the fact that he/╉she can control emotional
states through drug use.
A final factor influencing substance abuse is emotional inertia and rumination. Emotional iner-
tia (i.e., the autocorrelation of emotion across time) has also been identified as a central construct
in research on affect dysregulation (Kuppens et al., 2012) and substance use (Fairbairn & Sayette,
2013). In contrast, affective lability indicates an inability to maintain homeostasis and continu-
ity in emotional responding. Emotional inertia is indicative of dysregulation in emotion, such
that emotion is likely fixed by an inward, ruminative focus rendering the person disconnected
from important contextual stimuli that the emotion is expected to vary in response to (Fairbairn
& Sayette, 2013; Koval, Kuppens, Allen, & Sheeber, 2012). Research suggests that some of the
reinforcing properties of alcohol may stem from alcohol’s ability to disrupt emotional inertia
(Fairbairn & Sayette, 2013). Alcohol myopia theory (Steele & Josephs, 1988) predicts that tension-╉
reduction properties of alcohol are due, in part, to the effects of alcohol on limiting focus to
immediately salient stimuli.
Table 11.3 Studies of Emotion Regulation and Substance Use, For Single Strategies and Dual-Process
Constructs
consequences (i.e., alcohol abuse) among college students. In addition, non-╉acceptance of emo-
tion was related to more adverse consequences among the most problematic drinkers. Veilleux et
al. (2014) found that lack of emotional control strategies and lack of clarity about emotion were
both predictive of high-╉risk alcohol use (drinking to cope). Furthermore, Simons et al. (2005a)
have shown that expectancies about one’s competencies in the regulation of negative mood were
inversely related to coping motives for marijuana use. Additional studies have related emotion
regulation difficulties to substance-╉related problems in samples of college students (Chandley et
al., 2014; Messman-╉Moore & Ward, 2014) and clinical samples of individuals with substance use
disorder (Buckholdt et al., 2014; Fox et al., 2008). Wong et al. (2013) found emotional suppression
was positively related to prescription drug misuse and illicit drug use. In contrast, persons who
actively coped with negative emotions had less illicit drug use and were more likely to also use
other adaptive coping strategies, such as support-╉seeking and positive reappraisal.
Distress tolerance
Overall emotional experience may depend on the ability to tolerate negative emotions. This con-
struct is often measured using the Distress Tolerance Scale (DTS, Simons & Gaher, 2005), which
includes subscales termed Tolerance, Absorption, Appraisal, and Regulation (needing to act
immediately when distressed). Buckner et al. (2007) found that a better ability to tolerate distress
was related to lower frequency of alcohol use and was inversely related to alcohol and cannabis
problems. They suggested that individuals with low distress tolerance are more likely to use sub-
stances for regulating negative emotions. Winward et al. (2014) studied adolescents with heavy
episodic drinking (HED) and matched controls. The HED adolescents initially had low distress
tolerance but showed decreased emotional reactivity when they became abstinent.
Other studies have shown distress tolerance inversely related to coping motives in a sample of
current marijuana smokers (Zvolensky et al., 2009) and a sample of Posttraumatic Stress Disorder
(PTSD)-╉affected young adults (Marshall-╉Berenz et al., 2011). One study found a laboratory
measure of distress tolerance inversely related to alcohol use in a sample of younger adolescents
(Daughters et al., 2009). These studies complement findings showing that low distress tolerance
predicts lapse and relapse among smoking cessation clients (e.g., Brown, Lejuez, & Kahler, 2002).
showed alcohol problems were related to lower emotional intelligence and positively correlated
with PTSD symptoms. On a repeated-╉measures basis, occurrence of PTSD symptoms during the
day was related to increased alcohol use and associated problems the same night.
Affective lability
Some investigations of affective lability have used a dispositional measure, the Affective Lability
Scales (ALS, Oliver & Simons, 2004); others have constructed statistical indices of variability in
mood from repeated-╉measures data. The ALS was used in a longitudinal study with heavy-╉drinking
college students by Simons, Carey, and Wills (2009). A structural modeling test of the influence
of affective lability, controlling for behavioral dysregulation, found lability was not related to level
of alcohol consumption but it did predict change in alcohol dependence symptoms. Behavioral
dysregulation, in contrast, predicted abuse symptoms but not dependence symptoms. This find-
ing was replicated in an experience sampling study in which daily reports were obtained over a
two-╉year period and variability was indexed by a statistical algorithm (Simons, Wills, & Neal,
2014). Here, lability in negative mood showed a direct relation to the likelihood of alcohol depen-
dence symptoms. This research shows the value of distinguishing variability in mood over time
from mean level of mood (see also Simons & Carey, 2002, 2006; Simons et al., 2005b). Notably,
trait positive mood was related to a lower proportion of drinking days over the study period (cf.
Gilbert, 2012); whereas, trait negative mood was related to a higher proportion of drinking days.
Weinstein and Mermelstein (2013b) studied a sample of high school students through obtain-
ing experience sampling reports on palmtop computers. Reports of smoking were obtained over
one-╉week periods on two occasions and variability in negative mood was determined by a statisti-
cal algorithm. Greater mood variability predicted escalation of smoking in the subsample of girls,
while mean level of negative mood (but not its variability) predicted escalated smoking among
boys who scored higher on coping motives for smoking. This shows the value of including both
gender and motives for use in research designs.
Tarantino et al. (2015) surveyed a sample of college students with the MAAS as a predictor
and with measures of drug use and drug problems as outcome variables. Higher mindfulness
tendency was correlated with behavioral self-╉control and self-╉reinforcement, and was related to
lower levels of drug use and problems independently of other coping strategies. A clinical study
with a mindfulness-╉based smoking cessation program (Brewer et al., 2011) found that those who
practiced meditation more frequently showed a lower relation between craving and cigarette
use (Elwafi et al., 2013). Also noteworthy is evidence showing neurological changes suggesting
enhanced self-╉regulation as a result of mindfulness training (Tang et al., 2012).
Negative Internalizing
life events symptomatology
Figure 11.1╇ A conceptual model of direct and indirect effects of emotion dysregulation and
emotional self-control. Model emphasizes effects of emotional regulation via both socio-
environmental and cognitive/attitudinal constructs. See Wills et al., 2016.
one standard deviation above the school average in one of these four subscales were categorized as
high-╉risk. In earlier studies, all high-╉risk students were invited to participate in the intervention.
In later studies, all consenting high-╉risk students were randomly assigned to either the interven-
tion group or the control group. Two studies also included low-╉risk students in both the interven-
tion and control groups (Conrod, Castellanos-╉Ryan, & Strang, 2010; Conrod, Castellanos-╉Ryan,
& Mackie, 2011; Conrod et al., 2013). Internalizing symptom severity was measured using the
Depression and Anxiety subscales from the Brief Symptom Inventory (BSI). Externalizing
symptom severity was measured using the Conduct subscale from the Strengths and Difficulties
Questionnaire (SDQ; O’Leary-╉Barrett et al., 2013).
Conrod et al. (2010) aimed to improve various cognitive and behavioral problems associated
with specific high-╉risk personality factors. For instance, the cognitive distortion termed over-
generalization (i.e., when one makes universal assumptions based on experiences through one
specific situation) is often found in individuals prone to depression (O’Leary-╉Barrett et al., 2013).
By targeting cognitive distortions such as these, it was proposed that a variety of internalizing
and externalizing symptoms that may underlie substance use could be effectively addressed.
Interventions were focused on assisting students in each personality profile to adopt more adap-
tive coping mechanisms, so as to help students manage their personality risk in a way that does
not promote problematic substance use (Conrod, Castellanos-╉Ryan, & Strang, 2010).
The first part of the intervention involved a goal-╉setting exercise that encouraged behavior
change and development of new coping methods. Students were taught about their target person-
ality variable and associated non-╉adaptive coping responses (e.g., avoidance, aggression). They
then learned about the cognitive-╉behavioral therapy model and practiced applying it by analyzing
emotional responses in sample scenarios, as well as their personal experiences. Students were
encouraged to recognize and confront personality-╉specific cognitive distortions that could induce
risk behaviors. Post-╉exercise discussions were held to focus on personality-╉specific thoughts,
emotions, and behaviors (Conrod et al., 2010, 2013).
Across all studies, significantly lower frequency and quantity of overall alcohol consumption,
as well as binge drinking and rate of growth of binge drinking, were found at the completion
of intervention for high-╉risk adolescents assigned to the intervention group. In the 2013 study,
benefits of the intervention were also apparent at the 24-╉month follow-╉up, as displayed through
lower growth in drinking quantity and binge drinking frequency, compared to non-╉intervention
adolescents (Conrod et al., 2013). The intervention was also associated with a reduced likelihood
of marijuana and cocaine use (Conrod, Castellanos-╉Ryan, & Strang, 2010).
Conrod’s approach did not directly target substance misuse. Rather, the intervention targeted
individuals who displayed personality risk factors previously shown to correlate with substance
use disorders. By using specific personality profiles, the individuals learned which strategies of
emotion regulation were most beneficial, as well as which strategies were more detrimental in
relation to their personalities. By doing so, Conrod et al. addressed, at a more selective level, the
emotion dysregulation that is often proximal to substance use, or is involved with motivational
processes that inspire substance use.
Directions for further work
In this chapter, both specific strategies for controlling emotion and general attributes of emotion
regulation have been discussed and the available evidence about emotion regulation and sub-
stance use disorder has been reviewed. Although there is a sizable body of evidence on emotion
regulation from laboratory studies, unsettled questions remain about its applicability to clinical
and community samples. Progress has been made in research on substance use among adolescents
4
2
but a strong understanding of exactly how emotion regulation contributes to the development of
substance use disorder has not yet been fully delineated. Further, while emotion regulation has
often been considered as a single dimension, a body of evidence indicates that emotional self-╉
control and emotional dysregulation are distinct constructs, not opposite ends of a single dimen-
sion. The following section discusses major themes in the chapter and their clinical implications.
Summary 225
studied, and understanding biological variables as well as social learning factors will be impor-
tant for informing the design of future prevention and treatment efforts (Beauchaine, 2015). The
extent to which substance use disorder in adolescents can be reduced via training individuals to
have better emotion regulation skills is an open question, though there are promising results in
this regard (see for example: Conrod et al., 2013; Southam-╉Gerow, 2013; Wills et al., 2015).
Summary
Adaptive emotion regulation is essential for well-╉being and successful adaption in all aspects of
life. Hence, programs that successfully enhance emotional regulation in youth have the potential
to have far-╉reaching benefits in addition to reducing substance use behavior. For this reason, it
is an important target for intervention programs. The multifaceted nature of emotion regulation
provides both challenges and opportunities for the development of prevention programs. Thus,
future research is needed to identify specific components of emotion regulation that are the most
amenable to intervention and have the broadest impact on non-╉targeted emotion regulatory pro-
cesses. Phrased differently, the key question remains: How can research find the optimal interven-
tion target that has the largest cascading effects throughout the regulatory system?
6
2
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Chapter 12
functioning (approximately two standard deviations below what would be expected based on
someone of the same chronological age), as well as commensurate deficits in adaptive behavior
across social, conceptual, and practical life areas. These impairments must have occurred prior
to age 18 and be observed within the appropriate developmental period. Over time, prevalence
estimates of ID in the ASD population have decreased, the result of greater numbers of youth
being diagnosed with ASD without ID as well as potential diagnostic substitution. In the 2006
surveillance year, the Centers for Disease Control and Prevention (CDC, 2009) reported that 41%
of eight-year-olds with ASD had intellectual functioning in the ID range (ranging from 29% to
51% across sites). This rate decreased to 31% in the 2010 surveillance year (ranging from 18% to
37% across sites; CDC, 2014), though this latest surveillance suggests that an additional 24% of
youth with ASD had low levels of cognitive functioning but not in the range of ID (with 23% in the
borderline ID range). The spectrum can also be applied to one’s level of adaptive functioning—the
ability to function independently in age appropriate domains of every-day life, including social
(e.g., forming and maintaining interpersonal relationships, play and leisure skills), practical (e.g.,
dressing, grooming, toileting), and conceptual spheres (e.g., reading, writing, understanding time
and money).
There has been an apparent rise in prevalence rates in youth diagnosed with ASD over the last
decade, with ASD affecting between one in 110 in 2006, to one in 68 in 2010 (CDC, 2007; 2014).
Concerns over the methodology and interpretation of the latest rates have been noted, including
the substantial cross-site variability (Mandell & Lecavalier, 2014). Lord and Bishop (2015) suggest
a number of reasons for the increase in prevalence. First, given that the majority of the increase
comprises youth without ID, higher rates could reflect the broader criteria now employed in the
diagnosis of ASD (King & Bearman, 2009). Second, higher rates could reflect the greater availabil-
ity of training and tools at clinicians’ disposal in the assessment of ASD. Third, many of these tools
have low specificity in distinguishing ASD from other psychiatric or genetic disorders (Charman
et al., 2007, DiGuiseppi et al., 2010, Hus et al., 2013), which could lead to children being misdiag-
nosed with ASD. At the same time, Lord and Bishop (2015) suggest that prevalence rates of ASD
may still continue to rise, as future work addresses the possible under-representation of females
with ASD, the increasing awareness that can lead to more referrals, and the known disparities in
rates across demographic characteristics (e.g., race, neighborhood).
Emotional and behavioral problems, though not diagnostic, are also often associated charac-
teristics in the clinical presentation of ASD. There is considerable data indicating that individuals
with ASD are more likely to have clinically significant levels of these problems compared to both
typically developing individuals of the same age, and individuals of the same cognitive ability
(Leyfer et al., 2006; Simonoff et al., 2008; Totsika et al., 2011a; Totsika et al., 2011b). Using second-
ary data analysis on a UK national survey (Millennium Cohort Study), Totsika and colleagues
(2011a) examined rates of borderline/clinically significant mental health problems in 14,807 typi-
cally developing five-year-olds, compared to 82 children with only ASD, 432 children with only
ID, and 32 children with both ASD and ID, using a parent report questionnaire. Children with
developmental disabilities, across diagnoses, were more likely to have significant hyperactivity,
conduct problems, and emotional problems compared to the typically developing comparison
group. In the ASD samples, 59% of five-year-olds with no ID had hyperactivity problems, 46% had
conduct problems, and 38% had emotional problems. Higher rates were reported with regard to
hyperactivity (88%) and similar rates for conduct problems (57%) and emotional problems (39%)
in the youth with both ASD and ID. In another large scale UK population study, Totsika and col-
leagues (2011b) compared mental health problems among 17,727 typically developing youth, to
those of 47 youth with only ASD, 590 youth with only ID, and 51 youth with both ASD and ID,
again using a parent report questionnaire about symptoms in the last six months. Compared to
the expected 20% of the typically developing comparison group, youth with only ID had a two-to
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three-╉fold increase in rates of emotional and behavior problems, and youth with ASD had a three-╉
to four-╉fold increase. Approximately 70% of youth with ASD had clinically significant emotional
problems (compared to 42% of youth with only ID without ASD), and 65% had clinically signifi-
cant conduct problems (compared to 46% of youth with only ID without ASD).
Given the high rates observed in community samples, it is not surprising that many individu-
als with ASD experience multiple co-╉occurring mental health problems. In fact, 70% of youth
with ASD meet criteria for at least one additional psychiatric disorder, and 40% for two or more,
when using an adaptive structured interview to distinguish ASD symptoms from other psychi-
atric symptoms (Leyfer et al., 2006; Simonoff et al., 2008). Given the overlapping manifestation
among behaviorally-╉based disorders, there is some concern that discrete psychiatric diagnoses
could be overestimated, though even after focused examinations are taken into account, ASD
symptom severity and psychiatric rates remain much higher than expected in the general popula-
tion (Mazefsky et al., 2012). In community and clinically referred samples, levels of internalizing
symptoms (i.e., depression, anxiety) are often moderately correlated with the expression of exter-
nalizing symptoms (i.e., noncompliance, aggressive behavior, irritability; Gadow et al., 2006; Kim
et al., 2000; Lecavalier, Gadow, DeVincent, & Edwards, 2009; Weisbrot et al., 2005), leaving many
authors to suggest they may have an underlying basis in emotion dysregulation (Mazefsky et al.,
2013; Weiss, 2014).
Thompson (1994) defines emotion regulation as “the extrinsic and intrinsic processes respon-
sible for monitoring, evaluating, and modifying emotional reactions, especially their intensive
and temporal features, to accomplish one’s goals” (pp. 27–╉28). This conceptualization is useful as
it emphasizes the multiple strategies that may result in emotion regulation, and the notion that
an emotion regulation process can be either adaptive or maladaptive, depending on whether it is
successful in achieving the appropriate affective state and does not have negative long-╉term costs
(Campbell-╉Sills & Barlow, 2007). Gross and Thompson (2007) outline five broad classes of emo-
tion regulation strategies: Situation Selection, Situation Modification, Attentional Deployment,
Cognitive Control, and Response Modulation. The first four classes are considered “antecedent”
to emotional disruption. If we are able to successfully influence the situations that may cause dis-
tress, focusing on the most useful stimuli and having a good understanding of emotions, or alter-
ing how we think about our experiences, then we are able to maintain emotion regulation without
our affect ever becoming disrupted in the first place. However, when those strategies fail, and we
end up with high levels of negative affect (i.e., dysregulation), then we are required to employ the
last class, modifying our experience to regulate. Adaptive emotion regulation strategies are typi-
cally voluntary in nature, being consciously initiated with effort and control, whereas maladap-
tive strategies are often involuntary, being applied automatically in response to emotion-╉eliciting
stimuli (Aldao & Nolen-╉Hoeksema, 2010; Mazefsky, Borue, Day & Minshew, 2014).
recognition, children with ASD report more difficulties with insight into their own emotional
functioning and in interpreting their own emotional experiences, which is known as emotion
awareness (Losh & Capps, 2006; Rieffe, Terwogt, & Kotronopoulou, 2007); difficulties that also
extend to adults with ASD. Hill and colleagues (2004) surveyed 27 adults with ASD about three
aspects of cognitive processing of emotions: Identifying emotions (e.g., “When I am upset, I don’t
know if I am sad, frightened or angry.”), describing feelings (e.g., “I find it hard to describe how
I feel about people.”), and externally oriented thinking (e.g., “I find examination of my feelings
useful in solving personal problems.”), and found that compared to typically developing adults,
adults with ASD reported significantly greater difficulties with overall emotion processing.
Several studies have examined the specific strategies children and adults with ASD use to regu-
late their emotions, with considerable evidence demonstrating they are less effective than their
peers. Youth and young adults with ASD use adaptive strategies (e.g., problem solving, social
support, cognitive reappraisal, cognitive distraction, acceptance, exercise, and relaxation) less
frequently and maladaptive strategies (i.e., avoidance, expressive suppression) more frequently
compared to typically developing peers (Konstantareas & Stewart, 2006; Samson, et al., 2015).
Self-╉reports of using more maladaptive coping strategies have also been found among children
and adolescents with ASD compared to peers, and are associated with higher self-╉reported lev-
els of psychopathology (Mazefsky et al., 2014; Pouw et al., 2013). Jahromi and colleagues (2012)
reported a higher ratio of maladaptive to adaptive strategies among children with ASD compared
to controls, when employing a frustration task and coding ensuing strategies. Emotion regulation
strategies used by children with and without ASD were coded as constructive/╉adaptive (e.g., help-╉
seeking) and maladaptive (e.g., venting, avoidance). Not only did children with ASD use more
maladaptive strategies across the frustration tasks, but they also more quickly resigned the task
compared to their typically developing peers, and even more so when their parents were not avail-
able to assist them, suggesting the potential role of parental co-╉regulation for children with ASD.
The interplay between emotion regulation and ASD characteristics and impairment 239
valence of each image. Adults with ASD showed decreased brain activation in areas associated
with emotional awareness compared to adults without ASD in their sample. Further, although the
specific findings are inconsistent, studies largely indicate atypical patterns of neural reactivity dur-
ing emotional face processing (Harms et al., 2010) and emotional language processing (Lartseva,
Dijkstra, & Buitelaar, 2014) in ASD.
The only two neuroimaging studies to explicitly investigate emotion regulation in ASD both
utilized cognitive reappraisal tasks (Pitskel, Bolling, Kaiser, Pelphrey, & Crowley, 2014; Richey
et al., 2015). Cognitive reappraisal tasks provide an opportunity to isolate neural reactivity that
is due to regulation of emotion by requiring participants to increase or decrease their emotional
reaction to various stimuli. Importantly, behavioral valence ratings from both youth with ASD
(Pitskel et al., 2014) and adults with ASD (Richey et al., 2015) revealed significant differences
between conditions which supports the use of cognitive reappraisal tasks as an emotion regula-
tion probe in ASD. A consistent finding from both studies, despite the use of different stimuli, was
the decreased ability to suppress amygdala activation in ASD compared to typically-developing
controls, which may provide one mechanistic account for impaired voluntary emotion regulation
in ASD.
Another possibility is that problems with emotion regulation stem from underlying dif-
ferences in physiological arousal. There are a number of different measures of physiological
reactivity that have been used to investigate arousal in ASD, including pupillometry, heart
rate, heart rate variability, respiratory sinus arrhythmia, blood pressure, electrodermal activity,
and cortisol. One question that has been explored using a variety of these methods is whether
individuals with ASD have atypical baseline levels of physiological arousal, with some theories
suggesting baseline levels would be increased and others hypothesizing decreased baseline
arousal. A review of studies focused on baseline physiological reactivity found that approxi-
mately half found no difference compared to controls across a variety of physiologic indica-
tors, while the other studies were in both directions (Lydon, Healy, Reed, Mulhern, Hughes,
& Goodwin, 2014).
Currently, we may also infer conclusions about physiological differences associated with emo-
tion regulation based on studies of related constructs such as the processing of emotional faces
and response to stressors. One interesting conclusion from this work is that individuals with ASD
may perceive their physiological activity differently than their typically-developing peers. For
instance, Shalom et al. (2006) measured the concordance between a physiological measure of
skin conductance in ten children with ASD, and ten children without ASD, who were presented
with pleasant, unpleasant, and neutral pictures, and how pleasant and interesting they rated the
images. While physiological results across the image types were comparable across children with
ASD and those without, self-reported affect ratings were significantly different across the two
groups, such that children with ASD reported more similar answers when rating the pleasant-
ness and interestingness of unpleasant, pleasant, and neutral pictures when compared to children
without ASD. These findings suggest that children with ASD may perceive and consciously report
different experiences of emotional stimuli even though physiologically, they are comparable to
children without ASD. Recently, a study of high-functioning adults supported the importance
of the individual’s perception, by finding the perception of stress, but not physiological reactivity
during a social stressor, was related to social outcomes (Bishop-Fitzpatrick, Minshew, Mazefsky,
& Eack, 2016).
It is difficult to make firm conclusions about specific physiological reactivity differences in ASD
as there have only been a few small studies employing different tasks, mostly with inconsistent
findings. A focus on the higher quality studies does however, indicate discernable differences in
physiological responses during stressor tasks in ASD and, in particular, suggests that further study
0
4
2
Poor
problem-
solving & Difficulty
abstract reading
Lower reasoning social &
inhibition emotional
cues
Sensitivity to
Cognitive
change &
rigidity; Poor
environmental
flexibility
stimulation
Biological
Alexithymia, predisposition
Emotion
Limited (physiological
Dysregulation
emotional arousal, neural
in ASD
language circuitry,
genetics)
ability to take other’s perspectives (Samson et al., 2012). Poor perspective taking could lead
to misreading other’s intentions as negative or hostile, a perception bias that has been linked
to increased negative affect in non-╉ASD studies (Schultz, Izard, & Bear, 2004). Even if an
individual with ASD knows the right emotion regulation strategies to use, they face several
barriers in the effective implementation of these strategies. For example, problems with inhib-
itory control (Geurts, van den Bergh, & Ruzzano, 2014), a tendency to be rigid and have dif-
ficulty shifting (Granader et al., 2014), impaired abstract reasoning and poor problem solving
(Williams, Mazefsky, Walker, Minshew, & Goldstein, 2014), may interfere with the timing
of efforts as well as the generation of flexible solutions during novel situations (Mazefsky &
White, 2014).
A recent study found that repetitive behaviors were strongly correlated with the presence of
emotion dysregulation among children and adolescents with ASD (Samson, Phillips, Parker, Shah,
Gross, & Hardan, 2014). This is consistent with hypotheses that the tendency to be perseverative
and difficulty shifting may lead to sustained emotional reactions and difficulty down-╉regulating
negative affect in ASD (Mazefsky, Pelphrey, & Dahl, 2012). Heightened sensory sensitivity may
also interfere by decreasing the threshold for the experience of negative affect as well as creating
a physiologic state of stress which makes voluntary emotion regulation efforts challenging (Dunn
& City, 1997). Although this implies causality, the relationship is likely reciprocal. For example,
increased repetitive behaviors or unusual sensory reactions may also occur as a consequence of
problems with emotion regulation, and some have even argued that repetitive behaviors may be a
coping mechanism (Turner, 1999), further complicating the dynamic relationship between regu-
lation and expression of ASD symptomatology.
Experiencing highly dysregulated emotion undoubtedly further impairs one’s ability to
attend to and process information from the environment, including social information. Wood
and Gadow (2010) proposed a model describing the reciprocal relation between ASD and anxi-
ety that further illustrates this point. Specifically, they suggest that ASD-╉related stressors (e.g.,
social confusion; peer rejections and victimization; prevention or punishment of preferred
behaviors or interests; and frequent aversive sensory experiences) lead to increased overall
negative affectivity, anxiety disorders (specific type dependent on the experiences), or depres-
sion. In turn, such negative affectivity contributes to more ASD symptoms, conduct problems,
and personal distress, which lead to even further ASD-╉related stressors, completing a negative
cycle. Although Wood and Gadow (2010) focused their model on the development of anxiety
or depression, this dynamic cycle also applies to emotion dysregulation more broadly. As such,
if interventions can effectively improve emotion regulation, there is an opportunity not only to
support emotional well-╉being and decrease distress, but also to improve the course of ASD and
functional outcomes.
There are only two psychopharmacologic medications with U.S. Federal Drug and Safety
Administration approval for use in ASD. They are both indicated for the treatment of irri-
tability, which is arguably a manifestation of emotion regulation failure. These medications
include risperidone and ariprazole, antipsychotics with well-established evidence support-
ing their efficacy despite some significant adverse effects including weight gain and metabolic
changes (Marcus et al., 2011; McCracken et al., 2002). Off-label use of other medications is
common in ASD with an estimated two-thirds of children with ASD on at least one psychotro-
pic medication and over one-third on multiple medications (Spencer et al., 2013). Although the
pace of clinical trials research has increased recently, a review concluded that there was insuf-
ficient evidence to support the efficacy of mood stabilizers or serotonin reuptake inhibitors in
ASD (Siegel & Beaulieu, 2012). Further, studies of serotonin reuptake inhibitors in ASD have
focused on repetitive behaviors as the target symptom rather than anxiety, and there have actu-
ally been no randomized controlled trials of psychotropic medication use for anxiety in ASD
(Vasa et al., 2014).
In contrast, there is now considerable evidence that cognitive behavior therapy (CBT) is effi-
cacious in reducing symptoms of anxiety in youth with ASD who do not have ID, and there
is emerging evidence of its efficacy in adults with ASD. Ung and colleagues’ (2015) systematic
review and meta-analysis of 14 CBT trials for children and adults with ASD indicated moderate
treatment effect sizes across studies. Studies compared CBT to a wait-list (N = 8), treatment as
usual course (N = 3), or alternate treatment (N = 1). However, it is important to note, two of the
14 studies were open trials with no control condition. Seven studies were delivered individually
either with or without parents, six studies were delivered in a group format, and one study incor-
porated a combined individual and group format approach. Parents were involved in 11 of the
studies. No difference in treatment response was found based on informant (parent, child, clini-
cian) and modality (group and individual formats with and without parents). In summary, treat-
ment effects typically translated into clinically significant changes for 50–70% of participants (Vasa
et al., 2014). An earlier meta-analysis of eight randomized controlled trials of CBT with children
with ASD and at least average intellectual functioning reported large effect sizes for parent-and
clinician-reported child anxiety, and small effect sizes for child-reported anxiety (Sukhodolsky,
Bloch, Panza, & Reichow, 2013). Danial and Wood (2013) reviewed intervention studies focus-
ing on mental health problems for children five to 18 years of age with high-functioning autism
spectrum disorder (HFASD), and included randomized trials, group comparison studies, and
multiple baseline designs. Similar to other systematic reviews, they found CBT for anxiety to be
a promising treatment. Reviews also suggest that we know almost nothing about the long-term
effectiveness of CBT treatment in this population, even with reference to anxiety, where up to
44% of youth who improve post intervention show some reduction in gains at follow-up ten to
26 months later (Selles et al., 2015).
CBT studies to date have almost exclusively focused on anxiety. Only one randomized trial
exists on the efficacy of CBT to address anger problems in youth with ASD. Sofronoff and col-
leagues (2007) reported on a waitlist controlled trial of a six-week CBT intervention for anger
management among 45 ten-to 14-year-old children with ASD with at least average IQ, while
parents attended a concurrent parent group to review session material. Parents in the interven-
tion group reported significant decreases in child anger and increased confidence in managing
child anger compared to parents in the waitlist group. Children in the intervention generated
more appropriate coping strategies when given the hypothetical scenario, “Dylan is being Teased”
(Attwood, 2004) compared to those on the waitlist. Until further well-controlled studies are done
though, the efficacy and effectiveness of CBT for externalizing problems among youth with ASD
remains unclear (Danial & Wood, 2013).
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Research on the psychotherapeutic treatment of emotional concerns in adults with ASD lags
behind research on children and adolescents. A recent systematic review identified six studies that
used CBT to treat mental health conditions in adults with ASD, and included case studies and
case series, quasi-experimental designs, and randomized controlled trials (Spain, Sin, Chadler,
Murphy, & Happe, 2015). All participants were diagnosed with ASD with at least average intel-
lectual functioning, and treatment was focused on treating anxiety disorders, mood disorders,
or self-harm. Four studies provided CBT individually and two delivered it in a group format.
No parents or caregivers were reported to be involved. In their narrative synthesis of the find-
ings, Spain et al. (2015) reported decreases in self-and clinician-reported mental health symptom
severity. However, because of the lack of methodological rigor of the extant literature, results must
be interpreted with caution.
Although most of the psychotherapeutic studies in ASD have focused on CBT as the treatment
modality, there is emerging evidence in support of mindfulness-based interventions for anxiety
and depression in ASD. Spek, van Ham, and Nyklicek (2013) conducted a randomized waitlist
controlled trial to examine changes in anxiety, depression, and rumination following a nine-week
mindfulness-based therapy for adults ages 18 to 65 years old (M = 44 years) with ASD and average
verbal ability. Two clinicians facilitated the group and session content included body scans, medi-
ations, breathing exercises, and movement exercises. Compared to adults in the waitlist group,
adults in the mindfulness group reported a reduction in anxiety, depression, and rumination and
increases in positive affect.
Research examining the effects of mindfulness-based strategies with children and youth is also
surfacing. De Bruin, Blom, Smit, van Steensel, and Bogels (2015) evaluated a mindfulness training
intervention for youth 11 to 23 years old (M = 15.8 years) and their parents who participated in a
parallel mindful parenting group, using a pre-post design without a control condition. Youth and
their parents completed measures of mindfulness, worry, depressed mood, ruminations, quality
of life, and ASD symptoms before the intervention, after the intervention, and at follow-up. Youth
reported an increase in quality of life and a decrease in rumination following the intervention,
but no change in worrying, ASD symptoms, or mindfulness. Parents reported increases in mind-
ful parenting (i.e., attentive listening, emotional awareness, self-regulation, and nonjudgmental
acceptance) at post-intervention and follow-up. They also reported significant improvements in
their children’s social responsiveness at follow-up.
In a multiple-baseline design across participants, Singh et al. (2011) examined the effects of
Meditation on the Soles of the Feet on aggressive behavior of three youth (all male) ages 14, 16,
and 17 years with ASD without ID. At the start of the training, youth-mother dyads practiced
the meditations together. Once the youth learned the basics of the meditation, an audiotape was
provided for self-guided practice. Over the course of the meditation training, results indicated a
decreasing trend in aggressive behavior across all three participants, according to parent and sib-
ling reports of observed aggression. Once participants met the criterion of no aggressive behav-
iors for four weeks, there were reports of only one or two aggressive acts within the three-year
follow-up period. Results from these preliminary evaluations provide support for mindfulness-
based skills training as a component of interventions to address emotion regulation difficulties
among youth with ASD.
In addition to studies examining mindfulness practices with youth with ASD themselves,
indirect effects of parent mindfulness training on child externalizing problems have also been
reported. For example Singh, Lancioni, et al. (2006) investigated the effects of a 12-week parent
mindfulness training intervention on child behavior problems. They found that following par-
ent training, parents reported decreases in their children’s externalizing problems. These results
highlight that the children’s externalizing symptoms were reported to decrease, without any direct
42
intervention with the children. It is possible that the intervention influenced parent perceptions of
their child including unconditional acceptance and non-judgment rather than the externalizing
symptomatology itself. Nonetheless, this shift in perspective appears to have positive implications
on the parent-child dynamic and additional well-controlled studies are needed to elucidate how
parent mindfulness-based interventions help individuals with ASD and their parents.
Given high rates of ID among those with ASD, additional studies are needed to examine
treatments to help children and adults with ASD and ID cope with stressors and manage their
emotions. Frequently using single-subject designs, behavioral interventions using exposure and
desensitization have consistently shown to be effective in treating anxiety in this population (Lang
et al., 2011). Jennett and Hagopian (2008) reviewed treatments for phobic avoidance among chil-
dren and adults with ID; approximately one third of the participants in included studies also had
ASD, and all studies involved exposure to the feared stimulus and reinforcement of appropriate
behaviors, specifically approaching the feared stimulus. Results consistently indicate a high degree
of effectiveness, leaving the authors to conclude that behavioral treatments can be considered well-
established for phobic avoidance in this population. More recently, Lydon, Healy, O’Callaghan,
et al. (2014) systematically reviewed treatments for fears and phobias, including three studies (one
case study and two single-subject designs) in which participants had both ASD and ID. Authors
reported positive treatment outcomes with all of the behaviorally-based interventions: Reinforced
practice (Chok et al., 2010), contingent reinforcement and systematic exposure (Schmidt et al.,
2013), and stimulus fading and differential reinforcement (Shabani & Fisher, 2006). Behavioral
interventions have been used to teach relaxation strategies to address disruptive behaviors as well.
In a multi-element single subject design, Mullins and Christian (2001) examined the effects of
progressive muscle relaxation strategies to decrease disruptive behaviors of a 12-year-old male
with ASD and ID during unstructured leisure activities. There was a decrease in the duration of
disruptive behaviors when relaxation strategies were cued before leisure activities, suggesting that
the training had a positive impact on his problem behaviors.
Given the central role that emotion regulation plays in the onset or maintenance of emotion
disorders, and the high degree of emotion regulation difficulties in individuals with ASD, it is
surprising that few studies exist on evaluating the treatment of emotion regulation deficits. The
vast majority of studies focus exclusively on symptoms of anxiety in ASD, neglecting the need to
also target co-occurring depression or anger. Scarpa and Reyes (2011) evaluated a modified CBT
program to address emotion dysregulation in five six- to eight-year-old children with ASD and
average intellectual functioning compared to six children in a delayed treatment condition. Using
one-tailed tests of significance, the authors suggest improvements in child reported coping strate-
gies in response to vignettes, and parent reported child negativity/lability and emotion regulation.
More recently, Thomson, Burnham Riosa, and Weiss (2015) evaluated the feasibility of the Secret
Agent Society-Operation Regulation (SAS-OR; described in detail below) in addressing emotion
regulation in 13 youth with ASD, eight to 12 years of age, and their parents. All children had at
least average intellectual functioning and parent-reported problems with anxiety, depression or
anger/aggression. The SAS-OR program was found to have high participant and therapist satisfac-
tion and therapeutic alliance, excellent treatment adherence across sessions (including homework
completion and child engagement), and face validity. Results revealed parents reported significant
improvements in child emotional lability, internalizing symptoms, behavioral dysregulation, and
adaptive behavior. Independent clinician evaluation indicated significant improvements in child
overall severity and number of psychiatric diagnoses. Children reported significant improvement
in inhibition and dysregulation across anger, anxiety, and sadness, as well as in generating emo-
tion regulation strategies to hypothetical vignettes. An RCT of the SAS-OR program is currently
underway (ISRCTN67079741), and the details regarding each session and the treatment approach
are articulated below.
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and at school each day. Parents and teachers are encouraged to award a child a diary point when
they use their target skill for the week at home and at school (based on the child’s self-report). If
the child reaches their daily points “target,” which is negotiated between the parent and therapist
at each session, their points can be exchanged for a home-based reward. The child is also given
weekly “home missions” to complete with parent support between sessions, which involve prac-
ticing the skills that they are learning at home, at school and when they are out. After completing
each mission, the child is asked to answer questions in the Secret Agent Journal section of their
SAS-OR Cadet Handbook. These questions help the child to understand the benefits of using their
SAS-OR skills, building their intrinsic motivation to do so in the future when the Home-School
Diary reward system is gradually phased out.
Children are also given full-color pocket-sized collector “Code Cards” throughout the program,
and a Code Card holder. Each card features an image of a different relaxation and/or mindfulness
technique, and a description of what level of anxiety or anger it is best used for and where it is best
used (at home, at school and/or when the child is out). Children are encouraged to secretly refer to
their Code Cards to remind them of the strategies they can use to feel happier, calmer, and braver
and to make smart choices just before entering situations where they are likely to feel uncomfort-
able or distressed (with adult help where available). An example Relaxation Gadget Code Card is
shown in Figure 12.4.
Each SAS-OR session typically commences with a ten-minute review of how the child and
parent(s) did with completing the home missions and using the Home-School Diary during the
week. Any challenges are problem-solved to set the child and family up for success in completing
Figure 12.4 An example Relaxation Gadget Code Card from the SAS-OR Program (Front and Back of
Card shown)
Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-institute.net)
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their home missions and using the Home-╉School Diary the following week. For example, if a child
struggled to differentiate feelings of anger from anxiety and rates the intensity of their emotions
one week, they may just be asked to practice detecting when they feel happy or upset the follow-
ing week.
After reviewing home missions and the Home-╉School Diary with the child and parent(s), the
therapist facilitates a series of espionage-╉themed games and activities (including playing assigned
sections of the SAS computer game) that teach the child how to recognize and manage their emo-
tions (see below for further details). Based on literature showing that children with ASD often
struggle to accurately identify emotions in themselves and others (e.g., Rieffe et al., 2007; Uljarevic
& Hamilton, 2013), initial session content predominantly focuses on teaching children emotion
identification skills, as they are a prerequisite for them to be able to use their emotion regulation
strategies when needed. Sessions end with a review of the home missions to be completed during
the coming week and discussing the target behavior(s) and points target for the Home-╉School
Diary with the child’s parent(s).
Session content
In the first session of the program, the child and parent(s) are introduced to the aims of the inter-
vention (i.e., “to help them to feel happier, calmer, and braver”) and create a Challenge Card fea-
turing a picture of the child’s favorite fictional or real life hero or role model who has to be brave,
face their fears and do things that they do not want to do at times. On the card, the child creates
a hierarchy of boring, scary, or difficult things that they have to do in their own life (ranked from
“least” to “most” challenging). As the program progresses, the child is asked to use the emotion
regulation skills that they are learning to cope with unpleasant feelings and to face these fears or
challenges between sessions. Session rules and an in-╉session reward system for following the ses-
sion rules are negotiated in the first session. Children receive points for following the rules in each
session (e.g., trying their best) and if they reach their points target for the session, their points are
exchanged for an end of session reward. A rewards menu is negotiated with the child in the first
session, listing up to five different types of rewards that they would like to receive if they reach
their session points target. Recommended points targets for each session are provided in the SAS-╉
OR Facilitator Manual, although these can be adjusted as the therapist sees fit.
In Session One, the child is introduced to activities in the SAS computer game that teach them
how to recognize emotions in other people from facial expression and body posture/╉movement
clues (“Spot the Suspect” and “The Line Up” games), fostering emotional awareness based on cues
and context. They also practice the mindfulness technique of being aware of their own breath
(“The Breath Analyzer”), introducing them to attention shifting from negative emotions. At the
end of the first session, the therapist spends time alone with the child’s parent(s) explaining the
Home-╉School Diary monitoring and reward system. Home missions for the coming week include
the child practicing their mindful breathing (the Breath Analyzer Mission) and detecting how
other people feel from face and body clues (the Secret Spy Mission) with parent and school staff
support.
After the Home-╉School Diary and home mission review, Session Two commences with a cha-
rades game (“Detection of the Expression”) where the child, therapist and parent(s) take turns
acting out and guessing how each other feels from facial expression and body posture clues. The
child subsequently plays a SAS computer game activity (“Voice Verification”) that involves detect-
ing how people feel from the pitch, pace, and volume of their voice. They then play a game that
involves saying and listening to different secret messages said in different voice tones with their
parent(s) and the therapist, before learning the mindfulness technique of scanning their bod-
ies for physical sensations in the moment (“Body Scan”). Home missions for the week include
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practicing body-scanning and detecting how other people feel from their tone of voice with the
help of their parent and teacher mentors.
Session Three involves the child playing computer game activities that teach them the body
clues and thoughts that signal emotions of happiness, sadness, anxiety and anger within them-
selves (“Detective Laboratory”) and learning that different body clues signal different emotional
intensities (“Degrees of Delight and Distress”). Children draw their own body clues that signal
target emotions on body outlines, and play a game similar to statues with their therapist and
parent(s) to practice quickly identifying emotion body clues (“The Body Clues Freeze Game”).
They repeat the Body Scan activity introduced in Session Two before planning to practice this
skill for their weekly home mission with parent support, practicing awareness of their own arousal
through a focus on their internal cues.
In Session Four, the child creates anxiety-, anger-and/or sadness “Emotionometers” (pocket-
sized emotion scales featuring stickers showing the body clues and situations where they feel low,
moderate and high levels of the target emotion). They then learn how to piece together face-,
voice-, body-and situational clues that signal how someone is feeling in the “Secret Agent Viewing
Panel” SAS computer game activity, and plan how they can use their Emotionometers to detect
the type and strength of their emotions during the week. Learning to rate degrees of emotions is
common across all CBT interventions, and here is applied to internalizing and externalizing emo-
tional states to promote understanding and differentiation across emotions.
Session Five involves the child learning about relaxation “gadgets” to help them to feel hap-
pier, calmer and braver and to make smart choices. This concept is initially introduced to the
child through the first virtual reality mission in Level Three of the SAS computer game. Each
of the virtual reality missions in Level Three of the game involve the child choosing how their
avatar can cope with a challenge (e.g. trying something new, performing poorly at a game or
competition), with both appropriate (take some slow breaths, think helpful thoughts) and less
appropriate (scream and shout, run away) choices available (see the screenshot in Figure 12.5).
The child discovers the consequences of different response options for their avatar, allowing
them to learn through a depersonalized self-discovery process that using skills to stay calm
and cope typically leads to better outcomes than aggressive outbursts, avoidance, or escape
behaviors.
After the child finishes playing the first Level Three virtual reality mission in Session Five, the
therapist helps them to choose Relaxation Gadget Code Cards illustrating the gadgets or strate-
gies that they would like to use to feel happier and calmer in the situations shown on their anxi-
ety, anger and/or sadness Emotionometers. The child and parent(s) learn and rehearse the “O2
Regulator Gadget” (slow, mindful breathing) in session, before planning how they will use this
and other Relaxation Gadgets during the week in situations featured on the child’s Challenge Card
(created in Session One).
In Session Six, the child plays the second Level Three virtual reality mission in the SAS computer
game, which introduces them to the “Fire Engine” Relaxation Gadget (doing a physical activity to
burn up anxious or angry energy when really upset). They also learn about the “Relaxation Radar”
gadget—being on high alert for relaxing or friendly things around you (e.g., friends smiling at you
while you are giving a talk in front of the class). The possible role of sensory items (e.g., a piece of
fabric or scratch and sniff stickers) as Relaxation Gadgets is also explained to children in this ses-
sion, transforming sensory-seeking behaviors or interests that are common in children with ASD
(Little, Ausderau, Sideris & Baranek, 2015) into an adaptive coping skill. The child is introduced
how to use their five “super-senses” (sight, touch, smell, taste, and sound) to be aware of their sur-
roundings as well as their internal body sensations with the “Enviro-Body Scan” gadget, and they
attach stickers illustrating their chosen Relaxation Gadgets to the backs of their Emotionometers.
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Figure 12.5 Screenshot from a Level 3 Virtual Reality Mission in the SAS Computer Game
Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-institute.net)
Their home mission for the coming week involves using their Relaxation Gadgets to continue
climbing the hierarchy of situations featured on their Challenge Card.
Cognitive strategies for coping with emotional discomfort are taught in Session Seven of the
SAS-OR program, aimed at enhancing cognitive control. These include “shooting down” unhelp-
ful thoughts with more helpful alternatives (the “Helpful Thought Missile” Gadget) and being
aware of unhelpful thoughts and allowing them to pass when ready, as if they were printed on the
wings of an SAS spy plane or blimp (the “Thought Tracker”). Children continue rehearsing the
Enviro-Body Scan mindfulness activity introduced in Session Six, practicing their awareness of
physiological arousal and body cues as well as cues in the environment. They also plan their home
missions of being on “unhelpful thought alert” and continuing to progress up their Challenge
Card situational hierarchy, using their Relaxation Gadgets to help them cope.
Session Eight involves the child learning how to be a “Losing Champion”—that is, learning how
to use their Relaxation Gadgets to stay calm when they are losing at a game or competition, just
like their role model or hero does at times. Coping with uncontrollable situations like losing is a
common challenge for children with ASD that contributes to their friendship difficulties (Hebron,
Hunphrey & Olfield, 2015). This concept is introduced with the third Level Three SAS computer
game virtual reality mission, and then rehearsed in session with the child playing a game with
their therapist and parent(s). The child is asked to practice being a losing champion when play-
ing games with family, classmates and other friends as their home mission for the week, provid-
ing them with opportunities to practice using their Relaxation Gadgets during ecologically valid
social experiences.
In Session Nine, the child is taught how to use their Relaxation Gadgets and other strategies
to cope with another social challenge often faced by children on the spectrum–identifying, pre-
venting and managing bullying (Rowley et al., 2012). These skills are introduced to the child in
the final computer game virtual reality mission. The child learns clues to help them differentiate
friendly joking from mean teasing (e.g., whether the person says sorry or follows your instruc-
tions when you tell them to stop) and makes their own customized Bully Guard Body Armor
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Conclusion 253
Code Card featuring stickers showing the bully blocking strategies that they intend to use. The
child is encouraged to put these skills into action during the week (with the help of their parent
mentor) as their home mission.
Session Ten, the final session of the program, involves the child and parent(s) learning how to
use a step-╉by-╉step problem-╉solving formula (the “D.E.C.O.D.E.R”) to change situations that are
causing them distress. As children with ASD often struggle to detect social problems when they
first arise due to their challenges with recognizing how others feel and knowing the implicit social
rules for different situations (Rowley et al., 2012), the formula focuses on helping them detect
social problems in the first instance based on their own internal emotional state and other people’s
facial expressions, voice tones, body postures and movements, what they say and do and the situ-
ation that they are in. For example, if a child accidentally says something that offends someone,
they need to detect this before they can determine the best way to respond. The formula also
focuses on the child developing a detailed plan for their chosen solution with adult support before
putting it into action, including planning and rehearsing the Relaxation Gadgets that they will use
to stay calm. A summary of the D.E.C.O.D.E.R steps is shown in Figure 12.6.
After the D.E.C.O.D.E.R formula is introduced in Session Ten, the child, therapist, and parent(s)
play a ball game to review the skills that have been taught in the SAS-╉OR program, plan how they
can use these skills to cope with future challenges and schedule weekly home review meetings
of session content. The child finishes the final level (Level four) of the SAS computer game, and
is presented with a graduation medal to reward them for their efforts throughout the program.
Finally, the child and parent(s) plan how the child can use the D.E.C.O.D.E.R steps to solve an
upcoming problem for their final home mission, and the parent(s) are given tips on how to sup-
port their child in continuing to develop their emotion regulation skills (e.g., gradually phasing
out the Home-╉School Diary, continuing to prompt and reward skill usage when needed with the
help of visual supports). As described, preliminary trial results of the SAS-╉OR intervention have
been encouraging, with parents and children reporting high program acceptability ratings, and
children on the spectrum showing improvements in their emotion regulation skills (Thomson,
Burnham, Riosa, & Weiss, 2015). Future research will inform how the user-╉friendliness and effec-
tiveness of the program can continue to be improved.
Conclusion
There is robust evidence indicating that we can address a common outcome of emotion dysregula-
tion in youth with ASD (i.e., anxiety), and growing interest in targeting core underlying emotion
regulation skills, primarily based on mindfulness and cognitive behavioral approaches. As we
progress toward building this evidence base, an improved understanding of a transdiagnostic
approach that is not solely focused on symptom reduction will likely emerge, and with it, more
effective interventions that can address a broader array of profiles and deficits. Understanding the
dynamic process of emotion regulation through the lens of ASD symptomatology, and in the face
of ASD-╉related stressors, is important to support individualized skill development and improved
outcomes.
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Chapter 13
A pervasive pattern of instability of interpersonal relationships, self-╉image, and affects, and marked
impulsivity, beginning by early adulthood and present in a variety of context, as indicated by five (or
more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or
selfmutiliating behavior covered in Criterion 5).
2. A pattern of unstable and intense interpersonal relationships characterized by alternating between
extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self image or sense of self.
4. Impulsivity in at least two areas that are potentially self-╉damaging (e.g. spending, sex, substance
abuse, reckless driving, binge eating: (Note: Do not include suicidal or self mutilating behavior
covered in Criterion 5.)
5. Recurrent suicidal behavior, gestures, or threats, or self-╉mutilating behavior.
6. Affective instability die to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or
anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness.
8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights).
9. Transient, stress-╉related paranoid ideation or severe dissociative symptoms.
While Section II represents the traditional categorical perspective that PDs are qualitatively
distinct clinical syndromes, an alternative to the categorical approach is articulated in Section III
of the DSM-╉5. Section III contains “Conditions for Further Study” and includes those for which
scientific evidence was deemed unavailable to support widespread clinical use. PDs are concep-
tualized in Section III from a dimensional perspective, such that PDs represent maladaptive vari-
ances of personality traits that lie on a continuum from normal to abnormal. DSM-╉5 Section III
requires clinicians to consider two sets of criteria (Criteria A and B) in the assessment of BPD.
Criterion A requires judgment of the severity of problems in identity, self-╉direction, empathy, and
intimacy. Criterion B is used to situate an individual within a dimensional personality disorder
space, such that an individual’s functioning may be profiled across five PD trait domains (negative
affectivity, detachment, antagonism, disinhibition and psychoticism) and 25 PD facets (emotional
lability, anxiousness, separation insecurity, submissiveness, hostility, perseveration, depressivity,
suspiciousness, restricted affectivity, withdrawal, intimacy avoidance, anhedonia, manipulative-
ness, deceitfulness, grandiosity, attention-╉seeking, callousness, irresponsibility, impulsivity, dis-
tractibility, risk-╉taking, rigid perfectionism, unusual beliefs/╉experiences, eccentricity, cognitive/╉
perceptual dysregulation). The typical trait profile suggested for BPD requires moderate to greater
impairment in personality functioning manifested by difficulties in two of Criterion A features
(poorly developed identity, problems in self-╉direction, compromised empathy and interpersonal
hypersensitivity, and problems in intimacy). In addition, for Criterion B, high ratings on four
or more of the following seven pathological personality traits are required: Emotional lability,
anxiousness, separation insecurity, depressivity, impulsivity, risk-╉taking, and hostility; of which at
least one must be impulsivity, risk taking, or hostility.
stage or another mental disorder” (American Psychiatric Association, 2013, p. 647). In contrast
to the two years necessary for an adult PD to be diagnosed, only one year is necessary for child/╉
adolescent PD. Section III of the DSM-╉5 states that impairments in personality function are stable
over time and onset can be traced back to “at least adolescence or early adulthood” (American
Psychiatric Association, 2013, p. 762). In addition, the trait facets incorporated in Section III of
the DSM-╉5 mirror developmental findings from maladaptive personality trait frameworks (e.g.,
De Clercq, De Fruyt, et al., 2014; De Clercq, Decuyper, & De Caluwé, 2014). The ICD-╉11, and
national treatment guidelines for the U.K. (National Institute for Health and Clinical Excellence,
2009) and Australia (National Health and Medical Research Council, 2013) also “legitimize” the
diagnosis of BPD in adolescence. In all, current official classification systems for mental disorders
support the evaluation and diagnosis of BPD in adolescents.
Despite these advances, there has been a general reluctance among clinicians to diagnose
BPD in adolescence due to fear of stigma and concerns that personality is not stable in adoles-
cence. The five-╉fold increase in research on BPD in adolescents over the last ten years (Sharp
& Tackett, 2014) is addressing some of these fears, and researchers agree that BPD is a valid
and reliable diagnosis in adolescents (Chanen & Kaess, 2012b; Chanen & McCutcheon, 2013a;
Miller, Muehlenkamp, & Jacobson, 2008; Sharp & Fonagy, 2015; Sharp & Kalpakci, 2015; Sharp
& Kim, 2015; Stepp, 2012). For example, the extant literature supports the construct of adoles-
cent BPD in terms of its clinical description (Chanen & Kaess, 2012b; Fossati, 2014), correlates
and causes (e.g. Carlson, Egeland, & Sroufe, 2009; Sharp et al., 2011), studies that delimitate the
disorder from other related syndromes (e.g. Chanen, Jovev, & Jackson, 2007), follow-╉up studies
that demonstrate a prototypical course and outcome of the symptoms (e.g. Bornovalova, Hicks,
Iacono, & McGue, 2009; Chanen et al., 2004; Cohen et al., 2008), and twin/╉family studies that
aim to identify a genetic basis of the biological phenomena associated with adolescent BPD
(Distel et al., 2008).
Summary
BPD is a valid and reliable disorder in adolescence and can be assessed categorically using DSM-╉
5 Section II, and dimensionally using DSM-╉5 Section III. Prevalence studies have shown that
adolescent BPD occurs at rates around 1% (Michonski, Sharp, Steinberg, & Zanarini, 2013) to 3%
(Zanarini et al., 2011; Johnson, Cohen, Kasen, Skodol, & Oldham, 2008) in community samples.
In clinical samples, rates are 11% in outpatients (Chanen et al., 2004), 33% (Ha, Balderas, Zanarini,
Oldham, & Sharp, in press) and 43–╉49% in inpatients (Levy et al., 1999). BPD is, therefore, not
a transient condition of adolescence, but should be diagnosed and treated to prevent youngsters
from a lifelong trajectory of increasingly severe psychopathology.
skills, so the individual often resorts to short-╉term avoidance strategies (e.g., self-╉harm, impulsive
behavior, etc.) when experiencing unpleasant internal states.
Crowell and colleagues recently extended Linehan’s biosocial theory to develop a developmen-
tal psychopathology model with a specific focus on trait impulsivity. In their model, biologically
determined negative affectivity and high emotional sensitivity interact with trait impulsivity
and parental factors (invalidation and ineffective parenting) early on in development to confer
increased risk for impulse control deficits as development progresses. Impulse control deficits are
then further reinforced by the same parenting factors over time, culminating in BPD.
In another extension of Linehan’s biosocial theory, Selby and colleagues suggest, in their
Emotional Cascade Model (Selby & Joiner, 2009), that rumination (and catastrophization as
future-╉oriented rumination) potentiates the magnitude of biologically determined negative affect
which, in sequence, amplifies the level of rumination, initiating a vicious, self-╉perpetuating cas-
cade of negative emotions. This biologically determined deficit in emotional functioning interacts
with an invalidating family environment over time, from which a full syndrome of BPD emerges.
Fonagy and colleagues’ developmental theory of BPD (Fonagy, Gergely, Jurist, & Target, 2002;
Fonagy & Luyten, 2009; Sharp & Fonagy, 2008) describes emotion dysregulation as a core interac-
tive component with developing mentalizing capacity which, in the context of disrupted attach-
ment relationships, may foster poor self-╉other differentiation culminating in BPD over time.
This model of BPD is firmly rooted in the developmental psychology of emotion regulation.
Specifically, secure attachment and mentalizing capacity evolve when a parent communicates
contingent, marked, and ostensive cues to an infant/╉child. The brains of infants are presumed to
be hard-╉wired to preferentially attend to these cues (Fonagy et al., 2002; Kim, in press). Marked
communication (Fonagy, Gergely, & Target, 2007) refers to communication where a parent
understands the infant’s internal state, while concurrently signaling that the parent’s expression
of emotion concerns the infant, not the parent him/╉herself. The expression of emotion is marked
by modifying (e.g., exaggerating or slowing down) the display of the child’s affect, such that the
parent’s emotional expression resembles, but also modulates the child’s emotion simultaneously.
Ostensive communicative cues (Csibra, 2010; Gergely Csibra & Gergely, 2011) refer to the process
of calling attention to what the parent is about to communicate, for instance by making direct eye
contact with the child while calling the child by name, and/╉or speaking with a “motherese” into-
nation. These ostensive cues signal to the child that the parent’s emotion expression concerns the
child and is of importance. In all then, it is not essential that the adult is perfectly accurate every
time that he/╉she guesses what might be going on in the mind of the child; the point is that the
adult is genuinely interested in the child´s mind and this enables the child to develop a separate
sense of self and adequate emotion regulation capacity (Sadler et al., 2006). If these developmental
processes fail, a child is at risk for developing inadequate mentalizing, emotion dysregulation and
disturbed self-╉other processing—╉in short, BPD.
Summary
All developmental theories of BPD include a strong focus on emotion dysregulation. Moreover, all
theories emphasize the family and/╉or attachment context as highly relevant to the child’s develop-
ing emotion regulation capacity. Theories furthermore converge to suggest a reciprocal relation
between emotion dysregulation and other domains of functioning.
neglecting to do so may lead to a vague and non-specific discussion of problems in emotion regu-
lation related to specific disorders. Given the developmental nature of this volume, and that this
chapter is concerned with emotion dysregulation as it relates to BPD, we will draw on literature
in developmental psychology, developmental psychopathology, and the psychology of emotion to
set the definitional parameters for the remaining discussion.
While several definitions of emotion have been put forward, they all converge on the central
idea that emotions have evolutionary utility—that is, they prepare us biologically to appraise and
respond rapidly and flexibly to situations in service of our survival. Consistent with this view,
emotions are defined in the developmental psychology literature as “appraisal-action readiness
stances, a fluid and complex progression of orienting toward the ongoing stream of experience”
(Cole, Martin, & Dennis, 2004, p. 320). In this sense, emotions are always context-dependent,
although this context may include both the external and internal world. From a developmental
psychology perspective, and highly relevant to BPD, the family environment and the caregiving
relationship is regarded as the most relevant context influencing young children’s emotions. As
children mature into adolescence, peer-and romantic-relationships emerge as additional contexts
of high emotional salience (Cole et al., 2004). While most psychiatric disorders are characterized
by disturbances in emotions, emotions in and of themselves are not pathological. However, too
much or too little emotion may be indicative of pathology; we will return to how this bears on the
definition of emotion dysregulation later in this section.
Emotion regulation is defined in developmental psychology as either regulating or regulated
(Cole et al., 2004). Emotion as regulating refers to instances during which emotion regulates
another system or another person (e.g., a child’s sadness leads to a mother picking her up). Emotion
as regulated refers to a change in a particular emotion (e.g., a mother picking up a child makes
the child calm down). For the purposes of the current chapter, we will focus solely on emotion as
regulated. Consistent with the concept of emotion as regulated, is Gross’s (Gross, 1988) definition
of emotion regulation as the processes by which individuals (or context) influence the type, tim-
ing, experience and expression of emotion. This definition was expanded by Gross and Thompson
(2007) to define emotion regulation as the automatic or controlled, conscious or unconscious pro-
cesses by which emotions in self and/or others are influenced. Gross (1998) defines five regulat-
ing “processes” which include situation selection, situation modification, attentional deployment,
cognitive change, and response modulation. This definition implies that in order to effectively
regulate one’s emotions, one has to have available a set of skills to adopt in a particular situation
(e.g. when upset, an individual may know that turning to a loved one for support would help calm
him/her down), as well as implementing the skill appropriately (e.g., suppressing one’s anger when
expressing it would lead to negative consequences).
Keeping in mind the definitions of emotion and emotion regulation discussed above, emotion
dysregulation denotes instances where emotion regulation processes are derailed, or, put differ-
ently, the inability to flexibly enhance or suppress emotional expression in accord with situational
demands (Bloch et al., 2010; Bonanno, Papa, Lalande, Westphal, & Coifman, 2004). Because too
much or too little emotion may be indicative of pathology, emotion dysregulation, within a devel-
opmental psychopathology framework, includes not only problems in emotion regulation, but
also affect dysfunction (Cicchetti, Ackerman, & Izard, 1995). The inclusion of affect dysfunction
in the definition of emotion dysregulation has meant that a wide variety of constructs are stud-
ied under the umbrella of emotion dysregulation in BPD (Carpenter & Trull, 2013) including
emotional sensitivity, emotion reactivity, affectivity lability, prolonged emotional responses and
emotional intensity, to name a few. For conceptual clarity, it has been suggested that emotion dys-
regulation be viewed as a process, consisting of many interactive components, rather than an end-
state (Werner & Gross, 2010). To this end, Carpenter and Trull have developed a multi-component
4
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Emotion
sensitivity
Stimulus
Heightened and
labile negative
affect
Inadequate Maladaptive
appropriate regulation
regulation strategies strategies
Emotion dysregulation
consequences
model of emotion dysregulation relevant to BPD (see Figure 13.1). In this model, the experience
or subjective perception of a negatively-╉valenced stimulus in the environment leads to increases in
negative affect and affective instability. Heightened and unstable negative affect, in turn, impedes
the use of appropriate and effective regulation strategies, instead leading to increases in the use of
maladaptive strategies. The emotion dysregulation consequences that occur, as a result, reinforce
emotion sensitivity for negatively-╉valenced stimuli in the environment that maintains a vicious,
self-╉perpetuating cycle from which a full syndrome of BPD emerges. While this model is unmis-
takably rooted within Linehan’s (1993) biosocial theory of BPD, here, we infuse the model with
ideas from Fonagy and co-╉worker’s attachment-╉based theory of BPD, to suggest that it is most
often attachment-╉and relationship-╉based events that will provide the most evocative stimuli for
the initiation of this multi-╉component process of emotion dysregulation.
and causal effects of affective dysfunction and emotion regulation problems on the development
of BPD is surprising (Matusiewicz, Weaverling, & Lejeuz, 2014). While this research is lacking,
there is a growing body of cross-╉sectional research focused on emotion dysregulation among
adolescents with BPD. While the latter does not provide a test of the causal relations inherent in
developmental models, it does provide an important starting point that can guide future work
(Matusiewicz et al., 2014). In this section, we use the Carpenter and Trull (2013) model of emo-
tion dysregulation in BPD to organize the empirical literature for each component of the model.
Emotional sensitivity
Emotional sensitivity is defined as heightened emotional reactivity to social and non-╉social stim-
uli (Carpenter & Trull, 2013); or, emotional sensitivity may be defined as the tendency to have
emotional responses to low-╉intensity stimuli (Matusiewicz et al., 2014). While findings are mixed,
several studies have demonstrated heightened emotional sensitivity in adults (see Carpenter &
Trull, 2013; Daros, Zakzanis, & Ruocco, 2013 for a review). Specifically, Daros et al. (2013) con-
cluded, in a recent meta-╉analytic review, that patients with BPD have a sensitivity for rejection-╉
related stimuli (captured in facial expressions of anger and disgust), which interferes with their
capacity to adequately regulate their emotions.
Two studies have investigated emotional sensitivity in adolescents, operationalized as atten-
tional bias to emotional stimuli. Jovev et al (2012) used a modified dot probe task in 21 subjects
between the ages of 15–╉24, who met three or more criteria of BPD, compared to 20 healthy con-
trols. The aim of the task was to assess whether emotion cues in facial stimuli interfered with a
simple discrimination task. Results showed that youth with borderline features had an attentional
bias for fearful faces that reflected difficulty in disengaging attention from threatening informa-
tion during the preconscious stages of attention. Similarly, Von Ceumern-╉Lindenstjerna et al.
(2010) demonstrated a correlation between current mood and attentional bias to negative faces,
suggesting an inability to disengage attention from negative facial expressions during attentional
maintenance when in negative mood. Together, these findings suggest a diminished capacity for
affect regulation in the presence of negatively-╉valenced social stimuli.
Another way to operationalize emotional sensitivity is to evaluate whether individuals with
BPD accurately identify emotional expressions at earlier stages of expression (i.e., lower thresh-
olds of facial expressivity across all emotional valences). Findings in adolescents, like those in
adults, are mixed. Jovev et al. (2011) used a facial morphing task in which faces morph from neu-
tral to each of the six basic emotional expressions. No evidence of heightened sensitivity to emo-
tional facial expressions was found in the BPD group compared to the community control group.
Using a similar face morphing task, Robin et al. (2012) demonstrated that adolescents with BPD
were less sensitive to facial expressions of anger and happiness, i.e., they required more intense
facial expressions than control participants to correctly identify these two emotions. However,
they did not exhibit any deficit in recognizing fully expressed emotions.
A third way to operationalize emotional sensitivity is through evaluating the valence and inten-
sity of emotional reactions to aversive social or interpersonal events, in particular situations dur-
ing which there are perceived or real rejection and/╉or invalidation. While several social rejection/╉
invalidation studies of BPD have been conducted in college-╉age young adults (Ruocco et al., 2010;
Tragesser, Lippman, Trull, & Barrett, 2008; Woodberry, Gallo, & Nock, 2008), only one study has
included adolescents (Lawrence, Chanen, & Allen, 2011). This study examined the effect of social
exclusion, with the use of a Cyberball task, upon mood in a sample of young people (aged 15–╉24)
presenting for treatment early in the course of BPD, as compared with a healthy control group.
Cyberball is an experimental task designed to assess the effects upon mood of being excluded or
ignored without explanation in a social context (Williams & Jarvis, 2006). Results showed that
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ostracism did not selectively induce negative mood in adolescents with BPD; nor did borderline
adolescents show more difficulty in regulating their mood back to baseline; however, the BPD
group rated their mood as more intense across all mood states and across time compared to the
control group.
While more research is clearly necessary to further examine emotional sensitivity in adoles-
cents with BPD, two conclusions can be drawn from the emotional sensitivity literature thus
far. First, there seems to be preliminary evidence in support of emotional sensitivity among this
group in the form of a “negativity bias” manifested as hyper-responsiveness (hypersensitivity) to
negative emotions like anger and fear. This bias may not be specific to social-emotional stimuli
as several studies (see von Ceumern-Lindenstjerna et al.) have demonstrated negative biases in
borderline patients for non-social stimuli. Therefore, it may be that the negative bias for social
stimuli is part of this general bias toward negative emotion. This proposed hypervigilance for
negative emotion (or emotion in general according to Frick et al., 2012) is thought to associate
with reduced amygdala volume and enhanced amygdala responding to emotional stimuli, such as
negative facial expressions, coupled with regulatory deficits of the orbital and prefrontal cortices
(Domes, Schulze, & Herpertz, 2009; Frick et al., 2012). Indeed, three neuroimaging studies uti-
lizing adult samples have explicitly investigated neural responses to emotion recognition in BPD
and have confirmed this hypothesis. Donegan et al. (2003) showed that borderline patients dem-
onstrated significantly greater left amygdala activation to the facial expressions of emotion (vs.
a fixation point) compared to healthy control subjects. (Minzenberg, Fan, New, Tang, & Siever,
2007) found that borderline patients exhibited changes in fronto-limbic activity in the process-
ing of fear stimuli, with exaggerated amygdala response and impaired emotion-modulation of
anterior cingulate cortex (ACC) activity. Similarly, Frick et al. (2012) demonstrated stronger
activation of the amygdala in response to affective pictures, regardless of valence, compared to
healthy controls.
Second, while research in adolescents is still lacking, research in adults suggest that more com-
plex emotion recognition tasks more consistently distinguish BPD from non-BPD groups. For
instance, in the Minzenberg, Poole, and Vinogradov (2006) study, where facial, prosodic (the
aspect of speech that communicates meaning by variation in stress and pitch independent of lexi-
cal and syntactic content) and integrated facial/prosodic stimuli were used, borderline patients
showed no problems with isolated facial or prosodic emotion, but instead demonstrated deficits
in higher order integration of social information. Similarly, Dyck et al. (2009) investigated the
ability of individuals with BPD to recognize negative and neutral emotions in both timed and
untimed trials. They found that individuals with BPD were significantly impaired in their recogni-
tion when the task was timed; however, no such difficulty was noted when the participants were
not timed. Thus, the participants with BPD were significantly impaired when under time pressure
and were less able to correctly judge negative or neutral affect in a hasty manner. It is possible
therefore, that borderline patients have emotion recognition deficits when tasks require the inte-
gration of different modes of processing (emotion recognition and speed of response), or when
tasks are presented in the context of heightened emotional arousal (Dixon-Gordon, Chapman,
Lovasz, & Walters, 2011b).
Crucial for future research, in this regard, is the inclusion of psychiatric control groups, as
studies typically compare adolescents with BPD with healthy controls. The specificity of emo-
tional sensitivity to BPD, beyond mere “caseness” or neuroticism is, therefore, not clear. Moreover,
the use of psychophysiology and neuroimaging to assess emotional sensitivity beyond subjective
self-report in adolescents is completely absent and there is an urgent need for biologically-based
studies. Finally, it is highly probable that attachment-relevant interpersonal situations will evoke
stronger emotional reactions than more general social contexts. For instance, stimuli that include
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the faces or other identifying characteristics of actual attachment figures would increase emo-
tional salience in theoretically relevant ways.
Intense negative affect
As formulated by Carpenter and Trull (2013), the second component in the emotion dysregula-
tion process in BPD is the experience of intense, negative and labile affect. Intense, negative and
labile affect is seen as a direct result of emotional sensitivity to subtle events that may seem benign
to the casual observer, but which can cause rapid change in mood to an individual with BPD.
Typically, Ecological Momentary Assessment (EMA) methods, by which a research participant
repeatedly reports on symptoms, affect, behavior, and cognitions close in time to experience and
in the participants’ natural environment (Stone & Shiffman, 1994), provide the richest data in this
regard as it can track context-╉dependent (i.e., ecologically valid) valence, intensity and moment-╉
by-╉moment change in emotion, although trait-╉based approaches have also been used (Solhan,
Trull, Jahng, & Wood, 2009). In adults, EMA studies have generally supported greater negative
affective lability in BPD (see Nica & Links, 2009 for a review).
Only one study has used EMA methodology to assess negative affect in the context of adoles-
cent BPD (Scott et al., 2015). The study assessed the covariation of daily experiences of shame
and anger-╉related affects/╉hostile irritability and borderline symptoms in a community sample of
adolescent girls while they were going about their daily lives. Results generally supported the
hypothesized associations between shame and anger-╉related affects in those with greater border-
line features, such that, over the course of one week, shame (but not guilt) was associated with
greater hostile irritability, but only in girls with high levels of borderline symptoms.
measure and subjects are asked to rate the frequency of each statement using a Likert-╉type scale
ranging from 1 = “Almost Never” to 5 = “Almost Always.” A total score of emotion dysregulation is
derived by summing all responses (indicating greater difficulty) with additional emotion regula-
tion domains assessed for including 1) awareness and understanding of emotions; 2) acceptance
of emotions; 3) the ability to engage in goal-╉directed behavior, and refrain from impulsive behav-
ior when experiencing negative emotions; 4) access to emotion regulation strategies perceived
as effective; and 5) the flexible use of situationally appropriate strategies to modulate emotional
responses.
To our knowledge, there are no studies, in adolescents with BPD, using experimental mea-
sures to evaluate identification and differentiation of their own emotion. There are also no avail-
able studies of distress tolerance in adolescents with BPD. There are, however, a few studies that
have utilized the DERS in adolescent samples. In a sample of inpatient adolescents, Sharp, Ha,
Michonski, Venta, and Carbonne (2012) showed that adolescents who met DSM-╉IV defined
criteria for BPD evidenced higher total DERS scores compared to adolescents not meeting cri-
teria for BPD. In addition, DERS total scores correlated positively with a self-╉report measure
of borderline features. In another study, difficulties in emotion regulation were shown to relate
to social-╉cognitive (mentalizing) capacity (Sharp et al., 2011). Moreover, difficulties in emo-
tion regulation mediated the relation between impairment in social cognition and borderline
traits. In a study contrasting difficulties in emotion regulation strategies (DERS), with the use
of positive emotion regulation strategies, as measured by the Cognitive Emotion Regulation
Questionnaire, (CERQ; Garnefski, Kraaij, & Spinhoven, 2002) along with assessments of mater-
nal and paternal attachment security, Kim, Sharp, and Carbone (2014) showed that difficulties
in emotion regulation strategies and the use of positive emotion regulation strategies were dif-
ferentially implicated in the link between attachment insecurity and BPD features. Attachment
security functioned as a buffer against adolescent BPD by enhancing positive emotion regula-
tion strategies, while difficulties in emotion regulation strategies served to dilute the protec-
tive effect of attachment and positive regulation strategies, culminating in clinically significant
levels of borderline traits.
In all, two conclusions can be drawn from the above literature. First, like their adult counter-
parts, adolescents with BPD seem to experience a similar lack of emotion regulation strategies.
Second, this impairment appears to relate to attachment insecurity and also affect functioning
in other relationship-╉relevant domains, like social cognition. As with the other components of
Carpenter and Trull’s (2013) model of emotion dysregulation in BPD, more research is clearly
needed in this area. Research in adults highlight the need for considering the interaction between
components of emotion dysregulation, which should also be a goal of research in adolescent BPD.
For instance, research focusing on inadequate emotion regulation strategies in BPD would be sig-
nificantly enhanced if intense, negative affect is routinely assessed and controlled for in studies. In
so doing, one can begin to parse out the validity of different components of emotion dysregulation
to arrive at a more nuanced model of emotion dysregulation in BPD.
Maladaptive emotion regulation strategies may also include unobservable maladaptive cogni-
tive strategies that are employed to help manage intense and negative emotion. For instance, con-
sistent with the Emotional Cascades Model discussed above, adults with BPD have been shown
to engage in intense rumination, thereby increasing the magnitude of the negative affect that
caused the rumination in the first place, culminating in dysregulated behavior in order to distract
from rumination (Selby, Anestis, & Joiner, 2008). Individuals with BPD have also been shown
to engage in experiential avoidance (EA) (Dixon-╉Gordon, Chapman, Lovasz, & Walters, 2011a;
Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006; Iverson, Follette, Pistorello, & Fruzzetti, 2012).
EA is defined as an “unwillingness to remain in contact with uncomfortable private events (e.g.,
thoughts, emotions, sensations, memories, urges)” that often manifests in behaviors that serve
to avoid unpleasant experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996, p. 1154).
Typical EA behaviors include thought suppression, denial, self-╉distraction, substance abuse, and
self-╉injury. While these behaviors alleviate distress in the short-╉term, avoidance of unpleasant
thoughts and sensations actually increases the likelihood of experiencing them again in the future,
elevating physiological arousal and distress (Chawla & Ostafin, 2007). This sets into motion a
vicious cycle of using more avoidance-╉based strategies, thereby thwarting healthy and effective
emotion regulation.
While studies are generally lacking in adolescents on the use of maladaptive emotion regulation
strategies, there is an emerging literature for SIB as an emotion regulation strategy in adoles-
cents with BPD. Consistent with Crowell and colleagues’ developmental psychopathology model
of BPD, SIB and BPD appear to co-╉occur in adolescence (see Gratz, Dixon-╉Gordon, and Tull,
2014 for a review). Adolescents with a history of deliberate self-╉harm also report higher levels of
overall emotion dysregulation on the DERS and a specific impairment in access to effective emo-
tion regulation strategies (Perez, Venta, Garnaat, & Sharp, 2012). Studies in adolescents have also
shown that adolescents who engage in SIB exhibit reduced respiratory sinus arrhythmia (RSA)
at baseline, greater RSA reactivity during negative mood induction, and attenuated peripheral
serotonin levels (Crowell et al., 2005). These studies suggest that SIB may serve a similar emotion
regulation function for adolescents with BPD as suggested for adults.
Similarly, at least two studies have demonstrated EA is associated with BPD in adolescents.
In a community sample of 881 adolescents (Sharp, Kalpakci, Mellick, Venta, & Temple, 2014) a
prospective relation between EA & BPD was demonstrated and, measured one year after baseline,
controlling for symptoms of anxiety and depression. In adolescent inpatients with BPD, Schramm,
Venta, and Sharp (2013) found that EA made a significant and independent contribution to the
variance in borderline features, while partially mediating the relation between difficulties in emo-
tion regulation and borderline features. The results of these studies were interpreted in the context
of a mentalization-╉based account of BPD (Fonagy & Luyten, 2009) in which the capacity to be
open and curious about one’s own mental states, without becoming distressed by them or trying to
control them (that is, EA), comes about in the context of secure attachment with primary caregiv-
ers. Indeed, in another study, we have shown that disorganized attachment predicted EA, which
in turn predicted the capacity to accurately assess mental states in others (Vanwoerden, Kalpakci,
& Sharp, 2015).
Summary
A major limitation of the emerging research on emotion dysregulation in BPD (beyond the mere
lack thereof), is the fact that research is not particularly developmentally sensitive and relies heav-
ily on self-╉report. Most of the emotion dysregulation measures are downward extensions of adult
measures and generally, few studies have employed experimental paradigms of emotion dysregu-
lation. Importantly, few studies have adopted a prospective design and it is unclear to what extent
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transdiagnostic, integrating elements of psychoanalytic object relations theory and cognitive psy-
chology. Compared to treatment as usual, CAT has demonstrated effectiveness and more rapid
recovery, although differences were not as marked at two-╉year follow-╉up (Chanen, Jackson, et al.,
2009). The CAT model is currently being disseminated in Europe.
Mentalization-╉based treatment (MBT; Bateman & Fonagy, 2009) shares many common features
with CAT (Bateman, Ryle, Fonagy, & Kerr, 2007), and has been adapted for use in adolescents.
This therapy assumes that the development of BPD in adolescence and its treatment is grounded
in a phase-╉specific compromise in the capacity to mentalize that occurs during adolescence
(Fonagy, Rossouw, et al., 2014). MBT for adolescents (MBT-╉A), which incorporates monthly ses-
sions of MBT for families (MBT-╉F) has been shown to be effective in an RCT in a sample of self-╉
harming adolescents (most of whom met criteria for BPD; Rossouw & Fonagy, 2012). MBT-╉A was
more effective than treatment as usual in reducing self-╉harm and depression. This superiority was
explained by improved mentalization and reduced attachment avoidance, and reflected improve-
ment in emergent BPD symptoms and traits.
Finally, transference-╉focused psychotherapy (TFP; Clarkin et al., 2001) has been adapted for use
in adolescents. TFP is based on contemporary psychoanalytic object relations theory as developed
by Kernberg. TFP-╉A is a manualized psychodynamic treatment for borderline adolescents deliv-
ered in individual sessions, ideally twice a week but not less often than once a week (Normandin,
Ensink, Yeomans, & Kernberg, 2014). Although commonly used with adolescents with BPD, TFP-╉
A has not yet been evaluated in an RCT, but also shows potential for indirectly affecting emotion
dysregulation through the process of increasing self integration as therapy progresses.
Assessment
Intervention begins with a two-╉week assessment period that includes all members of the family
and focuses on the evaluation of psychiatric symptoms through observations, interview and
standardized measures. The aim is firstly, to identify conditions that may require adjunctive
treatments (such as medication), to highlight any comorbidities, and to make the therapist
aware of any psychiatric conditions that can impair the ability to mentalize. In addition, assess-
ment also aims to fully characterize the mentalizing capacity, cognitive, executive function and
emotional regulation of the adolescent, as well as the general mentalizing capacity of family
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members. The assessment of mentalizing in BPD patients will likely show that the adolescent
is able to mentalize, but does so intermittently; therefore, in highly charged situations, often in
the context of a family assessment session, the adolescent may show a temporary inability to
recognize the feelings and experiences of others resulting in hypermentalization (that is, the
over-╉attribution of mental states to others). Assessment tools that may aid clinical assessment
of mentalizing capacity in the adolescent include the Reflective Functioning Questionnaire for
Youth (Ha, Sharp, Ensink, Fonagy, & Cirino, 2013), which was recently validated and provides
an adequate measure of self-╉report mentalizing capacity in adolescents. A questionnaire-╉based
measure of hypermentalizing is currently being evaluated for its’ validity, but has shown prelim-
inary promise (Sharp, 2015). The Movie Task for the Assessment of Social Cognition (Dziobek
et al., 2006) has been used in inpatient adolescent settings (Sharp et al., 2009) and has shown
sensitivity to treatment outcome (Sharp et al., 2013). These measures provide valuable informa-
tion for a mentalization-╉based case formulation and may also be important in tracking change
and outcome.
Initial phase
The assessment phase is followed by the initial phase which consists of two sessions. First, two
parallel sessions with the adolescent and the family are carried out to share the mentalization-╉
based formulation. The aim is to make the adolescent and the family feel understood, and to use
the formulation to plan treatment. During these sessions, a crisis plan is developed which identi-
fies any triggers of emotional outbursts and/╉or impulsive behavior, including self-╉harm. In addi-
tion, a treatment contract is developed which sets out the duration of treatment and commitment
required from all those participating; it explains the importance of everyone’s engagement and the
process of working together in the therapy.
The family formulation session is followed by a psychoeducation session, which may be deliv-
ered to the individual family or in a group format. This aims to help the family understand that
behavior has meaning, that feelings arise in a relational context, and that people have a powerful
emotional impact on one another. Psychoeducation may involve informal discussion with the
family, using examples from everyday life, or in multifamily groups it may make use of group
discussion, role-╉play and videos.
Middle phase
The middle phase of MBT-╉A can be seen as the remediation and rehabilitation phase of ther-
apy, and lasts nine to ten months. It aims to enhance mentalization in the adolescent and family
through the development of mentalizing skills (i.e. active reflection on the mind of self and oth-
ers). This phase also aims to help the adolescent and family gain better emotion regulation and
impulse control (as dysregulation and impulsivity undermines the development and use of men-
talizing ability). MBT-╉A sessions are unstructured and focus on the young person’s current and
recent interpersonal experiences, while maintaining a constant focus on the mental states likely to
have been evoked by these experiences. The main tool of the therapist is the “mentalizing stance”
which is defined as an open, curious attitude towards the client. In addition, the therapist uses a
number of specific techniques that include supportive and empathic interventions, clarification
and elaboration techniques, basic mentalizing techniques, transference techniques, and inter-
pretive mentalizing techniques. In general, interventions are simple, “soundbite” interventions
that do not require excessive processing competencies on the part of the young person (Fonagy,
Rosssouw, et al., 2014). They are affect-╉focused and current (e.g., love, desire, hurt, catastrophe,
excitement), as these domains are most accessible for the construction of subjective states. To
facilitate accessibility, the therapist often uses his/╉her own mind as a model; not in the sense of
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Conclusion 273
self-╉disclosure, but as a normalizing influence suggesting to the young person how the therapist
may feel or may think in the context the young person presents.
Final phase
The final phase of MBT-╉A addresses separation issues along with managing anticipated challenges
in a mentalizing manner. It aims to increase the adolescent’s independence and responsibility, and
consolidate relational stability and a sense of mastery (as opposed to helplessness or passivity) in
the adolescent and his/╉her family. In addition, a coping plan is created for the family, setting out
what to do in the future if difficulties return. The final phase of MBT-╉A lasts for approximately
two months and commonly includes a tapering-╉off of sessions at the end. Some families also find
it helpful to return for one final family session a few months afterwards.
The discussion of MBT-╉A above was necessarily brief and readers are referred to the adult man-
ual for treatment of BPD (Bateman & Fonagy, 2006) or Fonagy, Rosssouw, et al. (2014) for a more
detailed discussion of MBT-╉A for BPD in adolescents.
Conclusion
The aim of this chapter was to provide an overview of the construct of emotion dysregulation
in the context of BPD in adolescents. Our review has demonstrated that BPD has been seen as
the quintessential disorder of emotion regulation. While these conceptualizations have strong
theoretical and clinical foundations, there is room for more empirical research to further support
these ideas. In this regard, we identify two important goals for further research in adolescents.
First, research should be guided by a process-╉oriented and multi-╉component model of emotion
dysregulation in order to assess the complex interactions involved in emotion dysregulation.
Failing to do so will result in a piecemeal and potentially clinically meaningless understanding
of emotion dysregulation in BPD. Second, it is important to study BPD in the context of other
psychopathology. High comorbidity between BPD and other disorders has led authors to inves-
tigate the location of BPD within the latent structure of psychopathology in general. It is impor-
tant that these methods are combined with experimental approaches to emotion dysregulation,
where feasible, to further harness the transdiagnostic potential of emotion dysregulation and its
treatment.
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Chapter 14
282 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
Leibenluft, 2011; Stringaris & Taylor, 2015). Unlike DMDD, SMD also included hyperarousal
symptoms such as insomnia, agitation, and distractibility, and required an onset of both chronic
irritability and hyperarousal symptoms before age 12 years. Consistent with prevalence estimates
of DMDD (Copeland et al., 2013), the lifetime prevalence of SMD was estimated to be 3.3% in a
community sample of children ages nine to 19 years (Brotman et al., 2006).
In a series of studies, SMD was compared to narrow phenotype bipolar disorder (NP-╉BD; i.e.,
a history of strictly defined, distinct episode(s) of euphoric mania/╉hypomania) in youth with
respect to pathophysiology, family history, and longitudinal outcomes. Evidence generally did not
support the conceptualization of SMD as a phenotype of bipolar disorder (see Leibenluft, 2011).
In fact, SMD (Brotman et al., 2006) and chronic irritability (Savage et al., 2015; Stringaris, Cohen,
Pine, & Leibenluft, 2009) in children and adolescents were found to predict the development
of unipolar depressive and anxiety disorders, but not bipolar disorder, in adulthood. Additive
genetic factors were found to explain a substantial portion of the relation between irritability and
anxiety/╉depression (Savage et al., 2015). In addition, risk for future manic/╉hypomanic episodes
was documented to be 50 times higher in youth who met criteria for NP-╉BD than in youth with
SMD (Stringaris et al., 2010). Finally, youth who met criteria for SMD were significantly less likely
than those with NP-╉BD to have a parent diagnosed with bipolar disorder (Brotman et al., 2007).
Thus, although some youth with NP-╉BD may exhibit irritability while euthymic and/╉or increases
in irritability during mood episodes, evidence strongly suggests that chronic, severe irritability
is not a developmental precursor of bipolar disorder. Further, any history of manic/╉hypomanic
episodes is exclusionary for the diagnosis of DMDD, such that NP-╉BD and DMDD cannot be
comorbid.
expression of irritability in MDD is episodic by definition, and the diagnosis of DMDD should not
be made if irritability occurs only within the context of a depressive episode (APA, 2013).
284 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
Amplification of Frustration
Dysregulated
attention-emotion
interactions
Decreased
Threshold
Misinterpretation
of social-emotional
stimuli
Decreased
context-sensitive
Increased regulation
probability
Behavioral findings
In the first investigation of reversal learning in SMD, Dickstein and colleagues (2007) compared
children and adolescents who met criteria for SMD to youth who met criteria for NP-╉BD and
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non-╉psychiatric control participants. Compared to controls, participants with SMD and NP-╉BD
both made more errors on the difficult response reversal trials. However, the two clinical groups
did not differ from one another on these trials, suggesting that impairment in cognitive flexibility
is common to both syndromes. Dickstein et al. (2010) further examined the diagnostic specific-
ity of response reversal deficits by comparing groups of participants who met criteria for SMD,
NP-╉BD, unipolar depression, and anxiety disorders, as well as healthy controls. The probabilistic
response reversal task that was used in this study included both reward and punishment (point
loss) contingencies. In contrast to the earlier findings, participants with SMD did not differ sig-
nificantly from controls (or other clinical groups) on the primary performance metrics that were
assessed. However, the effect size associated with the comparison between SMD and control par-
ticipants was medium-╉to-╉large, so that the lack of a significant group difference may have reflected
insufficient statistical power. In secondary analyses, youth with SMD and NP-╉BD both exhibited
greater difficulty than did controls in using reward and punishment expectancies (i.e., learning on
previous trials) to facilitate adaptive responding to this task.
Neural findings
Adleman and colleagues (2011) used fMRI to assess the neural correlates of response reversal
learning in children and adolescents with SMD, NP-╉BD, and no history of psychiatric disorder.
The paradigm employed in the scanner was similar to that used by Dickstein et al. (2010) and had
been adapted previously for fMRI in a study of youth with ODD and conduct disorder (Finger
et al., 2008). Behaviorally, participants with SMD performed more poorly than did both the NP-╉
BD and control groups throughout the task, suggestive of a generalized deficit in contingency
learning. With respect to patterns of neural activation, on incorrect versus correct trials, both the
SMD and NP-╉BD groups failed to exhibit an increase in activity in the caudate nucleus that was
shown by healthy comparison youth. The caudate, a component of the striatum, supports motor
learning to enable behavioral adjustment following errors (Packard & Knowlton, 2002). Thus,
findings for this region directly implicate difficulty learning from errors in both SMD and NP-╉BD.
Interestingly, however, only the SMD group exhibited dysfunction in frontal activity when com-
pared to both the NP-╉BD and healthy comparison groups. Specifically, youth with SMD exhib-
ited hypoactivation in the inferior frontal gyrus, which supports the resolution of error-╉related
conflict through motor response selection and mediates key sub-╉processes, such as maintenance
of attention and cognitive representation of goals and contingencies (Budhani, Marsh, Pine, &
Blair, 2007). Activity in other regions, including frontal and cerebellar regions, was also found
to distinguish the SMD group and further implicated dysfunction in detecting and adapting to
errors in SMD.
Summary of findings
Therefore, across both behavioral and neural metrics, youth with SMD show impairments in the
ability to detect and flexibly respond to changing environmental contingencies of reward and
punishment. Whereas the behavioral deficits appear to be shared with NP-╉BD, the two conditions
differ in their mediating neural circuitry. In particular, SMD has been characterized by a unique
and pervasive pattern of frontostriatal dysfunction in the context of reversal learning, which may
increase the probability of experiencing blocked goal attainment or other unexpected outcomes
and heighten the resultant frustration response (Blair, 2010; Leibenluft, 2011).
286 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
attention toward or away from particular stimuli, can facilitate emotion regulation (Posner &
Rothbart, 1998) and behavioral self-╉control (Mischel, Shoda, & Rodriguez, 1989). Such norma-
tive attention-╉emotion interactions appear to be disrupted in children and adolescents with SMD,
especially in the context of frustration (see Figure 14.1). One commonly used task in this domain
is the affective Posner paradigm, which experimentally manipulates demands on participants’
attention and elicits frustration through the use of rigged performance feedback (Perez-╉Edgar &
Fox, 2005). On each trial, participants view two display frames on opposing sides of the computer
screen. Next, a cue (e.g., blue illumination) appears inside one of the frames, followed quickly by
a target in one of the two locations. Participants are instructed to indicate its location as quickly
and accurately as possible. A cue validity effect is typically observed, i.e., responses are relatively
slower on “invalid” trials, when the cue and target are presented in opposing locations. The affec-
tive adaptation of this task includes an initial baseline phase in which participants complete the
trials as described; a second phase in which participants win or lose money based on their perfor-
mance; and a critical third phase entailing blocked goal attainment in which participants receive
noncontingent negative performance feedback that results in monetary loss on a substantial pro-
portion of trials (i.e., frustration trials).
Behavioral findings
The affective Posner task has been conducted with SMD samples in three separate investigations,
all of which included both behavioral and neural assessments (Deveney et al., 2013; Rich et al.,
2007, 2011). Behaviorally, children and adolescents with SMD were found to differ consistently
from non-╉psychiatric comparison participants in their affective responses to the frustration trials.
As expected, SMD participants reported higher levels of arousal (Rich et al., 2007), unhappiness
(Rich et al., 2011), and frustration (Deveney et al., 2013) than did the comparison participants.
In the two studies that also included participants with NP-╉BD, these youth were similarly char-
acterized by heightened negative affect in response to frustration (Rich et al., 2007, 2011). With
respect to task performance, the pattern of findings is less consistent. In one study, participants
with both SMD and NP-╉BD were less accurate in their responses than healthy comparison youth
(Rich et al., 2007); however, another study did not document any group differences in behavioral
performance (Rich et al., 2011). Further, two findings were unique to SMD: These youth reported
greater arousal in response to negative performance feedback than did both NP-╉BD and healthy
comparison participants (Rich et al., 2011), and SMD youth were slower than healthy comparison
youth in responding to invalid trials during the frustration phase (Deveney et al., 2013). This lat-
ter effect, which we will return to in the neural findings, suggests decreased flexibility in spatial
attention in the context of frustration.
Neural findings
An electroencephalographic investigation by Rich and colleagues (2007) compared youth with
SMD, NP-╉BD, and no history of disorder in their event-╉related potentials (ERPs) to targets pre-
sented within the affective Posner paradigm. Despite similarities in the behavioral responses of
SMD and NP-╉BD participants in this study, ERP profiles diverged between these two syndromes.
Most notably, across all phases of the task, the SMD group exhibited lower N1 and P1 amplitudes
than did both the NP-╉BD and healthy comparison groups. The N1 and P1 components occur very
quickly following the presentation of a stimulus and reflect initial attentional orienting. Similar
reductions in N1/╉P1 amplitude have been reported for ADHD (Jonkman et al., 2000) and sug-
gest a generalized deficit in attentional orienting in SMD. In a follow-╉up study, Rich et al. (2011)
used magnetoencephalography to evaluate the neural responses of SMD, NP-╉BD, and typically-╉
developing participants to the performance feedback portion of the frustration trials. When
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contrasting responses to negative feedback versus positive feedback, participants with SMD
uniquely showed heightened activity in the anterior cingulate cortex and medial frontal gyrus
relative to healthy comparison participants. Previous research has documented activity in these
brain structures to be associated with frustration (Moadab, Gilbert, Dishion, & Tucker, 2010),
which is consistent with the elevated arousal that was reported by SMD participants in response
to negative feedback in this study. Moreover, these results provide direct neurobiological evidence
for heightened frustration to blocked goal attainment in SMD.
Deveney and colleagues (2013) further explored the neural circuitry mediating frustration by
adapting the affective Posner task for fMRI with SMD and healthy comparison participants. In
response to frustration trials on which participants received negative feedback, SMD youth were
characterized by widespread neural deactivations, both relative to comparison youth in this con-
dition (i.e., between-╉group differences) and relative to their own responses to positive feedback
(i.e., within-╉group differences). In particular, SMD youth showed deactivations in the left and
right striatum, left amygdala, posterior cingulate cortex, and parietal cortex. Striatal deactiva-
tion is known to occur frequently in conjunction with negative prediction error, or conditions
in which an outcome is worse than expected (Schultz, Dayan, & Montague, 1997; Schultz, 2010).
Extrapolating from this knowledge and consistent with the response reversal findings, greater
deactivation in this region suggests that SMD youth experience blocked goal attainment as more
unexpected and/╉or unpleasant than do healthy youth. Deactivations in the amygdala and poste-
rior cingulate are more difficult to interpret, although as we review in the next section, Thomas
et al. (2013) similarly found in SMD attenuated amygdala and posterior cingulate activity to
high levels of facial anger intensity. Finally, the parietal cortex plays a key role in spatial attention
(Corbetta, Kincade, Ollinger, McAvoy, & Shulman, 2000), and deactivation in this area suggests
that frustration reduces attentional flexibility for youth with SMD, which may have contributed to
their slowed performance on invalid trials when frustrated.
Summary of findings
The affective Posner paradigm has generated both behavioral and neural data to support the pro-
posed pathophysiology of SMD. In response to blocked goal attainment, children and adolescents
with SMD show heightened activity in brain structures associated with frustration and, corre-
spondingly, they report elevated levels of negative affective arousal. In addition, unique striatal
and parietal cortex dysfunctions suggest that, relative to healthy comparison youth, youth with
SMD experience blocked goal attainment as more unexpected and have limited attentional flex-
ibility to regulate their frustration.
288 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
during social interactions (e.g., being told by one’s parents to stop playing a video game or another
preferred activity). Misinterpretations of others’ emotion cues in the setting of these interactions
(e.g., failing to identify the parent’s angry expression or, conversely, mislabeling the parent’s neu-
tral expression as angry) might exacerbate frustration in response to the precipitating events.
Behavioral findings
Guyer and colleagues (2007) conducted the first study of face emotion labeling in SMD, compar-
ing these youth to NP-╉BD, anxiety and/╉or unipolar depressive disorders, ADHD and/╉or conduct
disorder, and non-╉psychiatric comparison youth. Participants viewed child and adult faces dis-
playing angry, fearful, sad, or happy emotions. On each trial, participants indicated the emotion
being expressed. The SMD and NP-╉BD groups both made more identification errors than did all
other groups, and did not differ from one another. Further, in both SMD and NP-╉BD this impair-
ment was generalized across child and adult faces and across all emotions. In a subsequent eye
tracking study, Kim et al. (2013) replicated this broad deficit in face emotion labeling in SMD and
NP-╉BD relative to healthy comparison participants. However, whereas NP-╉BD was characterized
by reduced visual attention to the eyes in the facial stimuli, the pattern of visual attention to the
eyes in youth with SMD fell in between that in NP-╉BD and comparison participants. These data
suggest that, in SMD, the observed deficit in face emotion labeling is not fully explained by insuf-
ficient visual attention to emotion-╉relevant cues in others’ eyes.
In a more fine-╉grained examination of face emotion labeling in SMD, NP-╉BD, and healthy com-
parison participants, Rich et al. (2008) assessed the intensity of expression that was required to
label emotions correctly. Each trial began with the presentation of a neutral facial expression,
which gradually increased in emotional intensity to result in anger, fear, disgust, sadness, happi-
ness, or surprise. Participants were instructed to indicate, once they were aware, the specific emo-
tion being expressed by each face, and they were allowed to change their responses as each trial
progressed further. Across most emotions, both SMD and NP-╉BD participants required greater
intensity of facial expressions than did the comparison participants in order to label the emo-
tions correctly. In addition, within the SMD group, greater impairment in face emotion identifica-
tion was associated with poorer family functioning, including general relationships with family
members and typical interactions surrounding family rules, chores, and solving problems. Finally,
Deveney and colleagues (2012) examined children’s ability to label nonverbal emotional cues con-
veyed vocally. Extending the earlier findings for emotions presented visually, both the SMD and
NP-╉BD groups were found to perform more poorly than a healthy comparison group in identify-
ing the emotion in others’ speech.
Neural findings
Brotman and colleagues (2010) used an fMRI paradigm to investigate functional activity of the
amygdala to facial expressions in youth with SMD, NP-╉BD, ADHD, and no history of disorder. On
each trial participants used a rating scale to respond to one of four questions about the face being
presented. Importantly, some responses engaged attention to its emotional aspects (e.g., “How
afraid are you of this face?”) while other responses engaged attention to its non-╉emotional aspects
(e.g., “How wide is the nose?”). Behaviorally, participants with both SMD and NP-╉BD reported
being more afraid of the neutral faces than did ADHD and healthy participants. However, amyg-
dala responses to the neutral faces distinguished SMD and NP-╉BD. Specifically, participants with
SMD exhibited hyperactivity in the left amygdala when rating the nose width of the faces (i.e., dur-
ing implicit emotional processing), but hypoactivity in the left amygdala when rating their fear of
the faces (i.e., during explicit emotional processing). This response pattern was not shown in the
NP-╉BD, ADHD, or healthy comparison group. The amygdala is critical to detecting the emotional
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salience of environmental stimuli, particularly in terms of threat value (Davis, 1992). Thus, in
direct contrast to the findings for SMD, greater amygdala activity is normative when attending to
the emotional versus non-emotional aspects of a stimulus. Similarly aberrant findings of amyg-
dala hypoactivity to face emotion have been reported in children diagnosed with MDD (Beesdo
et al., 2009; Thomas et al., 2001), which is intriguing in light of the reviewed cross-sectional and
longitudinal associations between SMD/DMDD and unipolar depression (Brotman et al., 2006;
Copeland et al., 2013; Dougherty et al., 2014; Savage et al., 2015; Stringaris et al., 2009).
The brain-based assessment of face emotion processing in SMD was recently advanced through
three programmatic studies by Thomas and colleagues (2012, 2013, 2014), all of which included
participants diagnosed with SMD, NP-BD, and no history of disorder. First, Thomas et al. (2012)
examined the modulation of neural activity to faces that varied systematically along intensity
gradients of neutral to angry expressions and neutral to happy expressions; participants processed
faces both implicitly and explicitly in this task. In response to increasing intensity of anger expres-
sions, typically-developing participants exhibited parametric increases in activity in the amygdala
and posterior cingulate cortex, the latter of which similarly activates to emotional stimuli and
participates in motivation-driven allocation of spatial attention (Mohanty, Gitelman, Small, &
Mesulam, 2008). Both SMD and NP-BD participants, however, failed to modulate amygdala or
posterior cingulate activity in this manner, indicating impoverished neural responsivity to higher
levels of anger intensity. With respect to increasing intensity of happy expressions, SMD partici-
pants exhibited a distinct frontoparietal pattern that entailed low initial activity (i.e., in response
to neutral faces) coupled with increasing activity in several regions that implement attention
(Kanwisher & Wojciulik, 2000), face processing (Kanwisher, 2000), and emotion processing in
a social context (Beer & Ochsner, 2006). Considered with the behavioral deficits in face emo-
tion labeling that typify SMD, increasing frontoparietal activity to happiness intensity may reflect
greater effort required to correctly identify others’ happy expressions.
Thomas et al. (2013) focused on implicit emotional processing of angry, fearful, and neutral
facial expressions, utilizing a common fMRI paradigm in which participants indicated the gender
of each of a series of faces. Across all emotion types, participants with both SMD and NP-BD
exhibited hyperactivity in the right amygdala (i.e., increased activity during implicit emotional
processing); this finding for SMD is notably similar to that in Brotman et al. (2010). In response
to fearful expressions, only participants with SMD showed deactivation in several medial brain
regions that comprise a “default mode network” (Raichle & Snyder, 2007), which, among several
formulated functions, monitors information about one’s internal state. Extrapolating from cur-
rent knowledge of this network, the findings suggest that youth with SMD may not appropriately
monitor interoceptive cues in response to fearful stimuli to facilitate their identification.
Thomas et al. (2014) integrated the assessment of automatic face emotion processing that
occurs outside of one’s conscious awareness. The authors used a backwards masking paradigm in
which, on a portion of trials (“non-aware” trials), facial expressions were presented subliminally.
On other trials the faces were presented quickly but supraliminally, or of sufficient duration for
awareness (“aware” trials). Youth with both SMD and NP-BD exhibited greater activity in occipi-
tal regions during “non-aware” than “aware” trials of all face types, which was the opposite of the
occipital response pattern shown in healthy comparison participants and implicates disruption
in basic ventral visual stream functions (e.g., object recognition) in these two clinical syndromes
(Goodale & Milner, 1992). However, collapsing across “aware” and “non-aware” trials of angry
faces, only youth with SMD showed elevated activity in several regions that support higher-order
face processing and social cognition, including the posterior cingulate cortex, superior temporal
gyrus, and middle occipital gyrus (Allison, Puce, & McCarthy, 2000; Gallagher & Frith, 2003).
Finally, a recent replication study by Tseng and colleagues (2016) compared youth with SMD to
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290 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
healthy comparison participants in the neural correlates of masked and unmasked face emotion
processing. Again, when viewing angry faces, youth with SMD exhibited hyperactivity relative to
comparison youth in several brain regions associated with face and emotion processing, such as
the parahippocampal gyrus and superior temporal gyrus. Hyperreactivity of these structures to
both subliminal and rapid supraliminal anger expressions suggests heightened neural sensitivity
toward anger.
Summary of findings
In sum, SMD is characterized by extensive perturbations in face emotion processing.
Behaviorally, youth with SMD show broad deficits in identifying others’ emotional expressions
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and detecting subtle expressions. NP-╉BD shares these behavioral impairments and evidence for
basic neural dysfunction in the ventral visual stream; however, other neural disruptions appear
unique to SMD. Although the precise findings have varied across studies (and these response
patterns may not generalize to non-╉facial emotional stimuli; see Rich et al., 2007, 2010), an
overall pattern emerges in which youth with SMD seem to miscalibrate neural activity to faces
with respect to the appropriate depth of emotional processing (implicit versus explicit) and
the intensity or salience of emotional expression (neutral versus highly expressive). In addi-
tion, recent findings indicate that irritable youth preferentially process threatening face emo-
tions (Hommer et al., 2014; Stoddard et al., 2016). In the setting of everyday family and social
interactions, such miscalibrations may result in inappropriate responses, such as anger, toward
others.
Evidenced-╉based interventions
State of the literature
Currently, there are no well-╉established, evidence-╉based treatments specifically developed for
SMD or DMDD. However, a number of psychotherapeutic and psychopharmacological interven-
tions have been developed for related clinical syndromes (e.g., disruptive behavior disorders) or
selected symptoms that are common in SMD/╉DMDD (e.g., aggression, noncompliant behavior).
Below, we review these interventions and their evidence base with respect to the clinical symp-
toms or syndromes for which they were tested. Given the independent contributions of chronic,
severe irritability in youth to adverse outcomes, and the dearth of empirically-╉supported treat-
ments, there is a great need for the development of novel therapeutic approaches (Leibenluft,
2011; Stoddard et al., 2016; Waxmonsky et al., 2013). At the end of this section, we highlight
several novel approaches with promising initial findings.
Psychotherapeutic interventions
Numerous psychotherapeutic interventions have been tested for disruptive behavior and conduct
problems (Weisz, Jensen-╉Doss, & Hawley, 2006). Extant approaches fall into two general catego-
ries: Parent management training and cognitive-╉behavioral therapy. These may be delivered as
stand-╉alone treatments or in combination with one another. In this section, we briefly highlight
these interventions. In the final section of the chapter, we describe in greater detail two therapeu-
tic methods that may specifically target emotion dysregulation in SMD/╉DMDD.
292 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
Typically conducted with the parent(s) only, PMT techniques are grounded in parent-╉child
interaction research by Patterson and colleagues (Patterson, 1982; Patterson, DeBaryshe, &
Ramsey, 1989; Patterson, Reid, & Dishion, 1992). This work draws heavily on operant condi-
tioning (i.e., instrumental learning), in which behavior is shown to be shaped by the positive
and negative outcomes that follow it. Specific PMT techniques include instructing parents
in the use of positive reinforcement, selective attention and ignoring, and mild negative con-
sequences (reviewed in Kazdin, 2010; Sukhodolsky et al., 2016). Numerous clinician protocols
are available, including Kazdin’s (2005) 12-╉session and Barkley’s (2013) ten-╉session manuals. In
addition, a number of broader treatment programs for childhood disruptive behavior disorders
have a parent training component (e.g., Incredible Years, Webster-╉Stratton & Reid, 2010; Parent-╉
Child Interaction Therapy, Zisser & Eyberg, 2010; Positive Parenting Program/╉Triple-╉P, Sanders,
1999). A large meta-╉analysis reported that, across numerous treatment packages that entailed
some degree of parent training, factors associated with the largest effect sizes included a focus on
enhancing parental consistency, positive interactions, and affective communication, and the use
of in-╉session practice with the child (Kaminski, Valle, Filene, & Boyle, 2008). Efforts are underway
to adapt PMT to disruptive behavior in the context of other diagnoses, such as autism spectrum
disorders (reviewed in Sukhodolsky et al., 2016).
Cognitive-╉behavioral therapy
In contrast to PMT, cognitive-╉behavioral therapy (CBT) is conducted directly with the child, aim-
ing to help the child learn skills to reduce maladaptive responses to everyday situations (reviewed
in Kazdin, 2010; Sukhodolsky et al., 2016). Several CBT protocols have been developed for
school-╉age children and adolescents with disruptive behavior. Evidence supports these treatments
as “probably efficacious” (Eyberg et al., 2008), consistent with a meta-╉analysis by Sukhodolsky and
colleagues (2004) that reported a medium effect size of these interventions on outcomes.
CBT involves both in-╉session therapeutic techniques and out-╉of-╉session practice by the child,
often with monitoring of practice by the parent. The skills taught in CBT for disruptive behavior
draw on several theories, but most centrally the work of Dodge and colleagues regarding chil-
dren’s social information processing (Crick & Dodge, 1994; Dodge, 1980, 2003). In this frame-
work, cognitive processing of social cues comprises a series of steps: Encoding the cues of others,
interpreting these cues, searching for a response, selecting a response, and engaging in the chosen
response. Dysfunction in one or more of these processes is posited to underlie anger and aggres-
sive responding. Notably, the first two steps of this model (implicating impairments in encoding
and interpreting social cues) align with the findings, reviewed above, for misinterpretation of
social-╉emotional stimuli in SMD/╉DMDD, particularly in terms of heightened sensitivity to threat
cues (Stoddard et al., 2016; Thomas et al., 2014; Tseng et al., 2016). CBT emphasizes more adap-
tive ways to think about, and respond to, social situations that elicit anger and aggression. Specific
CBT protocols, among others, include Kazdin’s (2010) 20-╉to 25-╉session Problem-╉Solving Skills
Training (PSST), Sukhodolsky and Scahill’s (2012) ten-╉session treatment, and Lochman and col-
leagues’ (2010) group-╉based Anger Control Training. In the meta-╉analysis of CBT for disruptive
behavior, clinician techniques associated with the largest effect sizes were training in social skills,
modeling appropriate behaviors, providing direct feedback to the child, and assigning homework
to be done outside of the session (Sukhodolsky et al., 2004).
Psychopharmacological interventions
As described earlier, clinical and pathophysiological research has strongly suggested that SMD
is not a developmental presentation of bipolar disorder. This work has important treatment
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294 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
studies document that assigning verbal labels to emotionally evocative images, versus viewing
those images, serves to decrease activity in the amygdala and increase activity in the right
ventrolateral prefrontal cortex (Lieberman et al., 2007; Tabibnia, Lieberman, & Craske, 2008).
Moreover, clinical analog studies have shown that labeling one’s emotions during exposure to
a feared stimulus reduces physiological arousal relative to a variety of comparison conditions
(Kircanski, Lieberman, & Craske, 2012; Niles, Craske, Lieberman, & Hur, 2015). Given the
emotion dysregulation and aberrant patterns of prefrontal and amygdala activity that char-
acterize SMD and DMDD (Adleman et al., 2011; Brotman et al., 2010; Thomas et al., 2014;
Tseng et al., 2016), it is possible that verbally labeling irritable emotion may be helpful for
these youth. In addition, Feeling Thermometer ratings can be used to measure the success of
other emotion regulation strategies (e.g., cognitive restructuring) to decrease their irritability,
anger, or frustration.
296 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder
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Part III
Emotion Regulation
in Specific Behavior/
Population
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Chapter 15
Definition
Following the publication of this seminal volume, awareness of other forms of abuse such as child
sexual abuse and neglect also increased, along with an increased understanding of the physical,
emotional and behavioral consequences of all forms of abuse. However, it was not until 1999 that
the World Health Organisation Consultation on Child Abuse Prevention gave a definition of child
abuse as, “all forms of physical and/╉or emotional ill-╉treatment, sexual abuse, neglect or negligent
treatment, or commercial or other exploitation of children, resulting in actual or potential harm
to a child’s health, survival, development, or dignity in the context of a relationship of responsibil-
ity, trust or power.”
Forms of child abuse and neglect are generally recognised to fall into four main categories
(Higgins & McCabe, 2001). Firstly, physical abuse which involves hitting, shaking, throwing, poi-
soning, burning or scalding, suffocating, or otherwise causing the child actual physical harm or
creating the potential for harm. The second form is sexual abuse which involves forcing or entic-
ing a child to take part in sexual activities, not necessarily involving a high level of violence,
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irrespective of whether or not the child is cognizant of what is happening to them. The third
from is emotional abuse, which is defined as the persistent emotional maltreatment of a child
and includes the failure of a caregiver to provide an appropriate and supportive environment. It
includes acts that have an adverse effect on the emotional health and development of a child, such
as denigration, ridicule, threats, intimidation, discrimination, rejection and other nonphysical
forms of hostile treatment. The final form is neglect, which has been defined as the persistent
failure to meet a child’s basic physical and/╉or psychological needs and is likely to result in the
serious impairment of the child’s health or development. Neglect may result when a caregiver fails
to provide adequate food, clothing and shelter (including exclusion from the home or abandon-
ment), fails to protect a child from physical and emotional harm or danger, fails to respond to a
child’s basic emotional needs, does not provide adequate supervision, or does not ensure access to
appropriate medical care or treatment.
Prevalence
Child maltreatment is complex and difficult to study, consequently current estimates of preva-
lence can vary widely depending on a variety of factors such as differing legal and cultural defi-
nitions of child maltreatment used between countries; the type of child maltreatment studied;
the population studied and how the sample was recruited; the methods of research used; the
breadth and quality of official statistics and the extent of mandatory reporting; the breadth and
quality of population-╉based self-╉report surveys collected from victims, parents or caregivers
(Finklehor, 1994).
Prevalence estimates of abuse and neglect in the child population vary considerably depending
on the country of study. For example, in a review of international studies, Radford et al. (2011)
showed prevalence rates for different forms of abuse ranging from 1.8% to 34% for physical vio-
lence; 1.1% to 32% for sexual abuse; 5.4% to 37.5% for emotional abuse; and 6% to 41.5% for
neglect. Prevalence rates can also vary depending on the age of the population studied. In the UK,
a National Society for the Prevention of Cruelty to Children (NSPCC) prevalence study found
that 2.5% of children under 11 years of age and 6% of 11 to 17 year olds had experienced mal-
treatment by a parent or caregiver in the past year. For lifetime rates, it was found that one in 17
(5.9%) children under 11 years and one in five 11–╉17 year olds (18.6%) had experienced severe
maltreatment during childhood.
A further issue is that abuse and neglect are often hidden from view and therefore large numbers
of cases are not detected, reported or recorded, even where mandatory reporting exists (Theodore
& Runyan, 1999). Consequently, official statistics often reveal little about the true rates of child
abuse. There are currently over 50,000 children identified that are in need of protection from
abuse in the UK, yet the NSPCC estimates that for every child identified as needing protection
from abuse, another eight may be suffering abuse (Harker et al., 2013). In part this may be because
children do not disclose what is happening to them out of fear of the repercussions or due to fear
that they will not be believed. In addition, some victims may be too young to realise that what is
happening to them is wrong, or abuse may not be officially reported even if other family members
or adults know about it. Moreover, in many countries, there are no legal or social systems with
specific responsibility for recording, or responding to, reports of child abuse and neglect (Bross,
Miyoshi, Miyoshi, & Krugman, 2000).
Therefore, prevalence rate estimates gathered through research studies and official statistics in
particular, may often only represent the “tip of the iceberg” in terms of the extent of child abuse
and neglect. However, such data are useful to gain a picture of the general patterns of abuse and
have shown a global trend that has significant, deleterious consequences for public health (Krug
et al., 2002).
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Assessment
Early detection and intervention of abuse is important in limiting the damage done to the devel-
opment of the child. When early intervention does not occur, approximately one in three children
will suffer continued abuse (Seifert et al., 2010). Child abuse and neglect is rarely detected or
prevented before hospitalisation, most likely due to limited contact with non-╉family members and
because violent incidents often occur within or around the family, in “a circle of trust” (Finkelhor,
1994). It is estimated that 2% to 10% of children who visit hospital emergency departments are
victims of child abuse and neglect (Holt, Buckley, & Whelan, 2008; Hussey, Chang, & Kotch,
2006; Palazzi, de Girolamo, & Liverani, 2005). Therefore, hospital staff may be the first contact
and opportunity for physical abuse to be identified. However, recognising maltreated children
in the everyday routine of an emergency department is a major challenge and detection rates of
child abuse remain low, often going undetected by both clinical and nursing staff (Gilbert, Kemp,
et al., 2009; Louwers et al., 2012; Oral, Blum, & Johnson, 2003). This is influenced by factors
such as knowledge, training, attitude and the experience of health care professionals, and avail-
able resources for referral to name a few (Flaherty et al., 2008; Fraser, Mathews, Walsh, Chen, &
Dunne, 2010; Jones et al., 2008).
Due to limitations associated with identifying abuse at emergency departments, other screen-
ing assessments attempt to facilitate the detection of abuse before hospitalisation. For example, the
“Tool for identifying families at risk of or with already established infant and toddler abuse and
neglect problems” (INTOVIAN Tool), is a five-╉item checklist addressing risk indicators for physi-
cal and/╉or psychological violence, neglect, and disordered/╉abusive relationship patterns between
the child and caregiver. This tool aims to prevent violence, or to break the cycle of violence in the
family before children suffer more severe maltreatment. The tool can be used by professionals as
part of routine observations in children’s centers and nurseries, or by medical staff during routine
health examinations. Staff who have been trained in education and who work in nurseries and
children’s centers will likely be in a better position to detect signs of neglect, because it is more
long-╉term; whereas, staff in health and social services will be better placed to identify child abuse
(Essau, 2015). Professionals can use the aforementioned tool to assess the quality of the caregiver
and child interaction; levels of affection shown; and the psychological involvement of both the
caregiver and child, in order to uncover any potential issues regarding the caregiver-╉child rela-
tionship, which may be indicative of maltreatment.
Child factors
A number of child characteristics have been associated with greater likelihood of being abused
or neglected, which include age; being perceived as problematic; or having a disability or ill-
ness. In terms of age, the risk of maltreatment is greater for children under four years of age
or during adolescence. Fatal cases of physical abuse are more common among young infants
(Damashek, Nelson, & Bonner, 2013; Klevens & Leeb, 2010), who are particularly vulnerable due
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to their dependency, small size, and inability to defend themselves. In contrast, rates of sexual
abuse tend to rise after the onset of puberty, with the highest rates occurring during adolescence
(Finklehor, 1994).
Caregivers who perceive their children as having more problem behaviors are more likely to
physically abuse them (During & McMahon, 1991; Whipple & Webster-╉Stratton, 1991). In addi-
tion, difficult child temperament (as perceived by the parent) has been specifically associated with
emotional neglect (Harrington, Black, Starr, & Dubowitz, 1998). Such behavior and perceptions
may strain the parent-╉child relationship, increasing the risk of maltreatment.
Finally, it has been documented that children with disabilities are 1.8 times more likely to be
neglected, 1.6 times more likely to be physically abused, and 2.2 times more likely to be sexually
abused than are children without disabilities (Sullivan & Cork, 1996). It may be that due to the
demands of raising a child with a disability caregivers become overwhelmed and respond with
irritability, inconsistency, or punitive discipline. Furthermore, disabled children may be unre-
sponsive or have limited ability to interact with, or show affection to their caregivers, which conse-
quently may interfere with attachment and bonding (Hibbard & Desch, 2007). Compounding the
issue further, children with disabilities may be less able to protect themselves and are also highly
dependent on adults for their safety and well-╉being, meaning they may be particularly vulnerable
to abuse or neglect.
In relation to stress, it is believed that stress resulting from job changes, loss of income, health
problems or other stressors can exacerbate characteristics in the family, such as hostility, anxi-
ety, or depression, which in turn might increase levels of family conflict and child maltreatment
(Goldman, Salus, Wolcott, & Kennedy, 2003). Indeed, abusive parents reported more stressful
life events (Coohey & Braun, 1997) and scored higher on perceived daily stress (Williamson,
Borduin, & Howe, 1991), compared to non-abusive parents. Physically abusive mothers also per-
ceive themselves as using more inefficient coping strategies when faced with stress (Cantos, Neale,
O’Leary, & Gaines, 1997). While families who are coping with such problems may also lack the
time or emotional capacity to provide for the basic needs of their children, resulting in neglect
(DePanfilis, 2006).
Social support can also play a role in the occurrence of child abuse. Abusive mothers report
receiving less social support, compared to non-abusive mothers (Chan, 1994) and the support
that is received, seems to be weaker with abusive mothers reporting they receive less emotional
resources (e.g., listening, decision-making, companionship) from their social networks (Coohey &
Braun, 1997). A lack of social support may mean parents or caregivers have less of a support net-
work to act as alternative caregivers, or to provide additional support to the caregiver or the child.
A further contributing factor is failure to bond with and nurture the child. Abusive parents
show greater irritation and annoyance in response to their children’s moods and behavior and
have been shown to be more controlling and hostile, and less supportive, affectionate, playful and
responsive to their children (Bardi & Borgognini-Tarli, 2001; National Research Council, 1993).
Furthermore, abusive mothers have greater negative expectations of their children (Larrance &
Twentyman, 1983) and are less likely to blame themselves for failed mother–child interactions,
and give less credit to their children for successful mother–child interactions than other mothers
(Bradley & Peters, 1991). Such characteristics can impact upon the successful formation of the
parent-child relationship and thus, increase the risk for abuse.
The caregivers’ own childhood can also serve as a risk factor, specifically if they have been mal-
treated themselves as a child. Research has shown that abusive mothers are more likely to report
having been physically victimized as children by their parents (Coohey & Braun, 1997) and expe-
riencing corporal punishment as a teen has also been shown to be a significant predictor of per-
petrating severe child abuse (Ross, 1996). Additionally, neglectful mothers are three times more
likely to have been abused in childhood than mothers who did not neglect their children (Zuravin
& DiBlasio, 1996). This can be explained by social learning theory, which suggests that children’s
behavior is largely shaped by their parents via modelling and schedules of reinforcement such that
exposure to abusive and maltreating parents during their own childhood encourages the caregiver
to believe such behaviors are acceptable and effective, leading them to incorporate these into their
own parenting styles as adults (Dodge, Bates, & Pettit, 1990).
Substance abuse can also be a contributing factor. Research has demonstrated that physically
abusive mothers are more likely to have a history of drug problems (Whipple & Webster-Stratton,
1991) and, children whose parents abused alcohol and other drugs are more than four times more
likely to be neglected than children whose parents did not (Jaudes, Ekwo, & Van Voorhis, 1995).
Such substance abuse may limit the ability of the caregiver to provide adequate care for their
children or to make appropriate decisions regarding their welfare (Slack et al., 2011), particularly
when intoxicated, with one study reporting that 65% of maltreated children who had parents with
substance abuse problems were maltreated while the parent was intoxicated (Donohue, 2004).
Experiencing financial difficulties in the family has also been found to be a strong predictor of
child neglect (Slack et al., 2011), with a lack of familial financial resources having serious negative
consequences on the ability of the caregiver to meet even the most basic needs of their child. For
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example, poverty can affect the ability of the caregiver to provide adequate supervision (e.g., can-
not afford child care), housing, nutrition, medical care, clothing, and safety.
Finally, family breakdown and conflict can be a further contributing factor. Straus and Gelles
(1990) found that parents with higher rates of inter-╉parental verbal aggression were more likely
to perpetrate severe child abuse. Additionally, physically abused adolescents are more likely to
come from families experiencing high levels of family stress, and these adolescents perceived their
families as being less adaptive and cohesive (Williamson et al., 1991). Family life with such stress
and conflict may be so disorganized and hostile that caregivers are unable to meet the basic needs
of their children on a consistent basis (Hornor, 2014).
Community factors
A number of community characteristics may increase the risk of child maltreatment. These factors
include poverty; community disorganisation; and poor social cohesion. In relation to poverty, this
has been shown to adversely affect children through its impact on parental behavior and the avail-
ability of community resources (McLoyd, 1990). Communities with high levels of poverty tend
to have weaker physical and social infrastructures and fewer resources and amenities in place to
prevent and detect child abuse, such as accessible health care, social services, and affordable child
care, which can reduce the ability of caregivers to appropriately care for their children (Corcoran
& Nichols-╉Casebolt, 2004). Community disorganization can be a further risk factor. Rates of child
abuse and neglect are higher in communities characterized by high levels of unemployment, high
population turnover and high availability of alcohol and drugs (DePanfilis, 2002; Gillham et al.,
1998). Finally, children living in communities that lack social cohesion and solidarity have been
found to be at greater risk of abuse (Runyan et al., 1998), due to the lack of positive informal and
formal support systems for families (Cash & Wilke, 2003).
Societal factors
A range of society level factors are considered to have important influences on child maltreat-
ment. Many of these broader cultural and social factors can influence how caregivers treat their
children. These include factors such as the presence of policies and programs to prevent child
abuse and neglect, and the responsiveness of the criminal justice system. In addition, cultural
norms and the cultural definitions of generally accepted child-╉rearing principles, may contribute
to this issue. Specifically, social and cultural norms that promote or tolerate violence towards oth-
ers and support the use of corporal punishment or certain cultural practices that may be viewed
as abusive or neglectful to the larger society (e.g. genital mutilation). Moreover, social, economic,
health and education policies that lead to poor living standards, or to socioeconomic instability,
may also be a contributing factor to child abuse.
Outcomes
The consequences of child abuse and neglect can vary widely. Physical injuries and, in extreme
cases, death are direct consequences; however, there are also a variety of psychological and behav-
ioral outcomes. Various aspects of the maltreatment situation, such as duration, type and sever-
ity of abuse, can directly impact the development of negative outcomes (Manly, Cicchetti, &
Barnett, 1994).
Chronically maltreated children appear to be at a high-╉risk of developing clinical levels of
psychological problems (Ethier, Lemelin, & Lacharité, 2004). Research has shown that there
is a particularly strong association between childhood abuse and mood and anxiety disorders,
including depression, bipolar disorder, generalized anxiety disorder, panic disorder, phobias, and
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posttraumatic stress disorder (PTSD) (Gilbert, Widom, et al., 2009; Heim & Nemeroff, 2001; Hill,
2003; Katerndahl, Burge, & Kellogg, 2005; Kendler et al., 2000; Molnar, Buka, & Kessler, 2001). In
addition, traumatic experiences early in life are associated with other psychological conditions,
such as schizophrenia, reactive attachment disorder, eating disorders, and personality disorders
(Ackard & Neumark-╉Sztainer, 2003; Kaplan & Klinetob, 2000; Noll, Horowitz, Bonanno, Trickett,
& Putnam, 2003; Zeanah et al., 2004).
Heim, Shugart, Craighead, and Nemeroff (2010) conducted a meta-╉analysis of 124 studies
that investigated the relationship between child physical abuse, emotional abuse, or neglect and
various health outcomes. It was found that emotionally abused children were three times more
likely to develop depression than non-╉abused individuals. Physically abused and neglected chil-
dren also had a higher risk of developing a depressive disorder. Cicchetti and Rogosch (1997)
examined the level of adaptation of school-╉aged maltreated children who were evaluated over
a three-╉year period. Over this period, the maltreated children exhibited more externalising and
internalising behavior problems, less prosocial behavior, greater symptoms of depression, and
more withdrawn behavior than the non-╉maltreated children. This study confirms continuity in
the difficulties experienced by abused children. In addition, research has shown children who
experience maltreatment are also at increased risk for substance misuse, engagement in high-╉risk
sexual behaviors, delinquency and poor academic performance (Dubowitz, 2009; Felitti et al.,
1998; Lansford et al., 2007).
As well as causing immediate harm and later childhood impairment, abuse and neglect can
have many long-╉term consequences that endure well into adulthood. A longitudinal study
revealed that as many as 80% of young adults who had been abused as a child met the diag-
nostic criteria for at least one psychiatric disorder at age 21 (Silverman, Reinherz, & Giaconia,
1996). Adult psychological difficulties most frequently associated with child abuse include
depression, anxiety, PTSD, low self-╉esteem, poor adjustment, criminal behavior, risky sexual
behavior and substance misuse (Afifi et al., 2008; Fergusson, Boden, & Horwood, 2008; Huang
et al., 2011; Widom, Marmorstein, & White, 2006; Wilson & Widom, 2011). Moreover, chil-
dren who experience maltreatment are also at increased risk for adverse health effects and
certain chronic diseases as adults, including heart disease, cancer, chronic lung disease, liver
disease, obesity, high blood pressure and high cholesterol (Danese et al., 2009; Felitti et al.,
1998; Springer, Sheridan, Kuo, & Carnes, 2007). A further long-╉term consequence of maltreat-
ment is the heightened likelihood of abusing or neglecting one’s own children (Thornberry &
Henry, 2013), which, therefore, contributes to the establishment of an intergenerational cycle
of neglect and abuse.
Emotion regulation
Emotion regulation is generally defined as the internal and external processes by which the indi-
vidual manages the occurrence, intensity, and expression of emotions to reach goals or situational
demands (Cicchetti & Howes, 1991; Eisenberg & Morris, 2002; Thompson, 1994). The childhood
years are thought to be a critical period for the development of emotion regulation skills, and suf-
fering abuse and neglect during this time can interfere with the acquisition of these skills (Shields
& Cicchetti, 1998). Maltreated children can experience conflicting feelings and impulses arising
from being neglected and/╉or harmed by an adult who is often also an attachment figure. Abusive
and neglectful caregivers also likely fail to engage in behaviors that enable children to develop
optimal emotion regulation strategies. Consequently, maltreated children often exhibit a range of
emotion regulation deficits, with nearly 80% of maltreated children displaying dysregulated emo-
tion patterns, compared with only 36% of non-╉maltreated children (Maughan & Cicchetti, 2002).
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In the next section, we discuss how abuse and neglect can lead to the development of emotion
regulation problems, how these problems manifest in abused children and how these problems
can heighten the. risk of continued abuse and exacerbate negative outcomes and psychopathology.
Neurobiology
It is probable that the emotional difficulties displayed by maltreated children are not only a reflec-
tion of caregiver influence, but also affected by changes in neurobiological structure and function-
ing that occur as a result of abuse or neglect (Cicchetti & Tucker, 1994). These changes can reduce
a child’s capacity to regulate affective states and modulate behavioral responses to stressors, and
thus, may influence emotion regulation processes.
Maltreatment in childhood appears to be associated with the reorganisation of neural circuits in
ways that alter the processing of emotional information, which may underlie the emotion regula-
tion deficits reported in maltreated children (Pollak, 2008). For instance, youth with histories of
early-╉life abuse and trauma display greater amygdala activity to threatening cues and emotional
conflict, showing a hypervigilance to threat stimuli and reduced ability to regulate emotional
processing (Marusak, Martin, Etkin, & Thomason, 2015; McCrory et al., 2011). Engagement of
the amygdala is thought to support preferential processing to emotional stimuli (Vuilleumier,
Armony, Driver, & Dolan, 2001), in order to allow potential threats to be rapidly detected and
evaluated (LeDoux, 1996). Thus, the alterations in the neural systems of abused children alter
how they monitor the environment for threatening information. Pollak, Klorman, Thatcher, and
Cicchetti (2001) found that the event-╉related potential amplitude responses of maltreated chil-
dren exceeded those of non-╉maltreated children in response to angry facial expressions, but not to
fearful or happy expressions, reflecting a response bias for angry stimuli. These results suggest that
the abusive experiences encountered by these children during their development may enhance
the memory of salient stimuli, due to the stored mental representations that have been associated
with that stimulus over time. As such, maltreated children are particularly sensitive to, and quick
to detect, anger, as they develop an association between this emotion and abusive behavior from
their caregiver.
Furthermore, there is substantial evidence that amygdala reactivity is under inhibitory control
of medial prefrontal regions (Ochsner & Gross, 2005), particularly Pregenual anterior cingulate
cortex (pgACC) (Maier & di Pellegrino, 2012). Marusak et al. (2015) found an absence of nega-
tive regulation-╉related amygdala–╉pgACC connectivity in maltreated youth, indicating an absence
of effective inhibitory control. Maltreated children have also been found to exhibit dysregulation
of the hypothalamic-╉pituitary-╉adrenal axis following social interactions, signifying the impaired
ability to cope with stressors and negative emotions (Tarullo & Gunnar, 2006).
Collectively, these neurobiological findings imply abuse and neglect is associated with a simul-
taneous heightened sensitivity to conflicting emotional information and a lack of regulatory
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control over emotion processing. Thus, the combination of these factors is likely to limit the abil-
ity of the maltreated child to master appropriate emotional skills.
Additionally, different forms of neglect and abuse have been associated with differential expres-
sions of poor emotion regulation. For example, Pollak, Cicchetti, Hornung, and Reed (2000)
reported that neglected children, who often suffer from an extremely limited emotional envi-
ronment, had more difficulty in identifying and distinguishing between emotions, compared to
physically abused or non-╉maltreated children. Furthermore, a history of neglect has been found
to relate more strongly to a bias toward sad facial expressions; whereas, physical abuse has been
linked to a response bias to angry stimuli and a greater hostile attribution bias in ambiguous social
situations (Pollak et al., 2000, 2005; Pollak & Sinha, 2002; Shackman, Shackman, & Pollak, 2007).
This suggests physically abused children feel an exaggerated need to defend themselves from
perceived threats, which is reflected in their emotional processing (Dodge et al., 1990; Rieder
& Cicchetti, 1989). Pollak et al. (2005) suggested that in physically abusive home environments
children learn to associate anger with threat of harm and therefore, become better prepared at
identifying threats. In contrast, neglect is typically associated with an emotionally impoverished
environment, with few opportunities for meaningful social interactions. If children are deprived
of interactive emotional experiences with others, their capacity to tolerate intense emotional
states may be underdeveloped, which can manifest in problems discriminating between emotions.
When examining additional types of maltreatment, childhood sexual abuse has been associated
with lower impulse control, whereas emotional abuse has been linked to impulsivity and problems
with behaving in accordance with desired goals (Oshri, Sutton, Clay-╉Warner, & Miller, 2015).
In summary, emotion regulation deficits manifest in various ways, including difficulties in iden-
tifying, understanding, expressing and regulating emotions, and can be dependent on the devel-
opmental stage of the child and the type of abuse experienced.
Psychopathology
As noted above, child abuse and neglect have been associated with internalising disorders includ-
ing anxiety, depression, and PTSD (Cannon, Bonomi, Anderson, Rivara, & Thompson, 2010;
Gilbert, Widom, et al., 2009; Kaufman, Plotsky, Nemeroff, & Charney, 2000; Springer et al.,
2007), along with greater externalising problems, such as aggressive behavior and psychopathy
(Bernstein & Watson, 1997; Kolla et al., 2013; Lang, Klinteberg, & Alm, 2002; Weiler & Widom,
1996). Evidence has also indicated that many such outcomes associated with childhood abuse are
characterized by deficits in the processing and regulation of emotion (Burns, Jackson, & Harding,
2010; Etkin & Wager, 2007). Thus, child maltreatment may be linked with negative outcomes via
ineffective emotion regulation strategies, which may lead to a domino effect of deficits, resulting in
maladaptive functioning during childhood (Eberhart, Auerbach, Bigda-╉Peyton, & Abela, 2011).
Internalising problems, which can result from child abuse, have been linked with emotional
processing and regulation deficits. For example, enhanced anxiety symptoms are associated
with poorer emotional awareness and perception (Bradley, Mogg, White, Groom, & Bono,
1999; Eisenberg et al., 2001) and deficits in the regulation of emotions (Suveg, Morelen, Brewer,
& Thomassin, 2010; Suveg & Zeman, 2004). In addition, PTSD has also been associated with a
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lack of emotional clarity and acceptance, difficulty engaging in goal-directed behavior when dis-
tressed, and an attentional bias towards trauma related stimuli (Buckley, Blanchard, & Trammell
Neill, 2000; Cloitre, Miranda, Stovall-McClough, & Han, 2005; Tull, Barrett, McMillan, & Roemer,
2007). Similarly, depression is also characterized by deficits in regulating emotions (Joormann,
Siemer, & Gotlib, 2007), perceiving emotion in others (Stuhrmann, Suslow, & Dannlowski, 2011),
the inability to support oneself when experiencing negative emotions (Berking et al., 2011) and to
modify negative emotions (Ehring, Fischer, Schnülle, Bösterling, & Tuschen-Caffier, 2008; Kassel,
Bornovalova, & Mehta, 2007). Finally, substance misuse is widely theorized as an effort to regulate
or avoid negative emotions (Baker, Piper, McCarthy, Majeskie, & Fiore, 2004; Wupperman et al.,
2012). For example, negative affect has been shown to predict increases in desire to drink and
drinking levels in individuals treated for alcohol dependence (Birch et al., 2004; Falk, Yi, & Hilton,
2008; Gamble et al., 2010; Sinha et al., 2009) and deficits in emotion regulation skills have been
shown to predict relapse during and after cognitive–behavioral therapy for dependence (Berking
et al., 2011).
A number of studies have also reported emotional deficits in individuals with externalising
symptoms (Blair, Peschardt, Budhani, Mitchell, & Pine, 2006; Eisenberg et al., 2001; Hill, Degnan,
Calkins, & Keane, 2006), including deficits in empathy (Blair, 1995), experiencing emotion (Blair
et al., 2006; Frick, Lilienfeld, Ellis, Loney, & Silverthorn, 1999), and identifying emotional expres-
sions (Blair et al., 2004; Iria & Barbosa, 2009; Pham & Philippot, 2010). For example, antiso-
cial behavior has been linked with deficits in perceiving negative emotions in facial expressions
and an inability to distinguish between emotions (Blair, Colledge, Murray, & Mitchell, 2001).
Additionally, psychopathic traits reflect greater emotional desensitisation, and an inability to
empathize or respond to the emotional needs of others (Weiler & Widom, 1996).
The emotion regulation problems that characterize children of abuse and these disorders seem
to be important for understanding linkages between maltreatment and maladjustment. The
emotion-based deficits resulting from the abusive behavior of a caregiver and neurobiological
changes related to abuse, may in turn influence the development and maintenance of maladap-
tive psychological and behavioral outcomes (Dodge, 1991). This is supported by Kim-Spoon,
Cicchetti, and Rogosch (2013) who showed that poor emotion regulation predicted a subsequent
increase in internalising symptomatology. Early maltreatment was associated with high emotion
lability at age seven, which contributed to poor emotion regulation at age eight, which in turn was
predictive of increases in internalising symptomatology, from age eight to nine.
In addition, numerous studies have established that the relationship between childhood abuse
and various psychological symptoms is mediated by impairments in emotion regulation (Choi
et al., 2014; Schwartz & Proctor, 2000; Shields & Cicchetti, 2001). For example, in women with
a history of childhood abuse, emotion regulation difficulties mediated the relationship between
abuse and current post-traumatic symptomology (PTS) (Burns et al., 2010; Choi & Oh, 2014;
Stevens et al., 2013). Further to this, the relationship between specific dimensions of emotion
regulation and PTS was investigated among undergraduates with a history of trauma exposure
during childhood (Tull et al., 2007). After controlling for negative affect, three dimensions of
emotion regulation—difficulties in impulse-control, diminished access to effective emotion regu-
lation strategies, and a lack of emotional clarity—remained significant predictors of PTS symp-
tom severity. These findings provide support for the notion that difficulties in emotion regulation
could indirectly influence the maintenance of trauma symptoms. Specifically, abused or neglected
children were more likely to experience difficulties in emotion regulation, which then served to
exacerbate trauma symptoms. In turn, increased PTS resulted in increased physiological arousal,
maintaining the cycle of dysregulation, as increased arousal is harder to regulate (Tull et al., 2007).
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Interpersonal problems
Emotion regulation also appears to be important for understanding linkages between abuse and
neglect and subsequent problems forming relationships. Maltreated children are at greater risk of
unpopularity among their peers (Anthonysamy & Zimmer-╉Gembeck, 2007; Bolger, Patterson, &
Kupersmidt, 1998; Rogosch, Cicchetti, & Aber, 1995), and are more likely to be rejected by peers,
not only on a single occasion, but also across multiple years from second through seventh grade
(Bolger & Patterson, 2001). Evidence has indicated that children’s deficits in emotional under-
standing mediated the link between earlier abuse and later interpersonal functioning and rejec-
tion by peers (Briere & Rickards, 2007; Cloitre et al., 2005; Rogosch, Cicchetti, & Aber, 1995).
Shipman et al. (2005) found neglected children used avoidance strategies when responding
to other’s emotion distress. Such strategies reflect an emphasis on self-╉reliance when handling
emotional distress, as opposed to seeking help and support. For example, when asked how they
would respond to negative emotional displays in others, neglected children frequently indicated
that they would ignore or remove themselves from the situation. In contrast, non-╉maltreated
children generally indicated that they would provide the other child with assistance or support.
These avoidance strategies utilized by neglected children may hinder their ability to form and
maintain positive interpersonal relationships and have profoundly negative consequences for self-╉
regulation, which could add to the continuation of their abuse in contexts outside the home. This
is consistent with research, which demonstrates that emotional understanding is related to peer
acceptance (Cassidy & Parke, 1991; Denham et al., 1990; Underwood, 1997).
Children who have difficulty managing their negative emotions are more likely to become dis-
ruptive, impulsive and reactively aggressive in social interactions, leading to lower acceptance and
more rejection by peers (Maszk, Eisenberg, & Guthrie, 1999). Peer rejection can then place abused
children at risk of subsequent adjustment problems, including internalising and externalising dis-
orders (Kupersmidt & Coie, 1990; Ladd & Troop-╉Gordon, 2003). Kim and Cicchetti (2010) found
support for this mechanism. In this study early experiences of abuse and neglect were related
to emotion dysregulation, which placed these children at a greater risk of peer rejection, which
then contributed to internalising and externalising symptomology one year later, after controlling
for initial symptomology. Kim and Cicchetti (2010) argued that in the absence of positive peer
interactions and relationships, abused children may become more vulnerable to stress, which can
manifest as internalising or externalising disorders. Maladaptive emotion regulation, therefore,
may impede children’s abilities to establish positive peer relationships due to an underdevelop-
ment of certain traits, such as perspective-╉taking and empathy, which are vital to the development
of social competence.
decreased self-╉awareness may help neglected children cope with a home environment which fails
to support emotional expressiveness.
Maltreated children’s hypervigilance to potential threats and overregulation of distress responses
may also assist in reducing rates of abuse. For children who have experienced abuse, displays of
anger in their environment are the strongest predictors of threat and therefore a selective attention
to threat-╉related (i.e., angry) stimuli at the expense of attention to other emotional cues would
be adaptive, as children are quickly able to detect signs of anger and remove themselves from a
potentially dangerous situation (Pollak et al., 2005). Additionally, managing the intense emotions
arising from physical abuse may also include cognitive strategies that enable the child to maintain
a sense of control over their circumstances.
However, although emotional withdrawal and hypervigilance during conflict can result in
short-╉term relief for the abused child, it may also heighten the long-╉term risk of future abuse both
in the home and in other contexts. Thus, immediate goals may conflict with longer-╉term goals
and the emotional strategies developed may be unsuccessful at accomplishing both, leaving the
child vulnerable to further risks. In settings outside the home, these deviant strategies of emotion
regulation may simultaneously create other problems, such as social difficulties and poor peer
relations (Cicchetti & Schneider-╉Rosen, 1986). Ultimately, Thompson and Calkins (1996) suggest
that although children may adapt by trying to cope with the emotional demands of abuse and
neglect, there are likely to be no optimal approaches to emotion regulation available to them and
efforts are likely to result in a problematic mixture of adaptive and maladaptive outcomes.
In summary, emotion regulation strategies developed in the context of abusive homes may
serve specific protective functions, while concurrently resulting in maladaptive outcomes, with
evidence suggesting these emotional deficits play a role in the development and maintenance of
psychopathology and interpersonal difficulties. In turn, such problems can make a child more
vulnerable to future abuse and victimisation both in and outside the home.
Implications for intervention
The body of research on emotion regulation and child abuse and neglect has important implica-
tions for the development and utilisation of intervention programs targeted at abusive caregiv-
ers and their children. Difficulties with emotion regulation have become an important target of
clinical interventions in maltreated children (Cloitre, Koenen, Cohen, & Han, 2002) and many
approaches to individual psychotherapy with victims of abuse focus on improving emotion regu-
lation skills (Leahy, Tirch, & Napolitano, 2011; Paivio & Laurent, 2001). These skills play a vital
role in attaining successful social interactions and psychological adjustment and, therefore, may
be a source of resiliency related to maltreatment and psychopathology (Chang, Schwartz, Dodge,
& McBride-╉Chang, 2003; Shields et al., 1994). If intervention programs can help abused children
to develop such resiliency this may reduce the emotional, psychological and social problems asso-
ciated with neglect and abuse.
Several empirically supported group treatments emphasize building emotion regulation and
interpersonal skills in the aftermath of abuse; these include Dialectical Behavior Therapy (Robins,
Schmidt, & Linehan, 2004), Seeking Safety (Najavits, 2002), Trauma Adaptive Recovery Group
Education and Therapy, (Ford & Russo, 2006), and Skills Training in Affect and Interpersonal
Regulation (STAIR)/╉Prolonged Exposure (Cloitre et al., 2002). STAIR is a cognitive–╉behavioral
treatment that targets the development of emotion management and interpersonal skills. Each
session focuses on a different deficit understood within the context of the experience of child
abuse: 1) labelling and identifying emotions, 2) managing emotions, 3) distress tolerance,
4) acceptance of emotions and enhanced experiencing of positive emotions, 5) identification of
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Conclusion 319
trauma based interpersonal schemas and their enactment in day-╉to-╉day life, 6) identification of
conflict between trauma-╉generated feelings and current interpersonal goals, 7) role plays related
to issues of power and control, and 8) role plays highlighting the presence and expression of
emotion, related to developing flexibility in interpersonal situations involving power differentials.
This program was found to be valuable for the emotional development of women with a history
of child abuse, who showed significant reductions in negative mood regulation, anger expression
and interpersonal skills deficits, when compared to those on the wait-╉list (Cloitre et al., 2002).
However, an unmet need remains for the more extensive use of emotion regulation skills train-
ing in the context of child abuse and neglect (Hernandez, Nesman, Mowery, Acevedo-╉Polakovich,
& Callejas, 2009). In particular, policies and programs that focus on parenting behaviors are likely
to be beneficial. A large body of research suggests caregiver behavior can have a positive influ-
ence on children’s emotional development. Morris et al. (2011) examined specific parenting prac-
tices associated with children’s emotion management, assessing whether particular practices were
linked to successful emotion management. Findings indicated that certain practices were more
effective at improving children’s emotion regulation. Specifically, redirecting attention away from,
and cognitively reframing emotions with the child, were the most effective strategies used by
mothers to help children manage the expression of negative emotions, and were associated with
less expressed anger and sadness. Further parenting practices which have been linked to improved
emotion regulation skills include directing positive emotion and behaviors toward children, help-
ing children to label and discuss emotions, soothing children’s reactions through appropriate
physical contact and encouraging activities such as reading or drawing to reduce arousal (Calkins
& Hill, 2007; Eisenberg et al., 2001). Such practices should therefore be utilized in interventions
targeted at abusive caregivers.
Furthermore, school-╉based interventions that focus on promoting social emotional compe-
tence among children have been shown to be effective in fostering emotion regulation develop-
ment. For example, the Promoting Alternative Thinking Strategies (PATHS) curriculum has been
successful in reducing internalising problems among primary school students by teaching them to
identify, understand, and discuss their emotions (Greenberg, Kusche, Cook, & Quamma, 1995).
In the PATHS program improvements were seen in the range of emotion related vocabulary, flu-
ency in discussing emotional experiences, efficacy beliefs regarding the management of emotions,
and the developmental understanding of emotions. Such training could potentially be applied to
equip abused children with the emotional skills they fail to develop in abusive homes.
Conclusion
Through processes of caregiver socialisation and neurobiological changes, child abuse and neglect
can lead to a range of emotional problems during childhood, which can endure into adulthood.
These emotion regulation deficits are manifested throughout development in a variety of ways,
including difficulties in identifying, understanding, expressing and regulating emotions and
hypervigilance. Although the altered emotion regulation strategies developed by abused and
neglected children do have certain adaptive qualities, which allows the child to avoid further
emotional or physical harm by quickly removing themselves from conflict, evidence indicates that
such strategies also lead to a range of maladaptive consequences. Via mechanisms of emotion reg-
ulation, abuse can lead to internalising and externalising problems, and interpersonal problems,
including peer rejection. The presence of such psychological, behavioral and social problems can
result in the maintenance of abuse.
The extensive range of evidence, which indicates how critical emotion regulation problems are
in the relationship between child abuse and negative outcomes, has led to a range of interventions
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which target emotion regulation skill building. There is potential for further usage of such
approaches in interventions to train caregivers in the importance of socialisation to develop adap-
tive emotion regulation strategies in children, and for at-╉risk and abused children to build resil-
ience through improved emotional development.
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Chapter 16
Children of Divorce
Maria Caridad H. Tarroja, Ma. Araceli Balajadia-╉Alcala,
& Maria Aurora Assumpta D. Catipon
Effects of divorce
Parental separation and divorce significantly impacts children’s development. Many books and
articles have been written on the experiences of children whose parents separated and how the
parental separation affected them throughout their development, from childhood into adulthood.
The majority of studies report that compared to children from intact families, children of divorce
are at a higher risk for behavior and adjustment problems which may manifest in different facets
of their lives (e.g., academic performance, self-╉esteem, social relations, expression of emotions,
and psychological wellbeing) (Alubokin & Akyina, 2015; Boring, Velez, Sandler, Tein, & Horan,
2015; Schick, 2002). The terms parental separation and parental divorce are often interchanged,
perhaps because the impact of this event on children’s and families’ lives are similar. Regardless
of the term used, the importance of harmonious relationships between the divorcing/╉separating
couples remains imparative (Lee & Bax, 2000).
Studies on children of divorce show inconsistent results. On one hand, some studies suggest
the after-╉effects of divorce are short-╉term and that adjustment improves over time. On the other
hand, some longitudinal studies show that long-╉term effects on the children are undeniable and
are emphasized to bring attention to the phenomenology of children of divorce so that other
steps to preserve their best interests can be pursued. Likewise, findings from the 25 year study of
Wallerstein and Lewis (2004) demonstrate that the lives of children of divorce are forever changed
or transformed. Thus, divorce is not simply an acute stressor from which a child bounces back
because challenges throughout their life course and the shifting relationships therein, continu-
ously demand a series of adjustments from the child, who needs to deal with the many losses
associated with separation and divorce. Hence, the challenge is to develop interventions that may
enable children of divorce to maintain hope, develop a positive view of relationships, and carry
this perception into succeeding relationships they may have.
This chapter describes children of divorce, its prevalence, experiences, behavior and adjust-
ment issues, and interventions that have been identified in the literature that are helpful given
their needs. In addition, the role of emotion regulation in the manifestation of their psychological
problems and as a protective factor in their adjustment process, is discussed.
Prevalence of divorce
The Social Trends Institute (2012) reported that generally high rates of marriage in Asia and the
Middle East and low rates of cohabitation suggest that marriage is important in the life path
of adults, especially in these regions. However, it has less of a dominant role in Africa, the
Americas, Europe, and Oceania, where cohabitation or non-╉marriage is a common practice. Thus,
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development, especially in adulthood. Schick (2002) also found that significant differences in
levels of social withdrawal, behavior problems and academic difficulties occur between children
coming from intact families and children whose parents had been separated for a maximum of
two-and-a-half years.
However, it is important to note that recent literature has shown that children who enjoy a
joint-custody arrangement are generally better adjusted than those from single-custody homes
(Bauserman, 2002). Thus, when marriage cannot be salvaged joint custody may be a more viable
option, in addition to other critical factors, such as individual difference, the parents maintain-
ing a positive relationship with healthy, transparent communication and ensuring the child has
a sound support network to name a few. Amidst the negative outcomes in children of divorce, it
is worthwhile to reiterate that a few studies indicated psychological problems of these children
existed even before marital separation, and may not be attributable to divorce per se (Furstenberg
& Teitler, 1994). Other findings have suggested that the negative effects of parental separation and
divorce had only a short term impact on children’s well-being that was likely to disappear over
time (Allison & Furstenberg, 1989; Ambert, 1984). Moreover, a 2000 APA overview of the psy-
chological literature on the outcomes of divorce on children showed that the differences between
children of divorce and children from intact families is smaller and less pronounced than often-
times indicated i.e., the majority of children fall within the normal range of standard measures
of adjustment (Amato, 1994). Hetherington and Kelly (2002) concluded that 80% of the children
from divorced homes become reasonably well adjusted and insist that, this event is not a form of
developmental predestination. In sum, these studies (Bauserman, 2002; Schick, 2002) invite us to
re-appraise the individual experience of each child so that the long term impact of divorce, not
just on the individual child, but on society as well, can be attenuated.
Some scholars have examined specific effects of divorce on various intra and interpersonal vari-
ables, a specific area of interest has been academic achievement. Kim (2011) found that children
of divorce, specifically those within the first to third grade levels, showed significant delays in
their math test scores during and after the divorce of their parents. No such setback was seen in
this group in reading test scores when compared with children from intact families. However, a
more recent article has demonstrated that reading test scores and particularly children’s reading
comprehension scores are affected pre-and post-divorce. The problems appear to precede divorce
and even follow it. Specifically, it was seen that reading test scores are most affected in seven to 14
year old children, two to four years prior to the family disruption. For reading comprehension,
negative effects tended to persist and in fact, even intensify with the passage of time (Arkes, 2015).
Whereas, some studies posit that poor academic achievement directly results from the divorce
experience (Alubokin & Akyina, 2015), others qualify, that social class or socio-economic status
plays an important role in the eventual academic outcome of children from divorced families
(Grätz, 2015), as has been pointed out in an earlier section of this chapter. Children belonging to
higher social classes may have more financial resources and social support to overcome academic
problems brought about by the parents’ separation.
Potter (2010) found that elementary school children who experience parental divorce imme-
diately begin performing worse academically than their peers from intact families. According to
Schick (2002), inconsistent academic performance of children of divorce may be brought about
by the consumption of energy required to cope with the loss and re-adjust to their new situation
(Schick, 2002). Gruber (2004) also showed that children exposed to unilateral divorce are less
educated by adulthood.
Another area that can be affected by parents’ separation is social relationships. For example,
in a 25 year follow-up study conducted on a white, middle-class, divorced population from
California, USA, Wallerstein and Lewis (2004) maintained that divorce appears to affect the social
relationships of people at virtually every stage of development, from childhood to adolescence to
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adulthood. Instead of these children overcoming the impact of divorce when they reach adult-
hood, this is the time when they may be impacted significantly as long-hidden emotional prob-
lems stemming from parental divorce may suddenly emerge during young adult life (Wallerstein
& Blakeslee, 1989). According to Wallerstein and Blakeslee (1989) without clear inner images of
stable relationships they may struggle more than adults from intact families, to attain love, sexual
intimacy, and lasting commitment. Thus, 60% of the participants in the 25-year landmark study
had trouble with social relationships. They tended to expect failure in their lives, have a lingering
fear of loss due to childhood fears of abandonment, and experienced strong fear of change. In
addition, they feared betrayal and being alone, which was associated with self-destructive choices
in relationships.
Relationships between the child and their parents were not just affected in the short-term,
but also in the long-term, especially for fathers. De Graaf and Fokkema (2007) found that cus-
tody arrangements during divorce affect subsequent contact of fathers with their adult children.
Bouchard and Doucet (2010) examined the transition into parenthood of adults who were chil-
dren of divorce using the family systems theory. They looked into interaction and dynamics
among family members in explaining how far-fetching the impact of divorce is on relationships
within the family. They determined that in their sample of couples who experienced parental
divorce or separation growing up, and were expecting their first child, the quality of relation-
ship with the father continued to affect their relationship as adults. However, more importantly,
it was found that support coming from the gender-matched parent (women with their mothers,
and men with their fathers) predicted the level of positive adjustment of couples as they went
through this significant life transition. Moreover, it is significant to note that a more recent article
has emerged examining the effect of parental separation/divorce on relationships of children of
divorce in later life. Fergusson, McLeod and Horwood (2014) presented findings from a 30 year
longitudinal study of a birth cohort of over 1000 children in New Zealand, in 1977, stating that
parental divorces/separations alone was not sufficient to account for relationship outcomes of
children coming from these families. Instead, there are a host of different contextual factors that
contribute to this outcome, including parent factors (history of illicit drug use and criminality,
conflict and violence between couples), child abuse (sexual, physical maltreatment), and fam-
ily socioeconomic status at birth of the child. The presence of conduct problems in childhood
(from ages seven to nine) was also one of the covariates mentioned. This latter factor may be
related to challenges that children have in regulating their emotions which may lead to behavioral
difficulties.
Parents who divorce may have fewer resources to effectively maintain the stability of social rela-
tionships that their child sorely needs, as they themselves have trouble maintaining close ties with
their own families of origin. This is known as the “negative divorce effect” which states that adult
children who are divorced have even less frequent contact with their parents compared to their
never-married siblings (Kalmijn, 2014). This puts divorced individuals at risk for disconnection
from extended relatives at a time when they may need the support the most.
Children’s psychological well-being is another facet that may be affected by the parents’ separa-
tion. For example, several researches say that children of divorced parents generally score lower
on indicators or measures of well-being than children from intact families (Amato, 1991; Clarke-
Stewart, Vandell, McCartney, Owen, & Booth, 2000; Kurtz, 1994; Weaver & Schofield, 2014).
Thus, compared to children in intact, two-parent families, children of divorce show more symp-
toms of psychological maladjustment (e.g., exhibiting more conduct problems such as aggressive,
impulsive, and antisocial behaviors and more problems in their relationships with their moth-
ers and fathers (Amato, 1994; Hetherington, Stanley-Hagan, 1999), lower academic achievement
(Amato, 1994; Hethereington & Stanley-Hagan,1999; Wallerstein, 1991), more social difficulties
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and a reduced self-concept (Amato, 1994; Kurtz & Derevensky, 1993). Children may regress, dis-
play anxiety and depressive symptoms, appear more irritable, become demanding and noncom-
pliant, and experience problems in social relationships and academic performance. Not only in
the US has the negative effect of divorce been demonstrated, but in Europe as well. Dronkers
(1999) found that the presence of increased parental conflict during and after divorce was strongly
linked to a lower sense of well-being in secondary school pupils. Given this link between children
experiencing parental divorce and problems facing psychological maladjustment in children,
divorce has been identified as a stressor among health professionals as being potentially respon-
sible for maladjusted neuropsychological responses and for a decline in children’s physical health
(Nunes-Costa, Lamela, Figueiredo, 2009) as well as for the experience of pain symptomatology
(Lee, 2000).
From the period of 1996 to 2009, a birth cohort of approximately 35,000 Chinese adolescents
was tracked for changes in self-esteem. A decline in self-esteem rates were seen in that decade,
and one of the key factors seemingly contributing to this was the increasing divorce rate, which
led to decreased familial connections. Findings like these demonstrate that the impact of divorce
can be particularly troubling especially as self-esteem is generally found to be stable over time in
the general populace (Trzesniewski, Donnellan, & Robins, 2003).
Marquardt (2006) further noted that children of divorce experience early pressure to create
their own moral systems, as they cannot fully endorse the rules of two different households. Such
resulting behaviors and symptoms may indicate emotion suppression, which refers to consciously
inhibiting the ongoing expression of emotion-related behavior (Gross & John, 2003), as the com-
mon form of emotion regulation used by children of divorce. Moreover, a repressive style may have
adverse effects not only on subjective well-being, but also on physical health (John & Gross, 2004).
In an interview with over 400 divorced adults over 20 years who grew up in divorced homes,
Brooks (2010) found two dominant traits in most children of divorce, i.e., fear of abandonment
and fear of not being good enough to be loved. While adult children of divorce are consciously
aware of these fears, the underlying processes and underpinning beliefs often operate on a sub-
conscious level and it may be difficult to link back to limiting behavioral patterns. Brooks’ study
captured a pattern of four destructive relationship behaviors that both male and female adult
children of divorce engage in: 1) Trying to constantly please one’s partner and suppressing one’s
own needs for fear of rejection or in other words, being a martyr to please one’s partner to main-
tain the relationship, 2) looking for a relationship, sometimes taking on the first person who gives
attention and not wanting to be alone, 3) fixing a partner—falling for a person who needs help
and love to fix all their problems, and being convinced that love is the solution to everything, 4)
shutting down emotionally for fear of getting divorced and settling for superficial relationships
with no real commitment.
Simons (2009) noted that children of divorcing parents tend to be good actors as they put on
different masks to fit into their parents’ different worlds. This is further noted by Marquardt’s
(2006), who discusses the split existence of children of divorce. The children reported that they
felt like different people with each of their parents and that they believe their parents were polar
opposites (even when they were not). In addition, they felt they needed to keep more secrets from
their parents than other kids do, and that they did not want to resemble one of their parents too
much, as this may lead to alienation from the other parent.
Development of coping skills may be influenced by the stability or the lack of it in parents’
relationship. At best, research has consistently shown that children from divorced families exhibit
less stereotyped sex behavior, greater maturity, and greater independence (Emery & Coiro, 1995).
Such positive characteristics may reflect the children’s coping attempts, which in turn, suggests
active regulation of emotions that allow them to function or compensate for the weaknesses
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brought to the family system. However, the fact that they become vulnerable in situations that
they are not entirely ready for, e.g., when children leave the parental home earlier and have sex
at an earlier age (Amato & Keith, 1991) may suggest that emotions are not regulated enough for
self-╉protective purposes (Marquardt, 2005).
Mediating factors
Researchers agree that interparental conflict, rather than divorce or residential placement, is
the single most critical determining factors in children’s adjustment post-╉divorce. For example,
Reiter, Hjörleifsson, Breidablik, and Meland (2013) found that the rising prevalence of divorce
does not take away the emotional impact of it on adolescents. Rates of anxiety, depression, and
psychosomatic complaints continue to be present; however, the damaging effects of divorce can be
seen with those children who lose parental contact. The children who succeed after divorce appar-
ently are those who have parents who can communicate and work together. This indicates good
psychological health of the parents, and augurs well for the parent-╉child relationship. In addition
to this, contact and support from nonparental adults, such as extended family or support from
other authority figures, was cited as an additional factor in the adjustment of children of divorce
(Wolchik et al, 1993). With well managed interparental conflict, plus the continuing supportive
presence of the parents and extended family who are able to listen and value the emotions of these
children, the children can better learn to regulate themselves (i.e., they may possibly be aware of
their feelings, but not be overwhelmed by them).
Although divorce occurs in many cultural contexts, there is some evidence that social classes
have an effect on the impact of divorce on children. For example, the negative effect of parental
separation is concentrated among children from lower class families, but is less evident in higher
income families (Grätz, 2015). The decrease in parents income, often caused by having to support
two households, directly affects children’s basic needs, e.g., proper nutrition, clothing, and school
choices and extra-╉curricular activities. Some research has shown that while there are long-╉term
negative consequences of divorce, the consequences are more closely linked to fewer opportuni-
ties arising from lower educational attainment, rather than divorce per se (APA, 2004). Thus, if
educational opportunities are maintained amidst the divorce, the better the guidance the children
receive. This in turn can mitigate the after-╉effects of the experience of divorce, and facilitate chil-
dren’s ability to regulate their emotions. As a result, children of divorce can adjust better after their
parents’ separation.
Clarke-╉Stewart, Vandell, McCartney, Owen, and Booth (2000) indicate that the children’s psy-
chological development was not affected by parental separation per se. Instead stability of the
mother was noted, as psychological development was related to the mothers’ income, education,
ethnicity, childrearing beliefs, depressive symptoms, and behavior. Results further suggested that
what is most important for children in the years following divorce is not family structure or mari-
tal status per se, but family process such as family relationships, interaction, and communication.
An APA (2004) review of divorce literature summarized the following key factors that con-
tribute to healthy adjustment post-╉divorce. These include a healthy family system that enables
appropriate parenting, access to the non-╉custodial parent, custody arrangements, and low inter-
parental conflict. Appropriate parenting refers to the provision of emotional support, monitoring
of children’s activities, authoritative discipline, and maintenance of age-╉appropriate expectations.
Joint legal custody (which allows access to both parents, and shared decision making between
parents) is often associated with more frequent father-╉child visits, regular child support pay-
ments, and more satisfied and better adjusted children. For example, children of divorced families
with fathers who assist with homework, provide emotional support, and listen to their children’s
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problems have more positive academic achievement and fewer behavioral problems. Likewise,
children who alternate time between the parent’s respective homes after a separation experience
fewer psychosomatic problems than those living mostly or only with one parent (Bergström,
Fransson, Modin, Berlin, Gustafsson, & Hjern, 2015).
Such factors mentioned in this section allow children to adjust and cope better with the impact
of divorce. The process underlying adjustment, which will later be seen as bolstering the coping
capability of children dealing with divorce, is discussed in the next section.
Emotion regulation
Emotion regulation is critical in children’s development, cognitively, affectively, socially, and psy-
chologically. It has been found to be associated with social competence, cognitive performance,
and the management of stress (Thompson & Calkins, 1996). Studies have shown that children
who are able to effectively regulate their emotions perform well in school, relate positively with
others, and cope adaptively with life stressors (Barish, 2012).
According to Gross (2002), emotion regulation “refers to the processes by which we influence
which emotions we have, when we have them, and how we experience and express them” (p. 282).
He further explained that emotion regulation may involve maintaining, increasing, or decreasing
negative or positive emotions, occurs on a spectrum from the conscious to subconscious, and
is neither inherently good nor bad. A recent study on emotion regulation of mothers of young
children concluded that emotion regulation is composed of interrelated domains, which include
physiological, cognitive, and temperament aspects (Deater-╉Deckard, Li, & Bell, 2015). Hence, it
is important to consider these elements in understanding emotion regulation processes when
analyzing children of separated parents.
children who are in difficult circumstances or conditions of risk (Thompson et al., 1996). The
complex processes involved in emotion regulation may be more pronounced when dealing with
individuals who are at risk for displaying behavior problems due to their adverse circumstances
including children of divorced or separated parents. They further noted that there may be no opti-
mal means of regulating emotion (i.e., a child at risk might use a strategy that can result in both
protection and vulnerability). Likewise, under adverse circumstances, children may have more
difficulty regulating their emotions, not because they lack the strategies but because they employ
coping strategies that are most appropriate given their situations.
Influential factors
Emotional regulation is indeed an important element that impacts children’s adjustment to their
parents’ separation. A number of factors influence the development of emotion regulation, such as
the child’s age, temperament, neurophysiology, cognitive development, and social context are said
to influence emotion regulation (Morris, Silk, Steiberg, Myers, & Robinson, 2007).
A child’s ability for emotion regulation comes with neurological development, which is related
to a child’s chronological age. Thus, school-╉age children who experience the divorce at younger
ages are generally more likely to have problems as they lack the scaffolds for grasping the experi-
ence. However, infants and toddlers have little comprehension that a divorce has occurred and
thus, do not directly react to this change in their family set-╉up. The risks for this age group are
decreased interaction with the custodial parent and loss of contact with the noncustodial parent,
who can fade entirely from their lives. The experience can leave a tenuous and unstable model of
a parent, and a poor map for understanding and coping with emotions which is made possible by
stable primary relationships.
Thus, the child may benefit from frequent, short visits with the noncustodial parent that do not
disrupt the stable daily routine and secure attachment to the custodial parent (Thompson, 1998).
Wallerstein and Kelly’s (1980) observations, in which Piagetian influences are most notable, fur-
ther illustrates this. According to their observation, three-╉to five-╉year-╉old children commonly are
bewildered by divorce. Their limited cognitive capacity prevents them from fully understanding
its meaning and implications, leading to poor emotion regulation that results in unusual fantasies,
the fear of abandonment, emotional neediness, and aggressive acting out. The improved under-
standing of children six-╉to eight years old allows for greater acceptance of divorce; thus, grief
replaces denial. Adolescents have the most complete and abstract conception of the reasons for
their parents’ divorce, which Wallerstein and Kelly (1980) assert, facilitates their adjustment. They
suggest that perhaps the most difficult cognitive task for adolescents is to integrate the divorce
experience with their developing self.
In his paper, Gross (2002) described how reappraisal and suppression, as emotion regulation
strategies, impact emotion experience and behavioral expression. While reappraisal decreases
emotion experience and behavior expression, suppression decreases behavioral expression only
and not emotion experience. The latter impairs memory while the former has little to no impact on
memory (Gross, 2002). Similarly, a recent study claimed that recovery experiences depend on how
people were able to utilize emotion regulation strategies (Schraub, Turgut, Clavairoly, & Sonntag,
2013). Importantly, such resulting behaviors and symptoms indicate emotion suppression, which
refers to consciously inhibiting the ongoing expression of emotion-╉related behavior, as the com-
mon form of emotion regulation used by children of divorce. Moreover, a repressive style may have
adverse effects not only on subjective well-╉being, but also on physical health (John & Gross, 2004).
Another factor that has been shown to impact wellbeing outcomes following divorce is gender,
such that divorced children living with the same-╉sex parent showed fewer effects than children
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living with the opposite-sex parent (Kelly, 1998). Children living in single mother families have
attitudes that are more favorable to women, whereas, children living with single father families
have attitudes less favorable to women’s rights and gender equality (Prokic & Dronkers, 2009). In
addition, children living in single-parent families tend to have less trust in societal institutions
than children from two-parent families, and tend to have higher level of civic participation in
some countries. Such a relationship between the gender of children and the gender of the custo-
dial parent seem to point to a unique socialization process, which may include extensive cognitive
appraisal of gender roles, which is a core component of emotion regulation.
One important factor that can influence children’s ability to regulate their emotions is their
family, regardless of their individual and situational context. A tripartite model of familiar influ-
ence on emotional regulation has been described by Morris et al. (2007). In this model, emo-
tional regulation is developed through observational learning, modelling, and social referencing.
The second aspect of the model talks about how parenting practices pertaining to expression
and management of emotion can impact children’s emotion regulation. Thirdly, the emotional
climate of the family and its correlates such as parenting style, attachment relationship, marital
relationship and family expressiveness have been noted to impact emotion regulation. These
factors are important for all types of families. It is certainly significant to look into how these
different family variables and emotion regulation are affected with the change in family structure
following the separation of their parents. Following the model presented by Morris et al. (2007),
it is important to look at how each one can impact the emotion regulation of children of divorce
in particular.
Prior to the separation of their parents, children of divorce may have witnessed interparental
conflict or experienced domestic violence (Davies & Cummings, 1995). In the same research of
Davies and Cummings (1995), these stressors may trigger the development of problems in emo-
tion regulation, as they have observed them in their parents. They further noted that interparental
conflict may create negative affect for children, which may make them wish that their parents
separate to end the conflict both as a way of managing their parents’ relationship and of regulating
their own emotions.
Numerous studies have looked into the parental roles in children’s emotional regulation. In
a seminal review, Frankel, et al., (2012) enumerated different ways that parents can help their
children regulate their emotions, namely modeling emotion, responding to children’s emotional
expression, teaching emotion regulation strategies, and motivating through rewards and punish-
ments. Another study highlighted the role of maternal emotional regulation on parenting behav-
ior and how the latter can influence children’s emotional regulation (Morelen, Shaffer, & Suveg,
2014). Taken together, the findings from these studies suggest the critical role of parenting prac-
tices and behaviors in emotion regulation which may mitigate the impact of the change in family
structure brought on due to the parents’ separation.
A variety of studies have established the important role of family functioning and process in
the development of emotion regulation among children, including those who are in vulnerable
situations. It is reported that their reactions may not necessarily be due to their parents’ separation
or divorce but as a result of reduced social support from the father and the children’s perception
of interparental conflict (Schick, 2002). However, this does not undermine the impact of parental
influences on emotion regulation, it is also essential to look into other parent and child factors
that can explain the differences in how children develop emotion regulation.
Relatedly, Fosco and Grych (2012) described the family context of emotion regulation and
explained how the family systems approach can explain the emotion regulation of children.
Rather than looking into the impact of parents on their children’s development and adjustment,
some examined inter-parental relationships and family functioning and emotional regulation.
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According to Clarke-╉Stewart et al. (2000), more than parental separation, children’s psychological
development is influenced by mother-╉related characteristics such as income, education, ethnicity,
childrearing beliefs, depressive symptoms, and behavior. On the other hand, Fosco and Grych
(2012) found important family variables such as, family climate, maternal warmth, sensitivity, and
interparental conflict as significant predictors of emotional regulation of children. It is important
to note, however, that the relationship between interparental conflict and internalizing problems
can be mediated by children’s perceived threat, i.e., negative parental conflict resolution styles may
have greater impact on internalizing problems because of the children’s perceived threat of their
current situation.
Hence, it is recommended that family processes and functioning are included in order to
have a more complete understanding of emotion regulation, especially emotional regulation of
children (Fosco & Grych, 2012). These family processes and how they impact emotion regula-
tion may help explain the behaviors and well-╉being of children whose parents are separated or
divorced.
INTERVENTIONS 341
Interventions
This section discusses the various intervention programs geared towards helping children of
divorce and their families. While not necessarily targeting emotion regulation, key aspects of
these programs nevertheless target important areas of children’s functioning that are associated
with cultivating adaptive emotion regulation. Broadly speaking, skills for approaching, diffusing,
or temporarily avoiding interparental conflict may point to adequate situation selection, while
components of attentional deployment and cognitive change may occur in skill building sessions
where children are taught to reappraise their situation, understand their divorce related thoughts
and feelings better, and find better ways of solving problems related to these that are developmen-
tally appropriate. Findings in the literature have demonstrated the impact of divorce on children,
thus, interventions that are geared towards targeting crucial areas of potential disruption and
reverse negative lifelong consequences are paramount. As emotion regulation involves multiple
components, interventions that are dynamic and multi-╉factorial are required. As the succeed-
ing sections will show, most programs focus on children’s emotions, ensuring they are given the
opportunity to express what they are experiencing, untangling the confusion brought about by
this experience in order to help them derive support from others who are going through the
same experience. However, there are also components of cognitive processing of the experience,
which places the experience in perspective and provides opportunities for correcting maladaptive
thought patterns and beliefs. Finally, skill building components are also embedded into many
interventions, which target things such as coping, social competence, and stress management.
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Court-╉connected programs
Court-╉connected programs are spread throughout the United States (Pollet, 2009). According
to Pollet (2009), these programs intend to reduce the experience of emotional pain in children
whilst targeting better outcomes via a solution focused approach. Ten states in the US have court-╉
ordered or legislated parent-╉education programs for divorcing couples. On the other hand, 35
states have no such requirements. Basically, there are two streams of divorce programs: Those
that are offered by the state governments and those that are offered in the community, such as
through churches and schools. For example, in Alabama, a court judge may require attendance
of a child of divorcing parents to a four-╉hour program called “Families in transition” (for ages
six to 16). For this program there is a cost for attendance per child and there is also a parent
program that occurs simultaneously. Nevertheless, divorcing parties also have the option to file
a motion to waive their attendance to these sessions (p. 532 in Pollet, 2009). However, as previ-
ous literature and studies have shown, it may be in the best interest of the child for health care
providers and lawmakers to ensure the high rate of attendance in parenting sessions during and
after divorce.
School-╉based programs
A second category of interventions is those that are based in schools. Perhaps one of the most
studied of these is the Children of Divorce Intervention Program (CODIP), developed by
Pedro-╉Carrol and Cowen (1985) in the US, and now being run in various countries apart
from the US, such as Canada, New Zealand, and Australia. This program was designed with
five goals, which serve to lessen the impact of divorce, to provide a supportive environment
for children of divorce, to process divorce-╉related feelings, to clarify and promote the under-
standing of divorce-╉related concepts and misconceptions, to impart skills for problem-╉solv-
ing, and to foster positive self and family perceptions (Alpert-╉Gillis, Pedro-╉Carroll, & Cowen,
1989). Looking at the components of the program, crucial elements of emotion regulation are
addressed by its goals. For example, clarifying and promoting the understanding of divorce-╉
related concepts and potentially correcting misconceptions children may have surrounding
this can be seen to target the cognitive change component of emotion regulation. The CODIP
has been viewed as providing a multitude of advantages for children such as increasing their
healthy adjustment and reducing internalizing (anxiety, somatic symptoms) and externaliz-
ing (behavior) problems (Pedro-╉Carroll, 2005). In more recent years, the program has been
adapted for different age groups and countries. For instance, a feasibility study of the program
was undertaken for Dutch children in the kindergarten and first grade, with generally positive
results (Velderman, Cloostermans, & Pannebakker, 2014). Relatedly, the program was recently
piloted in two South African Schools for ten-╉to 14-╉year old boys, using an experimental
design; improvements in socio-╉emotional and behavioral functioning were reported (Botha
& Wild, 2013).
Another popular school-╉based intervention program provides support while also teaching chil-
dren skills for coping. Stolberg and Mahler (1994) conducted a study of 103 students in the third
to fifth grades, who had separated or divorced parents. They were assigned to one of three treat-
ment conditions (i.e., support; support and skill building; or support, skill building, transfer and
parent training procedures) with a no-╉treatment group serving as control. Those who entered the
support-╉alone condition experienced the most benefits, although the ones in the skill-╉building
conditions experienced long-╉lasting improvements in affect. Effective coping skills have been seen
in more recent literature to predict better emotion regulation skills in children going through
stressful events (Zalewski, Lengua, Wilson, Trancik, & Bazinet, 2011).
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Community-╉based programs
A third category of interventions is community-╉based programs. One program that has received
empirical support is the Kids’ Turn program, which was evaluated by Cookston and Fung (2011).
This is a supportive, skills based program, the goals of which included providing emotional
support for children and their families coming from a variety of cultures in processing nega-
tive emotions, teaching skills for preventing children’s at-╉risk behaviors, and “demystifying” and
“de-╉stigmatizing” the process of separation. While the study by Cookston and Fung (2011) on
61 parents yielded no changes in parenting behaviors, improvements were reported in terms of
interparental conflict, topics that parents fight about, parental alienation behaviors, anxiety and
behavior, as well as children’s internalizing behaviors.
In light of what the literature has revealed from this chapter on the benefits of ongoing positive
parental relationships and child adjustment, this program may yield much benefit in offsetting the
long-╉term negative consequences of divorce on children.
Other interventions have targeted specific areas of thinking and feeling which may contribute
to emotion regulation in the long term. One study used expressive art in the form of music, to
successfully target children’s irrational beliefs about the divorce, which are thought to be related to
depressive symptoms (DeLucia-╉Waack & Gellman, 2007). Another study (Rossiter, 1988) targeted
pre-╉schoolers’ capacity to express their pain at their parents’ separation (which they may not have
the cognitive wherewithal to comprehend yet), and increased their adjustment to the separation
or divorce. A component of parent feedback (telling them what their children need) was also
seen as germane to the program’s implementation. There are also significant relationships among
pretend play, creativity, and emotion regulation among children (Hoffman & Russ, 2012), indicat-
ing the potential use of play and storytelling in teaching children emotion regulation strategies
indirectly.
who are most at-╉risk for behavioral and emotional problems seem to benefit the most from these
programs. Importantly, the program has been shown to have a transformative affect, as it has been
linked to the intergenerational transmission of parenting behaviors (Mahrer, Winslow, Wolchik,
Tein, & Sandler, 2014). The longitudinal study showed that children whose parents participated
in the NBP program demonstrated a higher degree of warm parenting attitudes and lower levels
of harsh discipline attitudes when they themselves became parents. This seems to show that inter-
vention geared towards improving separated or divorced parents’ behaviors toward their children,
had long-╉lasting positive effects in terms of the children’s own parenting behaviors again, stressing
the crucial factor of adequate parenting in this time of crisis and change in the child’s life.
Additional programs have been cited in literature which target positive parenting skills to
improve child and adolescent behavior outcomes (Basson, 2013; Stallman & Sanders, 2014).
Parenting through Change is one example, which is associated with positive outcomes in the
literature. This program is designed to teach positive discipline and problem solving skills in par-
ents (Forgatch, 1994). A large randomized study of 238 divorcing mothers tested the efficacy of
this program. It determined effective parenting practices and teacher-╉reported school adjustment
in the treatment group although no direct effects on child outcomes were observed (Forgatch &
DeGarmo, 1999).
from intact families show that significant differences between the two groups are not the result
of parental separation or divorce alone but also by other factors, such as interparental conflict,
family and environmental factors. It is important to look at family factors in understanding emo-
tion regulation of children, especially those who are considered to be at risk for adjustment and
behavior problems as a result of parental separation.
A crucial protective factor is the cultivation of adaptive emotion regulation competencies. The
literature on different factors influencing outcomes of divorce do seem to point to ER as the inter-
nal process underlying the capacity of a child to adjust to divorce and rise from it. In fact, the
majority of interventions mentioned in this chapter, while not directly referring to the term emo-
tion regulation in their targeted goals, nevertheless focus on common and crucial elements of this
construct. Moreover, it is well worth mentioning that emotion regulation is not only something
that the child learns from these programs, but from parents who undergo skills training in those
programs that offer it.
Family functioning and other family process variables more than family structure may also
mediate the impact of separation on adjustment and behaviors of children of divorce. Again here,
we stress the importance of lessened inter-parental conflict, increase in contact with both parents,
especially with fathers, and in strengthening the ties even with extended relatives. This kind of
emotional support provides a “safety net” by which the child can come to rely in a time of poten-
tial upheaval in their lives. This safety net also provides the protective structure needed by the
child to develop strategies (which all seem to address emotion regulation) in dealing with the
challenges.
Thus, while there is enough evidence in terms of the effectiveness of certain programs to help
children of divorce adjust to their situations and cope with problems (Velez, et al, 2011), there may
be a need to understand the emotion regulation process in interventions that tap family systems,
in particular interparental conflicts.
“It takes a village to raise a child” they say. But what happens when this formerly tight village
(which the intact family and the extended networks that it weaves together represents) that the
child has come to rely on for security and comfort disintegrates? As this chapter has demon-
strated, the impact on the child’s life can be substantial, as their internal frame of reference is
greatly challenged with the onset of divorce. Interventions that help them adjust to their new
circumstance and help them regain some sense of control over their own lives are thus crucial.
Much has been said and written about the phenomenon of divorce and its effects on the major
players, particularly key family members. Likewise, sufficient attention and effort has been given
to children who are by products of these separation and divorce experiences. With all that has
been said and done, what else is left to be done? As has been shown by some well-researched
intervention programs, incorporating ongoing research into the practice of mental health pro-
fessionals working with children and families of divorce generates much valuable and relevant
information that increases our knowledge of this complex issue as well as the most effective ways
to deal with it.
In terms of practice-based research, other countries where divorce or separation occurs fre-
quently may do well to test the efficacy of the well-researched programs that help alleviate the
potentially destructive aftermath of divorce on children and their families. For instance, we have
not been able to find evidence of such programs in other Asian and most European countries
where divorce or separation is socially sanctioned. The effects of divorce or separation in countries
where they are not yet approved but where the instance of annulment is on the rise (as in the case
of the Philippines), may benefit from such research on the impact and efficacy of intervention
programs as well.
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3
Practitioners working with children and their families need to be able to approach the issue
of divorce with high levels of compassion and cognitive know-╉how regarding recent evidence in
this field. For example, it is recommended that focusing on the role of emotion regulation in the
adjustment of children of divorce or of separated parents be explored further. As highlighted by
Deater-╉Deckard et al. (2015), emotion regulation is best understood when all aspects are consid-
ered, namely the physiological, cognitive, and temperament domains.
Furthermore, in understanding emotion regulation of children of divorce, it is important to
involve the children themselves in research, to get their perspective not only the perspective of
their parents or the adults around them. One such research strategy is the use of Q methodol-
ogy which has been found to be useful in drawing out children’s experiences and emotions that
are going through difficult circumstances such as their parents’ divorce. (Ellingsen, Thorsen, &
Størksen, 2014). This methodology was undertaken as a form of participatory research with chil-
dren. The Q methodology which was developed by William Stephenson (in Ellingsen et al, 2014),
looks at emerging patterns of people’s feelings, beliefs about a certain topic, and determines the
degree of their agreement or disagreement with an issue or a point of view. Through the use of
subjective statements and visual images, Q methodology may enable researchers to elicit sensitive
feelings and issues from children participants in research. In the conduct of research on children
of divorce, it is important that all perspectives are taken into account, parents, peers, teachers and
the children of divorce themselves. Depending on their age and developmental stage, more appro-
priate methodology can be used aside from the usual survey and interview.
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Chapter 17
“I felt so sad. I was just crying. It just made my head hurt, my brain hurt, my
stomach hurt. It just got control of me. It got my mind twisted. I couldn’t
focus on anything else. A whole lot of days I couldn’t go to sleep without my
mum. I had some bad dreams, so my daddy gave me an invisible necklace. I
couldn’t live without her. It was like a curse. It was like prison.” Jasmine
(Zehr, 2011)
Parental incarceration
The United States (U.S.) incarcerates more individuals than any other country (Walmsley, 2013),
and approximately half of U.S. prisoners are parents (Glaze & Maruschak, 2008). Accordingly,
millions of U.S. children experience the collateral consequences of parental separation due to
incarceration. It has been documented that children and adolescents with incarcerated parents are
prone to a diverse array of maladaptive developmental outcomes, including aggressive and anti-
social behavior (Murray, Farrington, & Sekol, 2012), depression (Wilbur et al., 2007), attachment
insecurity (Poehlmann, 2005a), and diminished educational attainment (Haskins, 2014; Trice
& Brewster, 2004). Increasingly, evidence suggests that youth with a history of parental incar-
ceration also evidence detrimental effects on physical health, including health disease and other
chronic diseases (Gjelsvik, Dumont, & Nunn, 2013). What is strikingly absent from the literature
on parental incarceration is an investigation into the possible mediators and moderators of the
relationship between the experience of parental incarceration and the psychosocial and physical
health outcomes. One such factor may be emotion-╉related processes, such as emotion regulation.
The primary focus of this chapter is to review the literature examining emotion processes in
children and adolescents who have experienced parental incarceration with a specific focus on
emotion regulation. Background information on parental incarceration within the U.S. penal sys-
tem is presented first to provide the context from which to understand and interpret the research
regarding emotion processes. The first section thus provides information describing the variety
of contextual variables that characterize maternal and paternal incarceration and its sequaelae.
Second, we provide an overview of the negative effects of parental incarceration on children’s aca-
demic, social, and psychological functioning. Third, we discuss emotion processes and propose
two important factors that may explain, in part, why parental incarceration confers additional
risk for psychological maladjustment through:1) The disruption of the attachment relationship
between the incarcerated parent and the child, and 2) the development of poor emotion regulation
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352 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
skills. We also discuss how adaptive emotion regulation skills may be a potential protective factor
that may help to lessen the impact of the negative outcomes associated with having an incarcer-
ated parent. We conclude by highlighting the limitations of the current research in this area, the
challenges inherent in conducting research in this area, and the implications and directions for
future research.
and demonstrated the heterogeneous impact of parental incarceration on children (Turney &
Wildeman, 2015). In particular, when considering the impact of parental incarceration, it is
important to differentiate between incarceration in prison vs. jail as well as maternal vs. paternal
incarceration. Even the ground-breaking Adverse Childhood Experiences study (see below) did
not differentiate between parental incarceration in jail or prison, or maternal or paternal impris-
onment, nor take into account the length of parental imprisonment (Anda et al., 2001; Felitti
et al., 1998). Unfortunately, to date, no research that we are aware of has examined differences in
children’s experience of parental incarceration in prison or jail or how the length of incarceration
may impact child and family functioning. However, a growing body of research has examined the
experience of paternal vs. maternal incarceration.
Paternal incarceration is much more common than maternal incarceration (Glaze & Maruschak,
2008). The U.S. jail and prison population is predominately male and therefore, there are more
children impacted by paternal than maternal incarceration. However, maternal and paternal
incarceration is more likely to co-occur when a mother is incarcerated (Dallaire, 2007). Thus,
many children impacted by a mother’s incarceration may be experiencing separation from both
their mother and their father. The heterogeneous impact of parental incarceration is well docu-
mented in the literature (Murray et al., 2012) and may be partly a reflection of the diversity of the
experience of paternal, maternal, or dual-parental incarceration.
In comparison to incarcerated mothers, incarcerated fathers are less likely to report having lived
with the child prior to their incarceration and are less likely to remain in contact with their chil-
dren during their incarceration (Glaze & Maruschak, 2008). Conversely, most incarcerated moth-
ers report living with their child during the month prior to arrest and/or incarceration and being
the child’s primary caregiver. According to incarcerated mothers’ report, their adult children are
two-and-a-half times more likely to be incarcerated than adult children with incarcerated fathers
(Dallaire, 2007), and three times as likely to be incarcerated as adults, compared to children whose
mothers have never been incarcerated (Huebner & Gustafson, 2007).
According to the Bureau of Justice Statistics (Glaze & Maruschak, 2008), when fathers are incar-
cerated, their children likely remain in the care of their biological mother. When mothers are
incarcerated, their children are more likely to transition to the care of a grandparent or other
relative. Most children whose parents are incarcerated remain in familial care. However, approxi-
mately 3% of incarcerated parents report that their child is in the foster care system, with 11%
of incarcerated mothers, compared to only 2% of incarcerated men reporting that one or more
of their children are in state custody (Glaze & Maruschak, 2008). Thus, maternal incarceration,
because of the increased likelihood of severed or limited contact with both biological parents, may
serve as an additional or intensifying risk factor for these children.
As previous research has demonstrated (e.g., Sameroff, Bartko, Baldwin, Baldwin, & Siefer,
1998), as the number of risk factors in children’s lives accumulate, children evidence increased
likelihood of problematic outcomes, which may reflect the situation of children with an incarcer-
ated mother. Dallaire (2007) found that as the number of risks accumulate in the lives of adult
children of incarcerated parents, so too does their children’s risk for incarceration; the relation
was particularly pronounced for children of incarcerated mothers. As contextual (e.g., large fam-
ily size, single parenthood) and incarceration-specific (e.g., familial incarceration, number of
previous incarcerations) risk factors increased, the likelihood of intergenerational incarceration
increased as well. Specifically, Dallaire (2007) reported that:
Of the 21% of mothers who reported that their adult child was incarcerated, two-thirds of these moth-
ers had four or more risk factors. With 1 risk factor, 1% of mothers reported that their adult children
were incarcerated; with 4 risk factors, the percentage of mothers with adult children incarcerated was
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354 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
almost 6%. There was a similar trend for fathers, such that of the 8.5% of fathers who reported that
their adult child was incarcerated, almost three-╉quarters of these fathers had four or more risk factors.
With 1 risk factor almost no (0.1%) fathers reported that their adult child was incarcerated, but with
4 risk factors the percentage of incarcerated fathers with adult children incarcerated was 2%. (p. 448).
A body of research has indicated that numerous negative academic, social, and psychological
outcomes are present in children with an incarcerated parent. With respect to cognitive function-
ing, in a sample of children ages two-and-a-half to seven-and-a-half years of currently incarcer-
ated mothers, Poehlmann (2005b) found that 42.4% of children were characterized by sub average
cognitive functioning and delays as assessed by the Stanford-Binet. However, these findings were
mediated by the quality of the home environment. That is, children who lived in environmental
contexts with higher numbers of contextual risk (e.g., low education, unemployment) had poorer
cognitive outcomes, but these outcomes were mediated by positive, safe, stimulating home envi-
ronments. Hanlon et al. (2005) interviewed families of 88, nine to 14 year old youth in Baltimore
City whose mothers were currently incarcerated and participating in a parenting program. The
results indicated that although the youth did not show significant indications of psychological
maladjustment, school behavior problems and associations with deviant peer groups were evi-
dent. The authors posited that the longer term, consistent care provided by caregivers may have
mitigated some of the anticipated negative outcomes.
Regarding psychological outcomes associated with being a child of an incarcerated parent the
findings are mixed. When children are first separated from parents because of incarceration they
show many emotions, including sadness, worry, confusion, anger, loneliness, and sleep problems
(Poehlmann, 2005a). However, over time children and families make adaptations and adjust-
ments, and the relation between parental incarceration and psychopathology is less clear. Given
the myriad of contextual risks in the caregiving environments of children of an incarcerated par-
ent, it is difficult to disentangle the contribution of parental incarceration over and above the
impact of other significant experiences to which these children have been exposed. Increasingly,
it appears that there might not be a direct link between the experience of parental incarcera-
tion and children’s psychopathology. A comprehensive meta-analysis by Murray and colleagues
(2012) of 40 studies that examined the impact of parental incarceration in relation to a compari-
son group of youth who did not have experience with parental incarceration yielded two main
conclusions. First, the authors concluded that, “there are zero or only weak associations between
parental incarceration and children’s poor mental health, drug use, and educational performance”
(pp. 190–191). Second, they concluded that, “children with incarcerated parents are at signifi-
cantly higher risk for antisocial behavior compared with their peers” (pp. 191).
These findings compliment work conducted by researchers analyzing the FFCWB data set,
which has indicated that the impact of parental incarceration may be negligible (Turney &
Wildeman, 2015). Other researchers too have documented themes of resilience and adaptation
among these children and youth (Miller, 2007; Siegel, 2007). It is well documented, however, that
children with incarcerated parents experience high levels of risk in their environment, and they
show high rates of antisocial behavior, delinquency, and have high rates of incarceration as youth
and young adults (Huebner & Gustafson, 2007; Murray & Farrington, 2005). For example, Murray
and Farrington (2005) analyzed the date from the Cambridge Study in Delinquent Development
to investigate the effects of various types of parent-child separation including paternal incarcera-
tion. The results indicated that the experience of paternal imprisonment for boys prior to age ten
was related to future antisocial and delinquent outcomes, even up to age 40, even after controlling
for other risk factors. However, this study was conducted from 1953–1964 in Great Britain and
the results may not replicate to present times and to the US In conclusion, based on the recent
meta-analyses conducted by Murray and colleagues (2012), there appears to be no or little direct
link between parental incarceration and psychopathology.
Although there has been considerable research examining psychological outcomes for chil-
dren of incarcerated parents, very few researchers have studied emotion-related processes in this
sample. Emotion regulation and coping abilities in particular may help explain the diversity of
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356 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
outcomes in this population and act as an intervening variable, which can help better explain why
some children of parental incarceration demonstrate resilient outcomes; whereas, others evidence
significant adjustment problems. The following sections of this chapter provides an in depth focus
on the scant research that has examined the relations between the experience of parental incar-
ceration and attachment relationships given its foundational role in the development of emotional
processes, and the relation between parental incarceration and the development of children’s emo-
tion regulation skills.
Emotion processes
Attachment in children with an incarcerated parent
Attachment theory has been proposed as a useful theoretical framework to understand why chil-
dren with incarcerated parents may be an at-╉risk population, and also offers pathways to resil-
ience that can serve as junctures for intervention or prevention efforts. A secure mother-╉child
attachment relationship has been demonstrated to provide the necessary foundation for positive
emotional development that is integrally related to functioning in cognitive and social domains
(Cassidy, 1994; Sroufe, 2005). In particular, research has indicated that attachment security pro-
motes the development of key emotional processes such as emotional awareness and empathetic
responding in children (Kerns, 2008; Thompson, 2008). These emotion development skills are
foundational for the developmental of more advanced emotional competencies including emo-
tion regulation (Saarni, 1999). Infants and young children with incarcerated parents may not
form secure attachment relationships with the incarcerated parent which has significant implica-
tions for their risk of developing subsequent emotional and behavioral problems (Myers, Smarsh,
Amlund-╉Hagen, & Kennon, 1999; Parke & Clark-╉Stewart, 2001).
Poehlmann (2005a) studied attachment relationships in a sample of 54 children ages two-╉and-╉
a-╉half to seven-╉and-╉a-╉half years (M age = 56.8 months, 47% girls, 48% African American) with
a currently incarcerated mother. One of the eligibility requirements for participation was that
the mother had been the primary caregiver prior to incarceration. The average age of the child
when separated from his or her mother due to incarceration was 33 months. Multiple methods
of assessment and multiple informants (i.e., mothers, caregivers, children) were used to assess
attachment. The primary assessment of attachment relationship was based on caregiver and
mother report of the child’s initial two-╉week response to the maternal separation as well as on
children’s responses to an attachment story completion task in which children responded to four
increasingly stressful hypothetical events concerning parent-╉child relationships (Bretherton,
Ridgeway, & Cassidy, 1990). Results based on the story-╉completion task indicated that most
(63%) of the children were classified as having insecure relationships with mothers and caregiv-
ers; 54% of children had insecure relationships with both mothers and caregivers, and 28% had
secure relationships with both adults. Eighteen percent of children had one secure and one inse-
cure parental representation. Interestingly, rates of insecurity in the Poehlmann (2005a) study
were not significantly different than rates of insecurity in other high-╉risk populations (Cassidy
et al., 2007). In the Poehlmann (2005a) study, secure attachment relationships were more likely
when children lived in a stable caregiving situation, were older, and evidenced sad rather than
angry responses to the initial parental separation. These results indicate that parental incarcera-
tion negatively impacts children’s ability to form and maintain stable, secure attachment repre-
sentations with their incarcerated parent. To the extent that children with incarcerated parents
may be able to form and/╉or maintain a secure, organized attachment relationship with their
incarcerated parent or another caregiver, they may be protected from some of the other risks
associated with the experience of parental incarceration.
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Specific aspects of children’s interactions with an incarcerated parent in the context of incar-
ceration may stress the attachment and caregiving systems. In particular, attachment-related
thoughts and feelings may be an important issue for these children and families in relation to the
child’s level and quality of contact with the incarcerated parent (see also Poehlmann, Dallaire,
Loper, & Shear, 2010). There is mounting evidence that children’s contact with an incarcerated
parent may activate a child’s attachment system and that lack of contact may increase feelings
of anger. Shlafer and Poehlmann (2010) examined attachment representations in 57 youth (M
age = 9.1 years, range:four–15 years; 60% girls; 93% minority ethnicity/race) with an incarcer-
ated parent (86% had incarcerated fathers). Children were interviewed about their relationships
with their caregivers (primarily mothers) and their incarcerated parent using the Inventory of
Parent and Peer Attachment Inventory (IPPA; Armsden, 1986; Armsden & Greenberg, 1987).
Caregivers provided information about their perceptions of their relationship with the child. All
families were involved in a mentoring program thus measures were administered at baseline and
six months later. When asked directly about their relationship with the incarcerated parent, 39%
provided no answer, 31% perceived the incarcerated parent negatively, and 41% reported a posi-
tive relationship. Interestingly, for children who were older than eight years old and had no con-
tact with the incarcerated parent, they reported feeling alienated and having negative feelings
towards that parent. Children in this study who did have contact with their incarcerated parent
reported significantly fewer feelings of anger and alienation toward the incarcerated parent. This
suggests the importance of maintaining and developing the attachment relationship that may have
been present prior to incarceration.
Dallaire, Ciccone, and Wilson (2012) compared attachment security in a sample of 24 children
(M age = 7.7 years, range: six to ten years; 42% girls; 58% African American) with an incarcerated
parent (71% had incarcerated fathers) to a sample of 20 children (M age = 8.6 years, range: six
to ten years; 30% girls; 85% African American) separated from a parent for another reason (e.g.,
divorce, abandonment, substance abuse recovery). The authors assessed attachment security
through the use of the Attachment Family Drawing task (Fury, Carlson, & Sroufe, 1997) that
was then related to the child’s experience of contact and visitation with the incarcerated parent.
They found that greater contact and visitation with an incarcerated parent was associated with
more depictions of role-reversal in their family drawings. Role reversal involved depictions of
the mother as vulnerable or less important in the relationship than the child. The authors inter-
preted this finding as suggesting that children with incarcerated parents perceived that their care-
giver needed to be protected and it was their responsibility to be the protector. This research also
examined specific dimensions in the children’s drawings with caregiver behaviors such as warmth
and hostility. Children of incarcerated parents’ perceptions of caregiver hostility was related to
increased global insecurity as depicted in the drawings, whereas, both child and caregiver per-
ceptions of stress were associated with more child global pathology as well as “bizarreness/dis-
sociation” depicted in the drawings (p. 178). Interestingly, these findings were not seen in the
comparison group of children. This set of findings indicates that importance of considering the
effect of parental incarceration on children’s attachment relationship with both the caregiver and
the incarcerated parent. Not all children experience insecure attachment in this high risk context
and thus, future research needs to uncover what factors may help to strengthen the relationship
between the incarcerated parent and his or her child while incarcerated and also upon reunion
and reintegration into the family upon release.
In sum, attachment in the context of parental incarceration has been examined in two different
ways. Poehlmann (2005a) assessed children’s current representations of attachment with mothers
and caregivers and found high rates of insecurity. Other researchers have examined attachment-
related thoughts and feelings in relation to children’s contact with their incarcerated parent.
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358 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
Shlafer and Poehlmann (2010) found that lack of contact was associated with increased feelings
of anger and alienation with the incarcerated parent, and Dallaire and colleagues (2012) reported
that greater contact and visitation was associated with greater role reversal. These findings illus-
trate the heterogeneity of the impact of parental incarceration on children and their attachment-╉
related thoughts and feelings. Specifically, some children, particularly those with a non-╉residential
incarcerated father, may not show attachment-╉related difficulties as they may have developed an
attachment relationship with their mother or other caregiver. However, young children with an
incarcerated mother may be at-╉risk for attachment-╉difficulties as they are more likely to experi-
ence separation from a primary attachment figure. To further complicate matters, children who
wish to maintain an attachment relationship with their incarcerated parent via visitation and con-
tact may experience attachment-╉related distress following a visit or phone call with the incarcer-
ated parent. Although it is difficult to isolate the impact of parental incarceration on children’s
attachment relationships, attachment-╉related thoughts and feelings are important to consider, as
they are foundational to emotional development and coping. Attachment-╉focused research with
children of incarcerated parents has illustrated that they are at risk for developing insecure attach-
ments and, as discussed more in the next section, visitation and contact (or lack thereof) can also
impact the attachment system.
there were positive emotional moments during the visit, there were stressful, emotionally nega-
tive aspects as well. The findings from this research have important implications for interven-
tion and policy for child-╉friendly visitation to incarcerated parents. Further, from an emotional
development perspective, the visitation context provides caregivers with a valuable opportunity
to teach children how to manage emotional arousal in constructive ways. That is, drawing from
meta-╉emotion theory (Gottman, Katz, & Hooven, 1997), adopting an emotion coaching stance
in which instances of negative emotionality are viewed as “teachable moments” provides children
with the necessary support and scaffolding to experience, validate, and learn adaptive problem-╉
solving responses to manage negative emotional arousal. The use of emotion coaching strategies
has been demonstrated to result in positive psychosocial outcomes in low risk samples of children
(Lunkenheimer, Shields, & Cortina, 2007). Importantly, to be an effective emotion coach, care-
givers must be able to regulate their own negative emotionality, thereby providing the necessary
attention to the child’s emotional needs (Cassano & Zeman, 2010). However, the stress of the visit
not only affects children but also the caregivers who have their own set of emotional responses
to the brief reunion. Thus, managing their own emotions in order to be emotionally available to
their child is likely a challenging parenting task. Thus, future research needs to focus on devel-
oping ways to assist caregivers in becoming effective emotion coaches to help guide their child
through the myriad of emotional responses the child may experience when visiting the incarcer-
ated parent.
360 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
less developed in children who reside in families with high levels of stress (Dunn & Brown, 1994;
Shipman & Zeman, 1999) and that experiencing a greater number of risk variables is associated
with poorer emotion regulation (Lengua, 2002).
362 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
These findings point to the potential protective effect of anger regulation in this high-╉risk
sample of children. That is, adaptive regulation of anger not only predicted fewer externalizing
difficulties concurrently but also longitudinally. It is interesting that the regulation of anger but
not the regulation of the internalizing types of emotions (i.e., sadness, worry) predicted fewer
behavioral problems. Understanding the mechanisms underlying how children of incarcerated
parents learn adaptive emotion regulation skills is of key importance as this information could be
used in prevention and intervention programs. That is, it would be important to examine whether
children with stronger emotion regulation skills have: 1) More secure attachment relationships
with their incarcerated parent and/╉or caregiver thus setting the stage for more adaptive emotional
development, 2) experienced more effective and adaptive emotion socialization efforts at home by
their parent(s) or caregivers, or in the community (e.g., teachers, religious figures, sports coaches),
3) have been exposed to fewer numbers of risk variables, and/╉or (d) other variables that could
account for the stronger anger regulation skills.
significant trend indicated that non-╉ Caucasian children exhibited more social monitoring
behaviors than Caucasian children. The use of display rules was examined in relation to other
emotion management strategies. Children who used more anger and sadness coping responses
were observed to use more display rules suggesting a higher level of emotional competence.
Interestingly, children who inhibited their anger, sadness, and worry were less likely to use a dis-
play rule. Although this may seem counter-╉intuitive, display rules are considered to be adaptive,
emotionally competent behaviors that are sensitive to the demands of the social context whereas
inhibition is a global strategy of suppression of negative emotion that has been linked to negative
outcomes (Gross & Levenson, 1997). Thus, the inverse relations found between inhibition and
display rule use found in this study are consistent with the emotion regulation literature.
Finally, display rule use was examined in relation to psychological functioning and found to be
significantly negatively correlated with social problems, and marginally negatively correlated with
externalizing symptomatology. The number of positive behaviors displayed (another indication
of display rule use) was significantly positively associated with self-╉reported anxiety, whereas, the
number of negative behaviors displayed was marginally positively correlated with self-╉reported
depressive symptoms. Taken together, the findings from this study are consistent with those found
in the literature that has used middle-╉class, Caucasian samples (Cole, 1986; McDowell & Parke,
2000; Saarni, 1984). However, the patterns of findings relating display rule use to behavioral prob-
lems was not as robust as indicated in other literature. Research indicates that norms for emo-
tional responsiveness are sensitive to cultural variations (Cole, Tamang, & Shrestha, 2006; Markus
& Kitayama, 1994). Thus, the violation of norms held in Caucasian, middle-╉class samples (e.g.,
smile when you get a present you do not like) may not yield the same psychological or behavioral
outcomes in non-╉Caucasian samples, particularly for those children who live in high-╉risk contexts
characterized by parental incarceration.
364 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
problems. Interestingly, there were no significant findings for anger. Taken together, these find-
ings point to the importance of discarding assumptions and conclusions about emotion processes
based on data using low risk samples when investigating processes among unique samples such
as children with an incarcerated parent. It also appears likely that children in this sample have a
different emotion socialization history than children in low risk environments which may result
in their developing emotion regulation skills that may not lead to adaptive outcomes.
In sum, these five studies represent the scant knowledge base available on emotion regulation
and associated processes in children of incarcerated parents. Notably, four of these studies have
focused on children with an incarcerated mother and thus, it is not clear whether differences
would exist in emotion regulation processes for children of incarcerated fathers or for children
who have both parents incarcerated. Clearly, this field is ripe for additional inquiry, as the protec-
tive effects of children’s adaptive emotion regulation appear to be a promising avenue of investiga-
tion, with important implications for intervention programs.
made for findings emerging from the use of American databases, such as the Fragile Families and
Child Wellbeing Study (Wildeman, 2010) with respect to their applicability to other nations. Thus,
future research endeavors examining the effects of parental incarceration on children’s emotional
and psychological functioning must carefully report the demographics of their samples, elucidate
the areas in which generalizability may be limited, and may be sensitive to cultural differences.
Second, one of the most difficult issues facing researchers is that of selection bias (Johnson
& Easterling, 2012). That is, children of an incarcerated parent differ from children without an
incarcerated parent on numerous factors other than the incarceration dimension. Thus, differ-
ences observed between incarcerated vs. non-incarcerated groups of individuals may not only
be due to the incarceration itself but could also be due to a host of other factors (e.g., poverty,
poor parenting, prior psychopathology). Some research has not employed comparison groups to
determine whether maladaptive outcomes are due primarily to incarceration-specific experiences
or whether they are the result of children living in environments characterized by high levels of
stress and disadvantage that may explain differences seen between children of incarcerated vs.
non incarcerated parents. Along these lines, it is very challenging to determine the appropriate
comparison group. For example, does parental absence due to incarceration yield more deleteri-
ous outcomes than parental absence due to other family variables, such as divorce or military
deployment? Should the comparison group focus on controlling for living environments (e.g.,
high stress, parenting characteristics, housing, access to medical care) that approximate those of
children with an incarcerated parent? Researchers have responded to these challenges in a variety
of ways. Some research has not included a comparison group but instead examined high and low
exposure to incarceration-specific risk experiences within a sample (e.g., Zeman et al., 2016).
Other research has used large-scale databases and created comparisons between children with
and without an incarcerated parent (e.g., Murray et al., 2007) or with various types of parental
separation due to death, hospital, incarceration, or family discord (Murray & Farrington, 2005).
Still, others have collected data from community-based samples to create multiple comparison
groups based on different histories of parental separation (e.g., Dallaire & Zeman, 2013). Other
research has not used a control group (e.g., Lotze et al., 2010). Although the decision about the
nature of the comparison group(s) is ideally guided by the research question being investigated,
practical considerations in this research field also play an important role.
A third limitation concerns the reliance on self-report and on the use of paper and pencil mea-
sures. Although self-report is often the appropriate source when obtaining information about
private, internal processes (Zeman, Klimes-Dougan, Cassano, & Adrian, 2007), having multiple
sources of information on the children’s and the incarcerated parent’s functioning adds strength
to the validity of the findings and the conclusions that can be drawn (Adrian et al., 2011). Further,
relying only on the incarcerated parents’ report of their incarceration history and the effects of
their incarceration on family members may yield a biased perspective due to social desirability,
retrospective memory concerns, and possible malingering (Houck & Loper, 2002). Further, due
to a potentially erratic history of parental contact with the child before and during incarceration,
parents’ report of their child’s functioning may not be accurate. The challenges of incorporating
observational methods, often considered the gold standard in developmental research with young
children and those in elementary school, pose considerable logistics issues, particularly if the
observation is of an interaction between the child and the incarcerated parent. Many children
have limited or no visitation with their incarcerated parent (Poehlmann-Tynan et al., 2015), thus,
limiting the opportunity for incorporating observational methods. Further, the type of physical
arrangement in the jail for parent-child visitation may preclude video-or audio-taping (e.g., plexi-
glass barrier), although Poehlmann-Tynan and colleagues (2015) were able to conduct an obser-
vational study investigating children’s responses to visitation. Thus, it is evident why research to
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366 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration
date has relied primarily on self-or parent-report using survey methods, but researchers should
endeavor to find creative ways to obtain data that provides a more complete perspective. For
example, using momentary ecological assessment tools might provide real time indicators of chil-
dren’s and caregivers’ emotional reactions and regulatory efforts when faced with exposure to
stressors in the environment. Further, the use of psychophysiological indicators of stress and emo-
tional reactivity would also supplement and add validity to the findings derived from self-and
other-report concerning emotional processes.
Fourth, greater attention to the moderating effect of parent and child gender is warranted.
Regarding the importance of examining gender, much of the literature has examined parental
incarceration without taking into consideration how maternal vs. paternal incarceration may
exert unique effects on children. It is likely that sons and daughters may respond differently to
the absence of a same-vs. opposite-sex parent. A body of research has indicated the negative
outcomes for sons of incarcerated fathers including antisocial behavior as well as internalizing
problems (Besemer, van der Geest, Murray, Bijleveld, & Farrington, 2011; Murray & Farrington,
2005, 2008). However, some of this research has not included girls in the samples and thus, it is
not known if the antisocial outcomes are specific to all children or just boys. Using the National
Longitudinal Survey of Youth, Huebner and Gustafson (2007) identified 31 children with incar-
cerated mothers and compared this sample to 1666 children with no incarcerated mother. They
found that 26% of the children with incarcerated mothers were convicted in adulthood vs. 10%
in the comparison group. However, research has yet to make direct comparisons within the same
sample of the effects of maternal vs. paternal imprisonment on sons vs. daughters. Further, the
research examining emotion regulation in incarcerated parent samples has primarily investigated
these processes in children with incarcerated mothers, yet the emotion development literature
indicates the importance of fathers as well as mothers in emotion socialization processes (e.g.,
Cassano & Zeman, 2010; Cassano, Perry-Parrish, & Zeman, 2007; Lunkenheimer et al., 2007).
Relatedly, little research has considered the role of the caregiver in helping to ameliorate some
of the negative sequalae associated with parental incarceration (Cecil, McHale, Strozier, & Pietsch,
2008). For example, children may have a more consistent relationship with the caregiver such
as a grandparent when their mother is incarcerated. The nature of this relationship is key to
understanding how some children with an incarcerated parent display more resilience than other
children. For example, Mackintosh et al. (2006) found that when children perceived that their
caregivers responded to them with warmth and support, fewer behavior problems emerged.
Fifth, the negative effects of incarceration on emotional development may also differ depending
on the developmental timing of the child’s exposure to and experience of parental separation due
to incarceration. It may be that there are sensitive periods for emotional development in which
parental separation is particularly pernicious. For example, the first 12–18 months of age are con-
sidered critical for the development of attachment (Sroufe, 2005) and thus, maternal absence, in
particular, at this stage could have detrimental effects that could have far reaching implications for
all spheres of development. Although parental socialization of emotion is important through all
stages of childhood and adolescence (Klimes-Dougan & Zeman, 2007), the groundwork for later
emotional development occurs during the toddler and preschool years (Denham, 1998). Thus,
parental, and particularly maternal absence during these years may have a lasting negative impact
on emotional development. Further, having poor emotion socialization models during the early
childhood years also has been shown to lead to negative psychological, social, and academic out-
comes (Zeman et al., 2006). Given the difficulty with recruiting samples of youth with an incarcer-
ated parent, many studies have used wide age ranges in their samples, which are not of sufficient
size to allow for analyses by child age or developmental stage in order to answer these questions.
Even the landmark ACEs study (Anda et al., 2001) did not take into account the age of youth at
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time of parental imprisonment. Thus, future research needs to carefully consider the role of devel-
opmental status when investigating the effect of parental incarceration on children’s functioning.
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Chapter 18
Traumatic stress
Children may be exposed to several types of traumatic events across development, such as endur-
ing abuse or maltreatment at the hands of relatives, authority figures, or peers (Chapter 15), living
in negative, uncontrollable family environments (e.g., divorce, parental incarceration, bereave-
ment; Chapters 16, 17, and 19), or experiencing mass trauma due to the widespread violence, war/╉
terrorism, or natural disasters within the child’s respective community (September 11th terrorist
attacks, Hurricane Katrina). This chapter primarily focuses on this latter type of global traumatic
stress, as it impacts a large number of youth at one time and across multiple ecologies (ontogenic,
microsystem, or macrosystem; Weems & Overstreet, 2008). Research suggests that mass trauma
exposure is related to several negative posttraumatic outcomes in youth (e.g., Aber, Gershoff,
Ware, & Kotler, 2004; Eisenberg & Silver, 2011; La Greca, Silverman, Vernberg, & Roberts, 2002;
Norris, Friedman, & Watson, 2002; Osofsky, Osofsky, Kronenberg, Brennan, & Hansel, 2009;
Weems & Overstreet, 2008).
In this chapter, we draw from previous child trauma models (La Greca, Silverman, Vernberg, &
Prinstein, 1996; Lanius, Frewen, Vermetten, & Yehuda, 2010; Masten, & Narayan, 2012; Pynoos,
Steinberg, & Piacentini, 1999; Weems & Overstreet, 2008), and past research findings (e.g., Jeney-╉
Gammon et al., 1993; Kithakye et al., 2010; Marsee, 2008; La Greca et al., 1996; Punamäki et al.,
2014; Russoniello et al., 2002) to present a theoretical framework illustrating how youths’ emotion
regulation in the aftermath of natural disasters, war, or terrorism may affect posttraumatic stress
outcomes (e.g., resilience or posttraumatic stress disorder symptoms, anxiety, depression, trau-
matic grief, and aggression). Specifically, we propose that emotion regulation, at multiple levels of
analysis (neurobiological, cognitive, and behavioral), is critical to understanding youth reactions
and outcomes (both negative, such as the development of posttraumatic stress disorder [PTSD],
but also resilience) following trauma exposure. We also provide a brief overview of evidence-╉
based interventions aimed at alleviating posttraumatic stress reactions and trauma-╉related symp-
tomology highlighting techniques that focus on increasing emotional self-╉efficacy and helping
youth acquire adaptive emotion regulation skills.
event in person; or 2) “indirect or remote exposure,” such as learning of a traumatic event that hap-
pened to a close family member or friend, or experiences such as first-╉hand, repeated or extreme
exposure to aversive details of a traumatic event. Note that the DSM-╉5 does not consider exposure
to traumatic events via electronic media, such as broadcast over the internet or television, as a
qualifying traumatic event. An important difference between the DSM-╉5 and its predecessor (i.e.,
Diagnostic and Statistical Manual—╉Fourth Edition; DSM-╉IV-╉TR [APA, 2000]) is that the pres-
ence or absence of an emotional reaction (e.g., fear or horror; Criterion A2 in DSM-╉IV-╉TR) does
not determine whether an event is traumatic.
Epidemiological studies in the United States have shown that 25% of children and adolescents
in the general population will likely be exposed to at least one traumatic event by the age of 16
and that up to 20% of these trauma-╉exposed children also experience academic, emotional, and
physical difficulties across development (Costello, Erkanli, Fairbank, Angold, 2002; Copeland,
Keeler, Angold, & Constello, 2007). Prevalence rates of mass trauma exposure often depend on the
type of event and geographic region (e.g., hurricanes and earthquakes have differential probability
depending on where one lives). In terms of natural disaster exposure, Becker-╉Blease, Turner, &
Finkelhor (2010) found that the lifetime risk for disaster exposure was 13.9% among a representa-
tive sample of youth (ages two to 17 years) from the United States, while another study among
1140 children in South Africa and 901 youth in Kenya showed 16% were exposed to a natu-
ral disaster (e.g., earthquake, fire, flood; Seedat, Nymami, Njenga, Vythlingum, & Stein, 2004).
Research among children living in countries that are prone to political violence or war exposure
have shown higher rates of exposure with some estimates ranging from 90% (Crotia; Kuterovac,
Dyregrov, & Stuvland, 1994) to 100% (Bosnia; Goldstein, Wampler, & Wise, 1995). Ultimately,
mass trauma exposure is potentially highly prevalent among youth and is a global phenomenon.
mild). The prevalence rate of PTSD symptom severity for children exposed to Hurricane Andrew
decreased over time with 29.8% of children reporting severe to very severe levels at three-╉months
post-╉disaster 18.1% at seven-╉month follow-╉up and 12.5% at ten-╉month follow-╉up (La Greca et al.,
1996). In an even more recent, systemic review of 7920 youth exposed to war-╉related events (e.g.,
armed conflict), probable PTSD diagnosis ranged from 4.5 to 89.3% (pooled estimate of 47%) and
variability was mainly attributable to either study location, measurement methods or duration
since initial war exposure. For example, Weems et al. (2010) found no significant decline in PTSD
symptom severity among urban minority youth exposed to hurricane Katrina from two to two
and a half years following the storm.
Short-Term Outcomes
• Internalizing Problems
• Externalizing Problems
• Interpersonal Problems
Automatic Effortful • Poor Academic Achievement
• Biological Changes
Long-Term Outcomes
Emotion Regulation Mechanisms
Immediate Posttraumatic • Affective Disorder Onset
Stress Reactions • Substance Use
Behavioral
• Academic Failure
Negative Cognitions • Avoidance/Escape
• Exaggerated or Blunted
• Emotional Suppression
• Low Perceived Control HPA Axis Functioning
Mass Trauma • Negative Memories
Cognitive
Exposure • Negative Schemas
• Experiential Avoidance
• Natural Disaster Physiological Arousal • Rumination
• War Conflict • Distraction
• Increased Heart Rate
• Terrorism • Attention to Threat
• Cortisol Secretion
Neurobiological
Negative Affect Secondary Posttraumatic
• Fear/Anxiety • Prefrontal Cortex Stress Reactions
• Anger • Increased Parasympathetic
• Shame Activation
Physiological/Emotional
• Cortisol Reactivity
• Maintained or Increased Arousal
• Emotional Numbing
Cognitive Response
• Attentional Bias
• Cognitive Bias
• Memory Bias
Figure 18.1 An Emotion Regulation Model of Traumatic Stress Exposure in Youth and Potential Negative Outcomes
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Regulation Mechanisms in Figure 18.1; note that mechanisms on a continuum, such that a effort-
ful process may become more automatic over time or typically automatic processes come under
effortful control). Thus, the inability to effectively regulate their Immediate Posttraumatic Stress
Reactions will give rise to Secondary Posttraumatic Stress Reactions, that include cognitive biases
(sustained attention to threat, poor self-╉efficacy, or trauma memories), increased or maintained
heightened emotional arousal, and prolonged negative affect. Finally, Secondary Posttraumatic
Reactions may lead to further reliance of maladaptive or dysfunctional mechanisms via a negative
feedback loop, thus maintaining the experience of negative emotional distress (subjectively and
physiologically) and negative cognitions over time.
A vicious cycle of heightened emotional reactivity and dysregulation, coupled with negative
thought patterns, may result in short-╉and long-╉term negative sequelae (as aforementioned in the
preceding Posttraumatic Stress Outcomes section). In the short-╉term and as shown in past research,
youth may begin to experience internalizing problems (e.g., anxiety, depression; Copeland et al.,
2007), externalizing problems (e.g., aggression; Marsee, 2008; Scott, Lapré, Marsee, & Weems,
2014), interpersonal problems (e.g., peer bullying and victimization; Terranova et al., 2009a),
poor academic achievement (Scott et al., 2014; Weems et al., 2013) or certain neurobiological
changes across development (atypical maturation in amygdala volumes; Weems, Scott, Russell,
Reiss, & Carrión, 2013). Long-╉term effects may become even more serious with affective disorder
development (e.g., PTSD, Anxiety Disorders, and Major Depressive Disorder; Hoven et al., 2005;
La Greca et al., 1996), substance use (Wagner et al., 2009), academic failure (Porche, Fortuna, Lin,
& Alegria, 2011), and changes in neurobiological functioning (De Bellis, 2001; Weems & Carrión,
2007). The following sections further develop each facet of the model.
Neurobiological mechanisms
At the neurobiological level, theory and research suggest that emotional dysregulation
may largely stem from structural changes in prefrontal cortices of trauma-╉exposed youth,
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maladaptive parasympathetic-mediated control over stress responses, and both diurnal cortisol
release over time and cortisol reactivity to stress (Carrión et al., 2001; Carrión, Weems, & Reiss,
2007; Carrión, Weems, Richert, Hoffman, & Reiss, 2010; De Bellis, 2001; Feldman, Vengrober,
Eidelman-Rothman, & Zagoory-Sharon, 2013; Lou et al., 2012; Richert, Carrión, Karchemskiy,
& Reiss, 2006; Scheeringa, Zeanah, Myers, Putnam, 2004; Scott & Weems, 2014; Vigil, Geary,
Granger, & Flinn, 2010; Weems & Carrión, 2007). However, it is important to note that, relative
to other types of trauma, the study of neurobiological mechanisms among mass trauma-exposed
youth is quite limited. Nevertheless, we rely on these small, but consistent past research findings
(e.g., Feldman et al., 2013; Luo et al., 2012 Scheeringa et al., 2004; Scott & Weems, 2014; Vigil
et al., 2010; Yehuda et al., 1995; Yehuda, 2006), to illustrate how traumatic exposure may affect
neurobiological mechanisms related to emotion regulation and, in turn, their relation to mental
health problems.
Neuroimaging research comparing prefrontal cortical regions, that are theoretically linked to
cognitive emotion regulation (medial frontal cortex, orbital prefrontal cortex, dorsal prefrontal
cortex), has shown differentiated brain development and functional impairment among trauma-
exposed and non-exposed youth (see Carrión and Wong, 2012 for in-depth review). For exam-
ple, Richert et al. (2006) found that 23 youth with PTSD had larger volumes of gray matter in
the middle-inferior and ventral regions of the prefrontal cortex as compared to 24 children with
no PTSD and that decreased gray matter volume of the dorsal prefrontal cortex increased the
functional impairment of those youth with PTSD. The authors suggested that the larger volume
of the middle-inferior and ventral regions may reflect frequent prefrontal lobe activity aimed at
inhibiting emotional posttraumatic stress responses (thus maintaining PTSD symptoms), while
decreased dorsal volume may signify a predisposition towards difficulty engaging in cognitive
emotion regulation strategies, such as reappraisal. In terms of functionality, Carrión, Garrett,
Menon, Weems, and Reiss (2008) found that youth experiencing PTSD symptoms had reduced
middle frontal cortex activity and increased medial frontal activity during memory and executive
functioning tasks, as compared to an age and gender-matched healthy control sample of youth.
Together these findings suggest two possibilities: 1) youth may have predisposed deficits in reg-
ulating emotion using higher-order cognitive processing (Emotion Regulation Mechanisms in
Figure 18.1), or 2) traumatic stress exposure and subsequent maladaptive reactivity and regula-
tion may alter youths’ brain development and functionality in centers of the brain largely involved
in emotion regulation (Short or Long-Term Outcomes in Figure 8.1).
Accumulating research also has shown that maladaptive patterns of parasympathetic-mediated
control over the heart (i.e., indexed by heart rate variability [HRV] or respiratory sinus arrhyth-
mia [RSA]) is related to PTSD symptoms, anxiety, and aggression in preschoolers and adolescents
with trauma exposure (Scheeringa et al., 2004; Scott & Weems, 2014). Parasympathetic-mediated
control involves controlled modulation of emotions via a negative feedback loop between several
afferent and efferent neurobiological structures thought to be responsible for top-down emotion
regulation (e.g., nucleus ambiguus, medial prefrontal cortex) and the heart’s sinoartial (SA) node
(i.e., pacemaker) along the vagus nerve (Beauchaine, 2001; Oschner & Gross, 2005; Porges et al.,
1994; Thayer & Lane, 2000). Theoretically, the PNS’s function is to help youth maintain bodily
homeostasis during times of rest with lower resting HRV indexing a deficit in PNS-mediated
control over the heart it serves as a proxy for general emotional dysregulation (Beauchaine, 2001;
Porges, 2007; Thayer & Lane, 2000). Moreover, parasympathetic nervous system (PNS)-mediated
control allows youth to quickly and efficiently regulate the amount of time and degree of control
the sympathetic nervous system (SNS) has over bodily sub-systems (Porges et al., 1994; Thayer
& Lane, 2000). Porges (2007) posits that greater parasympathetic suppression is a flexible, adap-
tive response to stress, which in turn promotes functional behavior, while increased or blunted
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parasympathetic activation is a rigid and maladaptive response that leads to poor physical and
mental health outcomes.
In a study with 80 adolescents (ages 11–╉17 years) with whom most experienced Hurricane
Katrina or the BP Oil Spill (n = 76), we found that lower resting HRV was related to greater
anxiety problems (Scott & Weems, 2014). We also found evidence to support Porges’s (2007) the-
ory in that greater parasympathetic activation (i.e., increase in HRV from baseline to cognitive
stress task) was observed among the adolescents with higher levels of anxiety and aggression.
Schreeringa et al. (2004) found that among 144 preschool children (62 trauma-╉exposed and 62
non-╉exposed) those with high levels of PTSD had greater RSA withdrawal to a trauma reminder,
but only for those youth whose parents exhibited low positive discipline during a clean-╉up task.
Though a number of factors may explain these contradictory findings, developmentally younger
children with PTSD may display a more normative strong sympathetic-╉mediated response to
stressful situations (HRV or RSA withdrawal), but as youth continue to encounter repeated stress
responses for longer periods of time they may develop a vulnerability for emotion dysregulation
(low resting HRV) or engage in greater overcontrolling responses, such as the HRV attenuation
stress response found in our study (Scott & Weems, 2014).
Changes in neural mechanisms following stress (Carrión, Weems, & Reiss, 2007; Carrión et al.,
2010) and susceptibility to dysregulation in the normative stress response may also character-
ize individual risk for mental health problems among mass trauma victims. The persistent and
intense taxing of the stress response system over time may lead to a physiological dysregulation
of the system. Research suggests that after a period of relative cortisol hypersecretion elevated
levels may reverse in trauma exposed youth (De Bellis, 2001; Weems & Carrión, 2007) to relatively
low levels of cortisol in diurnal patterns and/╉or blunted cortisol reactivity in response to stress
(Feldman, Vengrober, Eidelman-╉Rothman, & Zagoory-╉Sharon, 2013; Yehuda, 2006). This low or
blunted cortisol response may result from an enhanced negative feedback loop at the pituitary-╉
adrenal level of the axis (Yehuda et al., 1995). A proposed mechanism for this sensitization is an
increased number of glucocorticoid receptors in the LHPA axis and, hence, facilitation of this
negative feedback loop (Yehuda, 2006). Dysregulation in the stress response system has been
associated with several mental health disorders among trauma-╉exposed youth, including PTSD,
anxiety, and depression (Feldman et al., 2013; Gunnar, 2001; Vigil et al., 2010; Weems & Carrión,
2009; Yehuda, 2006).
Cognitive mechanisms
At the cognitive level, youth seem to have a relatively large number of emotion regulation strat-
egies to use, though these higher-╉order, top-╉down regulatory processes are taxing to the indi-
vidual and more accessible to older children and adolescents (Gross, 1998b; Oschner & Gross,
2005; Richards & Gross, 2000). For example, some trauma-╉exposed youth may rely on cogni-
tive strategies that reduce emotional distress quickly (thus negatively reinforcing use), but at the
expense of chronic efforts to control internal reactions (e.g., emotional suppression, experiential
avoidance) and thus maintaining or increasing negative affect and physiological arousal over the
course of development (Polusny et al., 2011; Richards & Gross, 2000). Additionally, the use or
capability to use certain emotion regulation strategies may vary across development. Following
the September 11th attacks, Wadsworth and colleagues (2004) found an increase in the use of
emotion-╉focused coping and decreases in rumination and disengagement across adolescence to
adulthood. Cardeña and colleagues (Cardeña, Dennis, Winkel, & Skitka, 2005) reported that ado-
lescents were more likely to use distraction and disengagement than adults, who tended to use
strategies such as planning and acceptance. Furthermore, younger children exposed to trauma
may still be developing the cognitive skills to fully process the event or engage in higher-╉order
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cognitive emotion regulation (Shiner, 1998), such as reappraisal, and may be more susceptible to
engaging in temperamentally-╉driven emotional coping, such as using avoidance or withdrawal
(e.g., becoming sick and staying home from school).
A few studies have begun to examine the relation between specific cognitive emotion regu-
lation stratigies and negative outcomes in mass trauma-╉exposed youth. In one study, Polusny
et al. (2011) found that experiential avoidance (i.e., attempts at controlling, escaping, or avoid-
ing negative internal experiences) concurrently mediated the relation between disaster exposure
and PTSD symptoms among 288 adolescents exposed to severe tornados. In two other studies,
Prinstein, La Greca, Vernberg and Silverman (1996) and Noppe, Noppe and Bartell (2006) found
that distraction was associated with more severe symptoms of PTSD among hurricane exposed
youth and greater anxiety among youth remotely-╉exposed to September 11th, respectively.
Wadsworth et al. (2004) also found among 168 sixth to eight graders exposed to September 11th,
greater use of secondary control (cognitive restructuring, positive thinking, or acceptance) and
less use of involuntary engagement strategies (e.g., rumination) was related to fewer anxiety prob-
lems among all youth.
Behavioral mechanisms
At the behavioral level, youth have access to strategies that are accessible from early childhood to
regulate various emotions (e.g., fear or aggression; Buss & Goldsmith, 1998; Calkins & Johnson,
1998; Diener & Mangelsdord, 1999) and involve such behaviors as avoidance or withdrawal,
approach, suppression of emotional expression, problem solving and comfort or help seeking.
Research has shown that some of these behavioral emotion regulation strategies may shift fol-
lowing exposure to a traumatic event from typically adaptive to maladaptive strategies (Kennedy,
Charlesworth, & Chen, 2004). For instance, Kennedy et al. (2004) found in a prospective study 1-╉
2 months before and after the September 11th attacks that children remotely affected (i.e., watched
media coverage and lived in San Francisco, California) reported using more active coping strate-
gies (e.g., “think about it” and “talk to someone”) before September 11th, but after September 11th
used more avoidant coping strategies (“draw, read, or write” or “play a game”), which they viewed
as effective.
Research has shown that avoidant coping is consistently associated with greater PTSD symp-
toms (e.g., La Greca et al., 1996; Vernberg, Silverman, La Greca, & Prinstein, 1996), while active
coping (e.g., problem-╉focused) is related to lower depression symptoms in youth hurricane sur-
vivors (e.g., Jeney-╉Gammon et al., 1993). Pina et al. (2008) found that avoidant coping behaviors
(i.e., repression, avoidant actions) predicted post-╉Katrina PTSD and anxiety symptoms, which is
consistent with other research (Norris et al., 2002). Terranova, Boxer and Morris (2009b) exam-
ined predictors of PTSD symptoms in a sample of 152 sixth grade school children from southeast
Louisiana (neighboring Orleans parish) assessed at one-╉and-╉a-╉half months and eight months after
Katrina and found that negative coping (a combination of internalizing, externalizing and avoid-
ant coping) was associated with PTSD at one-╉and-╉a-╉half months. Peer victimization (i.e., being
bullied) was predictive of change in PTSD (PTSD symptoms at Time 2 controlling for symptoms
at Time 1) and results further indicated that negative coping interacted with level of hurricane
exposure to predict change in PTSD, such that high negative coping and high exposure was asso-
ciated with the highest PTSD symptoms at Time 2.
Though avoidance or withdrawal strategies have a strong and consistent relation with youth
problems post-╉trauma, other strategies have shown specific associations. For example, Wadsworth
et al., (2004) found that greater use of involuntary disengagement (e.g., emotional numbing,
escape) strategies and less use of primary control strategies (e.g., problem solving) were associated
with increased anxiety in girls exposed to September 11th. Furthermore, research also has shown
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that comfort and help seeking is associated with overall better mental health in youth exposed
to a natural disaster (i.e., 2008 Chinese Earthquake; Zhang et al., 2010) and the absence of PTSD
diagnosis among preschool children (ages one-╉and-╉a-╉half to five years) continuously exposed to
war conflicts.
Halberstadt, Thompson, Parker, and Dunsmore (2008) have demonstrated that specific parent-
ing beliefs of youths’ emotions increases the odds of the child using a specific type of emotion-╉
related coping strategy among 51 youth remotely exposed to the September 11th terrorist attacks.
That is, youth of parents who believed youth emotion was valuable was related to the child’s use of
typically adaptive coping strategies (i.e., problem-╉solving, support-╉seeking, and emotion-╉oriented
coping), while their belief that their child’s emotions were dangerous was related to typically mal-
adaptive coping strategies (i.e., avoidance and distraction). In a second study, Polusny et al. (2011)
found that the concurrent mediated relation between adolescents’ disaster exposure and PTSD
symptoms via experiential avoidance was stronger among those youth with parents experienc-
ing greater PTSD-╉related distress. In a third study, Hendricks and Borstein (2007) found, that
relations between PTSD arousal symptoms and both attentional control and cognitive avoidance
among 97 adolescents directly exposed to the September 11th attacks, disappeared once distal
contextual factors were statistically controlled for in the model (i.e., maternal personality charac-
teristics and adolescent’s perceptions of parenting), suggesting that family factors may also play a
large role in the development of PTSD symptoms beyond individual factors.
parental involvement. As a whole, TF-╉CBT does meet criteria for a well-╉established treatment (see
Silverman et al., 2008 for review) for reducing PTSD symptoms, depressive symptoms, shame, and
other emotional and behavioral problems (e.g., Cohen & Mannarino, 1996; Cohen, Deblinger,
Mannarino, & Steer, 2004; Deblinger & Heflin, 1996; Deblinger, Stauffer & Steer, 2001; Deblinger,
Steer, & Lippman, 1999; March et al., 1998).
School-╉based interventions
Increased risk created by disasters and terrorism within the family environment can be offset by
the presence of protective factors within other microsystems surrounding the child. For example,
school-╉based mental health interventions represent a protective factor within the school micro-
system that can counterbalance the negative developmental outcomes associated with mass
trauma exposure (Pynoos, Goenijian, & Steinberg, 1998). School-╉based interventions also allow
for the delivery of mental health services to a large group of youth and may serve youth whose
parents are not able to or are reluctant to seek out services in the community, or live in an area
that is struggling to meet the demand of services (i.e., reduction in mental health providers, but a
greater number of youth in need of mental health services).
One of the more promising school-╉based interventions for traumatized youth is the Cognitive
Behavioral Intervention for Trauma in Schools, which meets criteria for a “probably efficacious”
treatment of reducing PTSD symptoms (CBITS; Stein et al., 2003; Jaycox et al., 2010; Kataoka
et al., 2003). CBITS is composed of ten group sessions and one to three individual sessions and
is intended for school-╉aged youth. The therapeutic goals and components of CBITS closely align
with those of TF-╉CBT, as they focus on psychoeducation, affective modulation skills training, cog-
nitive processing, trauma narrative, in-╉vivo exposure, safety development, and include optional
sessions with parents and teachers. In a randomized field trial, Jaycox et al. (2010) compared the
efficacy of CBITS against TF-╉CBT among 195 hurricane-╉exposed youth at 15 months follow-
ing Hurricane Katrina. They found that the CBITS program was just as effective in significantly
reducing PTSD symptoms following treatment. Although the CBITS providers were limited in
their ability to tailor the intervention for each child to their specific trauma histories, as typically is
done in TF-╉CBT, CBITS was more accessible to youth, as 98% (91% completed treatment) began
the CBITS program as opposed to 23% in a community mental health clinic (15% completed).
Thus, implementing a trauma-╉focused CBT program in a naturalistic setting may bring services to
a large group of youth in a community whose citizens and infrastructure is struggling to recover
from a devastating natural disaster.
Another promising school-╉based treatment targeting mass trauma-╉exposed youth is the Grief
and Trauma Intervention (GTI; Salloum, Garfield, Irwin, Anderson, & Francois, 2009, Salloum
& Overstreet 2008; 2012). GTI is a 10-╉week school-╉based trauma and grief focused interven-
tion that was specifically designed for elementary-╉aged children (seven to 12 years of age) who
have experienced either trauma or grief associated with death, disaster, or violence. The primary
treatment components of GTI directly parallel those emphasized in TF-╉CBT (e.g., psychoeduca-
tion, affective modulation training, trauma narrative), though the active role of parents in GTI is
limited to one parent session and targets other post-╉trauma reactions, such as traumatic grief and
depression.
Salloum and Overstreet (2008) first tested the effectiveness of delivering GTI among 56 youth
(second to sixth graders) exposed to Hurricane Katina via after-╉school programs and in-╉school
mental health services (The LAST Project) just four months post-╉Katrina. Youth were randomly
assigned to an individual or group modality. Findings showed that both treatment modalities
led to fewer PTSD, depression, and traumatic grief symptoms at post-╉treatment and at a 20-╉day
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follow-╉up. In another study (Salloum & Overstreet, 2012), they randomly assigned 72 youth (sec-
ond to sixth graders) exposed to Hurricane Katrina to receive either GTI with coping skills plus
a trauma or loss narrative or GTI with coping skills only. Both treatment groups showed signifi-
cant reductions of PTSD, depression, and traumatic grief symptoms, though the GTI group who
received the trauma or loss narrative reported expressing their thoughts and feelings more, while
the GTI group who received coping skills-╉only training reported more ways of coping.
Evidence for the efficacy of similar treatment programs among youth exposed to hurricanes
and war/╉terrorism also has been demonstrated (earthquakes, Goenjian et al., 2005: war, Layne
et al., 2001; 2008). For example, Layne and colleagues (Layne et al., 2001; 2008) found sup-
port for implementing a trauma and grief group intervention (17 sessions vs. 10 sessions for
GTI) in war torn communities. More specifically, Layne et al. (2008) found in a randomized
control trial that reductions in PTSD, depressive, and maladaptive grief only occurred for the
treatment group and not for an active control group (classroom-╉based psychoeducational and
skills training) among 127 war-╉exposed youth in central Bosnia. Altogether, findings suggest
that GTI and similar treatment protocols are probably efficacious and it will be important for
future trials to include a control group (e.g., wait-╉list, well-╉established treatment for PTSD,
such as TF-╉CBT).
Weems et al. (2009; 2014) also demonstrated the efficacy of a school-╉based intervention on
reducing posttraumatic stress symptoms in the post-╉disaster environment, even when the inter-
vention was not specifically focused on treating post-╉traumatic reactions. In one study (Weems
et al., 2009), a prospective intervention design was utilized with a sample of 94 ninth graders from
New Orleans exposed to Hurricane Katrina and its aftermath. Thirty youth with elevated test
anxiety completed a primarily behavioral and exposure-╉based (e.g., relaxation training combined
with gradual exposure to anxiety-╉provoking test-╉related stimuli) group administered, test anxiety
reduction intervention. Findings suggested a statistically significant effect of the intervention on
test anxiety levels and academic performance with evidence of positive secondary effects on post-
traumatic stress symptoms (PTS). Moreover, change in test anxiety predicted change in PTS and
there appeared to be no negative effects on natural PTS symptom decline.
Only a limited number of studies have examined the efficacy of EMDR in youth exposed to
mass trauma. In one study, Fernandez (2007) showed significant reductions in PTSD symptoms
and PTSD diagnosis (61% vs. 9% from pre-╉to post-╉treatment) among 27 children (ages seven
to 11 years) who survived a primary school building collapse (27 of 59 children died) during the
2002 Molise earthquake in Italy. However, the lack of a control group limits one’s ability to dis-
cern whether reductions were due to the passage of time. In a more recent randomized trial, De
Roos et al. (2011) compared the efficacy of EMDR to CBT in 52 youth (ages four to 18 years) who
were exposed to a large fireworks factory explosion in the Netherlands. Youth in both interven-
tions showed significant post-╉treatment reductions in PTSD, anxiety, depression, and behavioral
problems and effects were maintained at three-╉month follow up, though EMDR produced these
results using fewer sessions. As with the Grief and Trauma Intervention, EMDR is a promising
treatment option for mass trauma-╉exposed youth, but further research with a control group is
needed to elucidate the efficacy and effectiveness of EMDR to ameliorate negative posttraumatic
outcomes.
Another component “Affective Expression and Modulation” occurs when the therapist asks the
child-╉parent dyad to share and talk about their feelings and to engage in written or verbal exer-
cises (e.g., produce a list of feelings in three minutes) and games (e.g., Emotional Bingo, Mitlin,
1998) aimed at helping the child identify their feelings. The dyad also learns a number of affective
modulation strategies (i.e., thought interruption, positive imagery, positive self-╉talk, and problem
solving through social skill building) to combat negative and intrusive cognitive-╉affective states
via guided instruction and in-╉session practice. In Cognitive Coping and Processing the child-╉
parent dyad is taught how to generate alternative thoughts that may aid them in changing the way
they feel.
Three studies have provided some support for the efficacy of TF-╉CBT among youth exposed
to mass trauma. In one study, Jaycox et al. (2010) showed that TF-╉CBT was just as efficacious
in reducing PTSD symptoms as the school-╉based CBITS (Jaycox, 2003), though the effective-
ness of such treatment in disaster settings is still debatable given the low frequency of youth
beginning or completing TF-╉CBT (23% and 15%, respectively). In a second study among 306
youth exposed to the September 11th World Trade Center terrorist attacks, researchers for
the CATS Consortium (2010) compared the effects of TF-╉CBT (12–╉20 sessions; adolescents
received the trauma and grief component therapy for adolescents [Layne et al., 2002], which
has comparable components) to a brief CBT program that included a parent component (4
sessions) at six-╉months post-╉treatment. Though youth were not randomly assigned to the
conditions given ethical and methodological issues cited by La Greca and Silverman (2009),
the researchers did employ a regression discontinuity (needs-╉based assignment), which allows
for comparison of regression slopes and intercepts across treatment groups (instead of mean
level comparisons). The results showed reductions in PTSD symptoms from pre-╉intervention
to six-╉month follow-╉up across both groups. However, youth assigned to the TF-╉CBT group had
greater trauma exposure and more environmental adversity (e.g., victimization) at baseline
and showed more clinical improvement on average as they moved from probable PTSD criteria
(as based upon the PTSD Reactions Index; Mpre-╉treatment = 36.61 vs. M6-╉month follow-╉up = 17.03;
scale ranges from zero to 80) to mild PTSD symptom criteria following treatment. In a third
study, Schreeringa et al. (2011) showed that TF-╉CBT may even be a viable treatment option
for younger children who experience traumatic events. Specifically, they found that PTSD
symptoms significantly decreased from pre-╉to post-╉treatment for those traumatized pre-╉
school children (three to six years of age) who received and completed treatment immediately
upon entering the study, as compared to wait-╉list control children assessed during the same
time frame.
Conclusions
In summary, mass trauma-╉exposed youth utilize a number of mechanisms or strategies that span
across neurobiogical, cognitive, and behavioral domains in an effort to regulate their negative
emotional responses following trauma exposure (Kennedy et al., 2011). Review of the findings
presented in this chapter further suggests that negative outcomes of PTSD symptoms, anxiety,
and depression are associated specifically with certain neurobiogical markers of poor emotion
regulation, such as structural and functional changes in prefrontal cortical regions, low HRV at
rest and blunted or increased HRV to stress, and lower cortisol responses over time. In addi-
tion, PTSD has been associated with the frequent use of maladaptive cognitive strategies such as,
experiential avoidance, distraction, and rumination; and behavioral emotion regulation strategies
such as avoidance, escape, and emotional suppression (Feldman et al., 2013; Jeney-╉Gammon et al.,
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Conclusions 389
1993; Kithakye et al., 2010; Noppe et al., 2006; Pina et al., 2008; Polusny et al., 2011; Prinstein
et al. 1996; Punamäki et al., 2014; Russoniello et al., 2002; Scott & Weems, 2014; Terranova et al.,
2009b;Vigil et al., 2010; Wadsworth et al., 2004). However, and as with many other psychological
processes, emotion regulation likely does not occur in isolation and youth may attempt to use
many strategies (either consciously or non-consciously) during a stressful situation. Conceptually,
youth may automatically respond to a particular trauma reminder or stressful event at first, but
if distress continues, may progressively move through more effortful emotion regulation strat-
egies until emotional distress subsides. Thus, over time youth may develop certain sequential
patterns of responding to both positive and negative emotional events. It would be beneficial for
researchers to use mixed modeling approaches (e.g., latent growth models; see Gullone, Hughes,
King, & Tonge, 2010 for example of using such methods to measure change in emotion regulation
over time) to examine patterns of emotion regulation mechanisms and whether they are uniquely
related to posttraumatic stress outcomes among trauma-exposed youth.
Additionally, emerging research has already begun to test the mediating processes of emo-
tion regulation as proposed in our conceptual framework and has shown evidence for a link
between mass trauma exposure and negative outcomes via emotion regulation (Polusny et al.,
2011; Marsee, 2008). However, it is still relatively early to draw definitive conclusions on causal
inferences, as these two studies were cross-sectional and focused on a single cognitive emotion
regulation strategy and general emotional dysregulation. Furthermore, it seems that contextual
factors, such as temperament and parenting behaviors, influence whether youth develop or con-
tinue to have problems following trauma (Halberstadt et al., 2008; Hendricks and Borstein, 2007;
Kithakye et al., 2010; Lengua et al., 2005; Punamäki et al., 2014; Polusny et al., 2011; Terranova
et al., 2009b). Future research will need to address the mediating and moderating role of emotion
regulation in the development and maintenance of youth outcomes using both prospective (i.e.,
pre-and post-trauma) and longitudinal designs that can capture time dependent changes in emo-
tion regulation mechanisms and posttraumatic stress outcomes independently and in relation to
one another. Researchers will also need to carefully consider developmental factors, as younger
children may be more prone to using maladaptive strategies (e.g., avoidance) as their access to
high-order cognitive abilities is limited.
Most of the aforementioned studies also relied on broad coping measures to capture emotion
regulation strategies, though the strategies measured may go beyond specifically changing or
modulating an emotional response and tell us little about youths’ ability to modulate emotions
in non-stressful situations (Compas et al., 2014). For example, seeking social support or com-
fort from parents, peers, or teachers during a stressful time may serve to ease worries about
losing a house or a loved one following a natural disaster (regulation of negative cognitions)
or blaming others may reduce stress (not necessarily related to an emotion) through migrat-
ing responsibility on environmental factors. Researchers also need to take caution when using
coping measures to predict child psychopathology symptoms or other negative posttraumatic
stress reactions as there is considerable overlap in measure constructs and items (e.g., behav-
ioral avoidance is a DSM-5 defined symptom of PTSD) and thus increases the odds of relations
being driven by shared method variance (Pfefferbaum, Noffsinger, Wind, & Allen, 2014).
In closing, it is important to note that effective interventions that target emotion regulation
skills are available to youth experiencing mental health difficulties following mass trauma expo-
sure. However, little is known about whether change in emotion regulation (increase in efficacy
or greater or lesser use of specific strategies) is the mechanism that leads to reductions in negative
outcomes following treatment or whether these skills require booster sessions to solidify their
flexible and adaptive usage.
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3
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Chapter 19
Nonsuicidal self-injury
Nonsuicidal self-╉injury (NSSI) is the deliberate damage to the body in the absence of fatal intent
(Nock, 2009). As well as being a symptom criterion for a diagnosis of Borderline Personality Disorder
(BPD; American Psychiatric Association, APA, 2013), NSSI is uniquely associated with symptoms
of depression, anxiety, substance abuse, and reduced well-╉being (Dilberto & Nock, 2008; Giletta,
Scholte, Engels, Ciairano, & Prinstein, 2012; Hankin & Abela, 2011; Hilt, Nock, Llloyd-╉Richardson,
& Prinstein, 2008). NSSI is distinguishable from other self-╉harm behaviors, such as substance use,
where the harmful consequences of the behavior are usually unintended, and from suicidal behavior
where the consequences are intended to be fatal (Nock, 2012). Yet, although distinct from suicidal
behavior, NSSI is a risk factor for later suicide (Klonsky, May, & Glenn, 2013; Whitlock et al., 2013).
Highlighting the transdiagnostic nature of NSSI (for discussion see Bentley, Cassiello-╉Robbins,
Vittorio, Sauer-╉Zavala, & Barlow, 2015), and the significant impact of the behavior on psychological
health and well-╉being, the APA recently included NSSI as a condition requiring further research in
the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-╉5; APA, 2013).
Theoretical perspectives on NSSI suggest poor emotion regulation is critical to the aetiology
and maintenance of the behavior. Regulation of negative emotional states is frequently cited as the
predominant motivation for engaging in the behavior (Klonsky, 2009; Martin et al., 2010; Nock
& Prinstein, 2004; Nock, Prinstein, & Sterba, 2009), and evidence-╉based interventions focus-
ing on improving individuals’ skills and capacity for emotion regulation hold promise for the
treatment of NSSI (e.g., Gratz & Tull, 2011). “Emotion regulation” in this context refers to a set
of responses that contribute to initiating, maintaining and modifying the occurrence, intensity,
duration and expression of emotion (Gross, 1998a, 1998b). These responses are both conscious
and unconscious, and may be both effortful and automatic (Gross, 1998a, 1998b; Koole, 2009).
Specific emotion regulation processes that have been implicated in NSSI, which will be focused
on in this chapter, include rumination, cognitive reappraisal, and expressive suppression (Armey
& Crowther, 2008; Hasking, Momeni, Swannell, & Chia, 2008; Hasking, Coric, Swannell, Martin,
Thompson, & Frost, 2010; Hilt, Cha, & Nolen-╉Hoeksema, 2008; Martin et al., 2010).
In the next sections, we describe the nature and extent of NSSI, differentiating it from suicidal
behavior. We broadly discuss the role of emotion regulation in the development, expression, and
maintenance of the behavior, and discuss specific emotion regulation processes and how they
might be implicated in NSSI. Finally, we discuss intervention approaches for NSSI and the evidence
related to their effectiveness. We conclude with the observation that although there are currently
no treatments developed specifically for NSSI among adolescents, and that treatment approaches
for self-╉harm (broadly defined) have inconclusive evidence regarding their effectiveness for this
population, findings from both empirical and intervention research, provide promising leads.
93
this section we present theories and perspectives which highlight emotion regulation as a critical
factor in understanding NSSI.
maladaptive coping styles play a role in NSSI. Indeed, Haines and Williams (1997) reported that
people who self-╉injure have difficulty coping with problems. Others have found that reliance on
avoidant coping strategies is associated with the presence of NSSI among adolescents (Evans,
Hawton, & Rodham, 2005), young adults (Andover, Pepper, & Gibb, 2007; Borrill, Fox, Flynn, &
Roger, 2009; Brown, Williams, & Collins, 2007), and adult prisoners (Kirchner, Forns, & Mohino,
2008). These studies suggest individuals who engage in NSSI are less likely to use coping strategies
aimed at resolving problems and are more likely to engage in avoidant behaviors which potentially
maintain high levels of emotional arousal.
It is unsurprising then that self-╉injurers are also more likely to engage in emotion-╉focused cop-
ing strategies (Borrill et al., 2009; Mikolajczak, Petrides & Hurry, 2009); perhaps in an attempt to
cope with the resultant negative emotions arising from problem avoidance. Interestingly, Williams
and Hasking (2010) reported that, when experiencing psychological distress, individuals who
relied on avoidant coping strategies were more likely to have higher scores on a measure of NSSI
which took into account the frequency, recency, severity and range of methods of self-╉injury used.
Further, the relationship between psychological distress and NSSI was positive among study par-
ticipants who did not rely on emotion-╉focused coping strategies, suggesting that inability to cope
effectively with distressing emotions is implicated in NSSI.
The cross-╉sectional nature of the above studies preclude conclusions regarding causal relation-
ships; however, they indicate that NSSI is associated with a constellation of behaviors aimed at
avoiding problems which, in turn, maintain emotional turmoil occasioned by these problems.
Lack of effective emotion-╉focused coping may leave individuals with no other recourse than
to engage in NSSI to alleviate their negative emotional states. Such a dynamic is proposed in
the Experiential Avoidance Model of NSSI (Chapman, Gratz, & Brown, 2006) which conceptual-
izes self-╉injury as a means of avoiding unwanted internal experiences such as bodily sensations,
thoughts, memories and emotions, and the events and contexts that occasion them.
The Experiential Avoidance Model of NSSI provides a theoretical framework that makes sense
of the empirical findings in the coping literature and accounts for the initial motivation for prob-
lem avoidance as a means to avoid or escape from unwanted thoughts, memories and emotions
associated with stressful situations and life events. According to the model, limited access to effec-
tive strategies to regulate emotional arousal is a key factor, as their absence leaves individuals to
contend with their unwanted emotions which are often experienced as intense. Without effective
strategies to modulate their emotional states, individuals use NSSI to further escape from them.
Chapman and colleagues (2006) contend that the behavior is maintained through behavioral rein-
forcement and may become rule governed through verbal rules which specify that NSSI is related
to feeling better.
that while Nock and Prinstein identified two functional domains for NSSI, they acknowledged
that regulating emotional states (i.e., the intrapersonal domain) was more commonly reported by
people who self-╉injure. Accordingly, the authors observed that the social/╉interpersonal function
of NSSI may be secondary to the intrapersonal function of feeling better.
2010; Webb, Miles, & Sheeran, 2012). It describes five emotion regulation processes that contrib-
ute to how emotions might be experienced and expressed. The first of these emotion regulation
responses is situation selection which describes the process whereby an individual chooses to enter
into and engage in different types of situations which might evoke different emotions. Individuals
might choose to engage in NSSI as an alternative to engaging in situations which they anticipate
will cause distress (McKenzie & Gross, 2014). They may also engage in NSSI as a means to enter
new and more desired situations (e.g,. going to hospital and receiving medical attention).
The second is situation modification—╉where individuals might choose to alter the situation in
which they find themselves so as to increase or decrease the likelihood of experiencing specific
emotions. Consistent with Nock and Prinstein’s (2004) Functional Model of NSSI, individuals
engage in NSSI to elicit alternative responses from others which in turn modifies the situations
in which they find themselves (e.g., increased caregiving or reductions in external demands from
others; McKenzie & Gross, 2014).
Attentional deployment refers to the selective attention to different aspects of a situation.
Therefore, an individual might choose to attend to aspects of a situation that are likely to evoke
specific types of emotional responses or may choose to disregard or distract from these emo-
tional cues. Importantly, Webb and colleagues (2012) observe that attentional deployment can
be applied to internal experiences such as memories where the individual is re-╉immersed in the
initial situation that gave rise to the emotion that is then re-╉experienced. Although not conceptu-
alized within Gross’ model of emotion regulation, Webb and colleagues (2012) classified rumina-
tion as an example of attentional deployment which is consistent with its definition in Selby and
Joiner’s (2009) Emotional Cascade Model for Dysregulated Behaviours as rumination continually
focuses attention on emotionally relevant stimuli. Several of the theories described above suggest
that NSSI is a form of attentional deployment, with the Experiential Avoidance Model of NSSI
positing that it distracts from aversive internal experiences.
A fourth emotional regulation response is cognitive change which refers to the interpretations
and appraisals placed on emotionally relevant stimuli. McKenzie and Gross (2014) suggest NSSI
might be a mechanism by which individuals change their self-╉views: Transforming higher-╉order
self-╉construals that may be overwhelmed by responsibilities and external demands and, therefore,
lead to negative emotional states, to lower-╉order self-╉construals focusing on bodily experiences
which may not evoke the same intensity of emotion. Alternatively, individuals may engage in
cognitive change to reinterpret and ascribe different meanings to specific emotional stimuli so as
to change their emotional experience.
Finally, individuals can choose to limit the expression of the emotional response through
response modulation and in doing so regulate the behavioral, experiential, and/╉or physiological
expression of the emotion. Engaging in NSSI might be a form of response modulation as the
subsequent release of endogenous opioids soothes the physiological arousal that accompanies
negative emotional states (McKenzie & Gross, 2014).
positive emotion; and increased experience of negative emotion and lower expression of negative
emotion, which has been associated with negative health outcomes (Gross & John, 2003). Among
adolescents, the reduced use of cognitive reappraisal in conjunction with a greater tendency to
engage in expressive suppression is related to depressive symptomatology, school refusal and anx-
iety (Betts, Gullone, & Allen, 2009; Hughes, Gullone & Watson, 2011; Hughes, Gullone, Dudley,
& Tonge, 2010). These studies hint at the protective effect of reappraisal and suggest expressive
suppression is associated with maladaptive outcomes in psychological health and reduced well-
being among adolescents.
Given the contribution of cognitive reappraisal and expressive suppression in the regulation
of negative states, it may be speculated that the ability to effectively engage in reappraisal might
reduce the likelihood of engaging in NSSI, as it is likely to reduce the intensity and duration of
negative emotion. Expressive suppression, on the other hand, would therefore increase the likeli-
hood of engaging in NSSI as it has the tendency to increase the experience of negative emotion.
In support, among adolescents aged 13–18 years (Hasking et al., 2010), and young adults aged
18–30 years (Williams & Hasking, 2010), cognitive reappraisal was negatively correlated with
NSSI; whereas, expressive suppression had a positive correlation. Comparisons between groups
of 18–30 year olds who did not engage in NSSI, those who engaged in infrequent and low sever-
ity NSSI, and those who engaged in frequent (at least once per month) NSSI which resulted in
wounds requiring first aid, revealed significant group differences in mean scores for expressive
suppression, but not for cognitive reappraisal (Hasking et al., 2008). The moderate/severe group
had the highest mean score for expressive suppression, while those who did not engage in NSSI
had the lowest. In other work, while there were differences in the use of cognitive reappraisal
between self-injurers and non-self-injurers aged ten years and above, no differences were found
for the use of expressive suppression (Martin et al., 2010). In the latter study, individuals who
self-injured were 3.3 times more likely to report difficulty with using reappraisal to regulate their
emotional states compared with those who did not self-injure.
The discrepant findings in the above studies may be due to different criterion variables under
investigation. Hasking and colleagues (Hasking et al., 2008, 2010; Williams & Hasking, 2010) were
interested in frequency, recency and severity of NSSI; whereas, Martin and colleagues (2010)
focused on NSSI history. It might be that the two emotion regulation processes have differential
contributions to the presence of NSSI (i.e,. whether and when individuals engage in the behavior),
and to the severity of the behavior (i.e,. the extent to which they engaged in the behavior in regard
to frequency, recency, severity etc.). Cognitive reappraisal may be more pertinent in the former
case; while, expressive suppression may be related to the latter (see Voon, Hasking & Martin,
2014a).
Such an observation is consistent with findings from earlier studies on a related construct of
emotional inexpressivity. A personality trait which confers a tendency to restrict displays of emo-
tions regardless of the valence of the emotion or the manner of expression, it is similar to expres-
sive suppression. Research findings show that although emotional inexpressivity did not reliably
distinguish undergraduates with and without a history of NSSI (Gratz, 2006; Gratz & Chapman,
2007), it was significantly associated with frequency of NSSI among women who engaged in NSSI
(Gratz, 2006; Gratz & Roemer, 2008).
A set of studies from a longitudinal dataset produced mixed findings. In two, neither cognitive
reappraisal nor expressive suppression predicted first episode NSSI among adolescents (Andrews,
Martin, Hasking & Page, 2014; Tatnell, Kelada, Hasking & Martin, 2014); although, findings by
Voon, Hasking, and Martin (2014b) suggest reappraisal may protect against NSSI onset in younger
cohorts. Further, Voon, Hasking, and Martin (2014c) suggest persistent and increasing use of cog-
nitive reappraisal may have a slight protective effect in reducing medical severity of NSSI although
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it did not contribute to changes in frequency and duration of the behavior over a two-╉year period.
Use of expressive suppression, while differentiating youth who self-╉injured from youth who did
not, had no bearing on NSSI over the same two-╉year period. Finally, Andrews, Hasking, Martin,
and Page (2013) reported adolescents who continued to engage in NSSI 12-╉months from baseline
reported less tendency to engage in both cognitive reappraisal and expressive suppression com-
pared with adolescents who stopped self-╉injuring, which is consistent with the general consensus
that NSSI is associated with deficits in emotion regulation.
The above studies suggest cognitive reappraisal and expressive suppression are pertinent con-
structs in the underlying processes of NSSI, although further research is required to clarify their
roles. Given NSSI is used as a means of emotion regulation, with the assumption being that this
strategy is used when other emotion regulation techniques are lacking, increased understanding
of what kinds of emotion regulation processes among adolescents are most effective in modulat-
ing the negative emotional states that precede or co-╉occur with NSSI can be beneficial in refining
interventions.
Cognitive-╉behavioral therapy (CBT)
CBT is a treatment approach that comprises both cognitive and behavioral components (Stoffers
et al., 2012). One of the earliest interventions applied to self-╉harm behaviors is a form of CBT
known as Problem Solving Therapy (Brausch & Girresch, 2012; Washburn et al., 2012). The inter-
vention assists individuals to cope with and resolve problems and includes cognitive restructuring
to engender a more positive orientation to problems, as well as skills training in coping and ratio-
nal problem-╉solving. Use of this intervention to address self-╉injurious behaviors draws on early
conceptualisations of such behaviors as a general deficit in coping skills. However, the strength of
evidence for the intervention was weak (Brausch & Girresch, 2012; Washburn et al., 2012). While
initial evaluations were promising (showing a trend towards reductions in self-╉harm behaviors),
the intervention did not produce statistically significant differences compared to controls.
The need for more comprehensive intervention approaches to self-╉harm behaviors led to the
development of Manual Assisted Cognitive-╉Behavioral Therapy (MACT; Washburn et al., 2012).
This intervention integrates CBT with solution-╉focused therapy and includes a bibliotherapy
component aimed at improving emotion regulation, and coping with negative cognitions (Kerr et
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al., 2010). Conducted over six sessions, MACT includes a functional analysis of self-╉harm behav-
iors, education on emotion regulation and problem-╉solving strategies, management of negative
thinking, management of substance use, and relapse prevention (Weinberg, Gunderson, Hennen,
& Cutter, 2006). Two early evaluations of MACT showed reductions in frequency of self-╉harm
and duration between self-╉harm episodes in the intervention group, but these outcomes were not
significantly different from similar reductions in the control group (see Evans et al., 1999; Tyrer
et al., 2003). Kerr and colleagues (2010) noted that the non-╉significant results in these studies
could be due to the heterogeneity in how the intervention was delivered. Following these trials,
Weinberg and colleagues (2006) evaluated the efficacy of MACT in reducing NSSI and suicide
attempts among women with BPD (aged 18–╉40 years). Participants were randomly assigned to a
MACT intervention or treatment-╉as-╉usual (TAU). The authors reported significant reductions in
frequency of NSSI post-╉treatment as well as at six-╉month follow-╉up. Moreover, NSSI severity was
significantly lower compared with TAU at follow-╉up.
Further emphasising the utility of focussing on factors other than coping with and resolving
problems, Slee, Garnefski, van der Leeden, Arensman, and Spinhoven (2008) developed and eval-
uated a CBT intervention to address deliberate self-╉harm among 15-╉35 year olds and reported
significant reductions over nine months in the number of self-╉harm episodes among the interven-
tion group compared with TAU. The intervention comprised 12 individual sessions focussing on
identifying cognitive and emotional factors maintaining self-╉harm behaviors, and included the
use of cognitive and behavioral strategies to address these maintaining factors. Strategies include
addressing cognitive distortions, emotion regulation, and problem-╉solving. A follow-╉up study
(Slee, Spinhoven, Garnefski & Arensman, 2008), showed that improved emotion regulation par-
tially mediated reductions in self-╉harm following the intervention.
More recently, Taylor and colleagues (2011) evaluated the efficacy of a similar intervention
(Manualised Cognitive-╉ Behavioral Therapy) developed specifically for adolescents aged 12–╉
18 years. This intervention comprised eight to 12 individual therapy sessions utilising a standard
manual which included modules on identifying cognitive and emotional triggers for self-╉harm
behavior, as well as modules teaching skills in managing cognitive distortions, mindfulness,
problem-╉solving, and assertiveness. Preliminary findings were promising and showed reductions
in frequency of deliberate self-╉harm post-╉treatment and at three-╉month follow-╉up. However, the
study did not include a control group and, therefore, inferences regarding its efficacy cannot be
made conclusively.
Stage 1 DBT as developed by Linehan is designed to be completed over a 12-╉month period with
weekly one-╉hour individual therapy sessions, and two-╉and-╉a-╉half-╉hour group skills training ses-
sions covering the following topic areas over two rotations:
1. Mindfulness
2. Distress tolerance
3. Emotion regulation
4. Interpersonal effectiveness
The explicit focus on emotion regulation not only underscores the importance of emotion regu-
lation in dysregulated behaviors, but differentiates DBT from similar therapies. Similar to CBT-╉
based interventions described above, individual therapy sessions focus on the identification of
cognitive, emotional and situational triggers for target self-╉harm behaviors, and counselling/╉
coaching on the use of appropriate cognitive and behavioral skills to cope with these triggers
(Koerner & Dimeff, 2007). This is achieved through the use of chain analysis which proceeds with
identifying antecedent factors leading up to the focal behavior (typically self-╉harming behaviors
such as NSSI). These antecedent factors include situational, social, cognitive and emotional fac-
tors. The aim of chain analysis is to identify points at which individuals may interrupt the chain of
events leading up to the behavior. As such, unlike CBT-╉based approaches, chain analysis does not
just focus on temporally proximate antecedent triggers. For example, an individual may identify
feeling angry as a precursor to NSSI. The negative emotional state may be preceded by a comment
from a family member or friend. Negative cognitions arising from the comment may also be iden-
tified, as well as general factors such as feeling physically unwell or stressed which can contribute
to the individual’s overall vulnerability or sensitivity. Using chain analysis, the therapist will work
with the client to recognize the vulnerabilities associated with feeling unwell/╉stressed and nega-
tive cognitions and to identify strategies to prevent future recurrence of the behavioral chain.
Evaluations of DBT among adults with BPD have demonstrated reductions in self-╉harm among
participants. Stoffers and colleagues (2012) reported that the pooled effect from three trials
undertaken between 2001 and 2005 showed significant reductions compared with TAU. However,
a more recent Australian trial (Carter, Wilcox, Lewin, Conrad & Bendit, 2010) did not find sig-
nificantly different results between a modified DBT program and TAU.
DBT has been adapted for adolescents (DBT-╉A) by decreasing duration of treatment to a 16-╉
week program, using age-╉appropriate terminology and inclusion of family members in the skills
training groups (Groves, Backer, van den Bosch, & Miller, 2012). However, these programs have
not been subjected to randomized control trials and results are mixed (Brausch & Girresch, 2012;
Kerr et al., 2010; Washburn et al., 2012). Non-╉significant group differences were reported when
comparing DBT-╉A with TAU on suicide attempts (Rathus & Miller, 2002) and self-╉harm (Katz,
Cox, Gunasekara & Miller, 2004). Two other studies reported significant post-╉treatment reduc-
tions in self-╉harm (James, Taylor, Winmill & Alfoadari, 2008) and NSSI (Fleischhaker et al., 2011);
although the absence of a control group limits conclusions regarding the efficacy of these inter-
ventions among adolescents.
Mentalization-╉based therapy (MBT)
MBT draws on psychodynamic theories (Kerr et al., 2010; Stoffers et al., 2012), and aims to
“strengthen patients’ capacity to understand their own and others’ mental states in attachment
contexts in order to address their difficulties with affect, impulse regulation, and interpersonal
functioning which act as triggers for acts of suicide and self-╉harm” (Bateman & Fonagy, 2009,
p. 1355). Thus, MBT assists with improved interpersonal function by building individuals’ capac-
ity to mentalize and be aware of how thoughts and emotions influence their own and others’
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behaviors (Kerr et al., 2010). Stoffers and colleagues (2012) noted that, comparing the interven-
tion with TAU, MBT achieved significant reductions in self-╉harm among adults in two trials
undertaken in 1999 and 2009.
More recently, Rossouw and Fonagy (2012) reported findings from a randomized control trial
of MBT for adolescents. Significant group differences among adolescents randomly assigned to
the MBT treatment group versus TAU controls were found. Those in the treatment group had
lower scores on self-╉harm at the end of the 12-╉month period, and showed greater reductions
in self-╉harm over the course of treatment. Although results are promising, further replication is
required.
1 The intervention groups comprised of the “RCT” group in Gratz & Gunderson (2006) and the “open trial
completers” in Gratz & Tull (2011). The control group were the TAUs in Gratz & Gunderson (2006).
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Conclusion 409
useful component in interventions for NSSI. As described above, reappraisal features in several
existing interventions, in the form of cognitive restructuring to address cognitive distortions
and beliefs.
Although specific interventions for NSSI in adolescence have yet to be developed, the above
observations dovetail with available intervention approaches for self-╉harm behaviors generally.
Emotion regulation skills that feature in these intervention approaches include: Cognitive restruc-
turing to address cognitive distortions and negative thinking styles such as in CBT-╉based inter-
ventions; acceptance of emotions through mindfulness and use of distraction as featured in DBT;
and awareness of emotion and their contribution to actions and behaviors as in DBT (see emotion
regulation module) and MBT. The current state of intervention research for self-╉harm behaviors
does not at present point to any single component which influences treatment outcome. It is likely
that a combination of these skills is warranted as the research suggests comprehensive approaches
which address cognitive and emotional triggers for NSSI have greater utility. Further examination
of how specific emotion regulation processes contribute to or modulate the underlying emotional
distress which precedes or accompanies NSSI is warranted to assist with identifying further areas
for inclusion in treatment for the behavior.
Glenn, Franklin, and Nock (2014) highlight that in addition to emotion regulation skills train-
ing, effective interventions for self-╉harm also include: 1) A focus on improving interpersonal
functioning, 2) high intensity and frequent sessions, and 3) incorporation of interventions to
address other co-╉occurring maladaptive behaviors or risk factors such as substance use. These
may be applicable to treatment interventions for NSSI among adolescents.
In the absence of empirically tested interventions for NSSI among adolescents, Washburn and
colleagues (2012) distilled from the available literature additional elements to guide the man-
agement and treatment of NSSI among this population group. They suggest that assessment for
NSSI is important and should, at a minimum, aim to improve understanding of current and past
behaviors including methods, locations, frequency, severity, urges and age of onset. Motivational
enhancement (e.g., through motivational interviewing) may be necessary both prior to and dur-
ing treatment. Additionally, cognitive and behavioral interventions can be useful to address self-╉
derogatory and distorted beliefs about NSSI (e.g., through Socratic questioning and thought
monitoring), and include contingency management and behavioral activation. Dialectical strate-
gies such as acceptance and tolerance of distress may also be useful to address the urge to engage
in NSSI.
More broadly, Washburn and colleagues suggest individuals may benefit from interpersonal
approaches to understand and modify maladaptive interpersonal styles which may coincide with
the negative emotional states that precede or accompany NSSI. Skills training is likely to be central
and should focus on improving emotion regulation, problem-╉solving, interpersonal and commu-
nication skills. In addition, treatment may need to focus on physical factors such as body image
and physical self-╉care.
Of particular importance is the need to address “social contagion” when working with groups
(Washburn et al., 2012). It ought to be noted that some DBT skills training groups address this by
expressly discouraging discussion of the types of self-╉harm behaviors participants engage in. Finally,
“contracts for safety” or “no-╉harm agreements” can be either ineffective or harmful, and treatment
should focus on contingency management and relapse prevention instead (Washburn et al., 2012).
Conclusion
NSSI is a behavior that typically begins during adolescence and adversely impacts on psychologi-
cal health and well-╉being. Frequency of NSSI during adolescence predicts its maintenance into
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adulthood, as well as increasing risk for suicide behavior. Consequently, prevention and early
intervention addressing the behavior among adolescents is of critical importance.
The general consensus is that NSSI is a behavior that functions to alleviate negative emo-
tional states. While distal factors such as a genetic predisposition to emotional sensitivity and
reactivity may interact with invalidating childhood environments to predispose individuals
toward a vulnerability to engaging in NSSI, poor emotion regulation is likely to maintain the
behavior. It is, therefore, unsurprising that interventions to address behaviors such as NSSI
have focused on building individuals’ capacity for emotion regulation. While there are no spe-
cific interventions that have been developed solely for NSSI among adolescents, the existing
interventions for self-╉harm behaviors provide promising leads. Research findings on specific
emotion regulation processes (e.g., cognitive reappraisal, expressive suppression, and rumi-
nation) and how they may be implicated in increasing or decreasing the emotional arousal
associated with NSSI provide further clues that can assist with developing better targeted
interventions among adolescents. This is particularly important as the evidence for effective
interventions for adolescents addressing self-╉harm behaviors such as NSSI remain inconclu-
sive. Thus, replication and adaptations of existing intervention approaches accompanied by
rigorous evaluation is therefore, warranted.
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Part IV
Epilogue
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Chapter 20
Transdiagnostic approaches
The broad construct of emotion regulation refers to multiple and diverse processes that individu-
als use to modulate emotional experience and involves neuro-╉anatomical, neuro-╉chemical, physi-
ological, behavioral, cognitive, and interpersonal systems, among others (Gross, 1998). Systems
are divided into multiple domains for greater specificity (e.g., the cognitive system can be under-
stood across adaptive and maladaptive cognitive strategies; automatic and conscious processes),
and domains can be separated further into sub-╉domains (e.g., automatic cognitive processes can
be broken down into particular strategies, such as suppression, distraction, and cognitive avoid-
ance). Each of these regulatory processes can be defined, assessed, and conceptualized along con-
tinuous or (likely arbitrarily defined) discrete dimensions.
These multiple regulatory systems and domains operate in close coordination, as activation of
one system typically calls for response (either activation or inhibition) of other systems (Werner
& Gross, 2010). As an example, behavioral problem solving (generating and weighing options;
choosing and acting on decisions) calls for the activation of multiple cognitive, physiological, and
behavioral systems. It is no surprise that such coordinated emotion regulation processes have
been implicated in the onset, maintenance, and amelioration of nearly every psychological disor-
der or problem set (Kring & Sloan, 2010).
Such a complex and influential system deserves an epistemological approach that honors
the inter-╉dependent nature of emotion regulatory systems. An explicit transdiagnostic research
agenda recognizes this complexity and inter-╉relatedness amongst systems and has the potential
to optimize research efforts across pathology groups and regulatory systems. The modern-╉day
transdiagnostic research agenda emerged from two parallel efforts (Ehrenreich-╉May & Chu, 2013;
Mansell et al., 2009). First, pathology researchers were interested in explaining the tremendous
co-╉occurrence (comorbidity) amongst related disorders and increasing understanding of what
mechanisms accounted for commonalities in presentation, impairment, and development across
disorders. Until the turn of the millennium, clinical research was frequently conducted in the
context of single-╉disorder research agendas. Efforts by experts across diverse fields of clinical psy-
chology (Barlow, Allen, & Choate, 2004; Fairburn, Cooper, & Shafran, 2003; Harvey, Watkins,
Mansell, & Shafran, 2004) attempted to summarize converging lines of evidence generated in
isolation of each other. Transdiagnostic work signaled a desire to identify and integrate these con-
verging lines of research that helped explain the commonalities and distinctions across disorders
and problem sets.
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A second aim of transdiagnostic research sought to economize and enhance the effects of
evidence- based treatments for psychological disorders. Most evidence- based intervention
research has produced treatment protocols designed to treat a single disorder, resulting in literally
hundreds of distinct treatment protocols to treat individual problem areas (Chorpita & Daleidan,
2009), despite the fact that the majority of protocols were primarily comprised of a highly over-
lapping set of clinical practices (e.g., in vivo exposure, problem solving). Thus, a second goal of
transdiagnostic research has been to consolidate evidence-based interventions into a more effi-
cient set of empirically-supported practices. It has also been hypothesized that treatments might
gain robustness to the degree that common practices targeted core underlying mechanisms that
maintained the diverse classes of pathology.
A transdiagnostic framework might be particularly relevant for children and adolescents. The
high rates of comorbidity (the co-occurrence of two or more disorders) seen in adult popula-
tions are even higher in children and adolescents, where both within-class (e.g., multiple anxi-
ety diagnoses), and across-class comorbidity (e.g., diagnosis of anxiety and conduct disorder)
make comorbidity the rule rather than the exception (Angold, Costello, & Erkanli, 1999; Garber
& Weersing, 2010). The field has become increasingly aware of the importance of dimensional
conceptualizations of distress and multiple-domain outcomes (functional impairment, symptom;
Achenbach, 2005). Dimensional models are particularly relevant where great symptom overlap
exists across disorders, as they do in youth, and where rapid development leads to transitory
symptoms across developmental stages. In addition, multiple informants (e.g., youth, parent,
teacher, doctor, coach) add complexity to any diagnostic picture that may be best accommodated
by dimensional and multi-domain models.
A transdiagnostic approach may also help explain divergent trajectories and multifinality (the
case where a single risk factor leads to the subsequent expression of different disorders), key con-
cepts in developmental pathology (Nolen-Hoeksema & Watkins, 2011). As one example, longitu-
dinal evidence suggests that many, but not all, teens and young adults who develop depression first
display evidence of anxiety earlier in life. Which teens and adults ultimately develop depression,
which retain their anxiety disorders, and which show remission from anxiety? Transdiagnostic
research encourages simultaneous evaluations of multiple processes (risk factors, mediators,
moderators) across disorders. Such an approach permits unique understanding of the relative
impact of multiple processes that lead to unifying and distinctive outcomes.
As implied in its name, transdiagnostic research aims to identify or change mechanistic pro-
cesses that unify related disorders and problem sets. However, it is critical to note that the bound-
aries of each disorder class (e.g., anxiety disorders) and specific disorder (e.g., generalized anxiety
disorder) are respected even as researchers aim to identify commonalities (Ehrenreich-May &
Chu, 2013). It would be an error to mistake transdiagnostic research with prior attempts to “lump”
all of diagnostic categories into a single or limited set of general personality traits or distress fac-
tors (Taylor & Clark, 2009). Transdiagnostic research acknowledges that traditional diagnostic
categories, represented by classification systems, such as the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5; American Psychiatric Association, 2013), still retain helpful organiz-
ing heuristics. After all, individual anxiety disorders still share many more commonalities with
each other than they do with conduct or schizophrenic disorders. Thus, transdiagnostic research
encourages unifying frameworks while retaining the knowledge we have gained from the science
of diagnosis.
This framework is consistent with initiatives to identify the dimensional neurobiological under-
pinnings of psychological disorders. The recently initiated National Institute for Mental Health’s
(NIMH) Research Domain Criteria (RDoC) project (NIMH, 2011) aims to bring mental health
research in line with other areas of medicine that base diagnostic systems on underlying biology
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and not just clinical presentations of symptoms (Insel, 2013). RDoC emphasizes underlying bio-
logical and behavioral mechanisms as the root units of understanding pathology. In this way,
transdiagnostic research can provide a bridge between traditional classification-╉oriented research
and tomorrow’s dimensional, mechanism-╉oriented conceptualization of emotional distress.
The current chapter reviews the state of emotion regulation research from a transdiagnostic
framework. The first half of the review focuses on experimental, survey, and neurobiological
research that explores etiological and maintenance roles of emotion regulation across disorders.
The second half of our review evaluates transdiagnostic psychological interventions that incor-
porated emotion regulation techniques or assessed emotion regulation processes as outcomes.
By taking a transdiagnostic approach to our review, we hoped to demonstrate how investigations
that take a multi-╉disorder approach can help the field understand more about both the underlying
process and the organizing disorders of multiple problems in a unifying framework.
Citation Sample Characteristics and ER Measures ER components (all that Processes found to be Processes found to be
Design were assessed) universal disorder specific
Aldao & Nolen- N = 252; Undergraduate COPE (Problem-Solving Rumination, thought Rumination, suppression, and None
Hoeksema (2010) students with symptoms of subscale), ERQ, RRS, suppression, reappraisal, and reappraisal were significantly
depression, anxiety, and eating WBSI problem-solving related to anhedonic
disorders depression (.44), anxious
arousal (.24), and eating
disorders symptoms (.15)
Conklin et al., N = 81; Clinical trial patients Brief COPE Maladaptive strategies and Not analyzed Not analyzed
(2015) with comorbid alcohol use adaptive strategies
and anxiety disorders: GAD
(67.9%), social phobia
(50.6%), panic disorder (9.9%)
Desrosiers et al. N = 187; Mood and Anxiety DERS, ERQ, FFMQ, Rumination, reappraisal, Simple mediation Reappraisal linked to
(2013) Disorder Clinic patients, ages PSWQ, RRS worry, and nonacceptance model: Rumination linked depression; Worry linked to
17–81, with GAD (42.9%), to anxiety and depression; anxiety
MDD (20.1%), or social phobia Multiple medation
(12.2%) model: Rumination linked to
depression
Vine & Aldao N = 211; Undergraduate ATTC, DERS Emotional clarity Emotional clarity deficits Specific indirect
(2014) students, ages 18–32, linked to anhedonic pathways: anhedonic
with seven symptom depression, social anxiety, depression and shifting
types: anhedonic depression, borderline personality, binge attention; social anxiety and
anxious arousal, social anxiety, eating, and substance abuse acceptance and strategies;
borderline personality, binge symptoms borderline personality
eating, restrictive eating, and symptoms and shifting and
alcohol use. strategies; alcohol use and
impulse
Gruber et al. N = 60; Adults with euthymic CCL, GRS, PSWQ Rumination, worry, and BP and INS significantly linked None
(2008) bipolar disorder (n = 21), negative automatic thoughts to rumination and worry;
insomnia (n = 19), and non- finding not significant when
clinical control (n = 20) analysis controlled for anxiety
and depressive symptoms
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Brockmeyer et al. N = 140; Women, ages 18- ER self-report: DERS Experience and differentiation MDD and AN linked to MDD sample had increased
(2012) 65, with MDD (41), anorexia of emotions and attenuation elevated difficulties in difficulties in attenuating and
nervosa (39), healthy controls and modulation of emotions experience and differentiation modulating emotions
(60) of emotions
Queen & N = 76; Youth, ages 12–18, CBCL, CEMS, EESC, Cognitive reappraisal, Higher comorbidity linked Possibility that expressive
Ehreneich-May with comorbid anxiety and ERQ-CA, PANAS emotion suppression, to higher youth reported reluctance, emotional
(2014) depression (57.9%) or a emotional awareness, negative affect, expressive expression, emotional
primary anxiety disorder expressive reluctance, reluctance, emotional awareness are linked to
(42.1%) emotional inhibition, positive expression, emotional depression, but lack of
affect, negative affect awareness; Parent depression-only group makes
report: inhibition of sadness this difficult to determine
Garnefski et al. N = 271; Youth, ages 12–18, CERQ Self and other blame, Catastrophizing Internalizing: self-
(2005) with Internalizing symptoms rumination, catastrophizing, blame and rumination;
(8.9%), Externalizing putting into perspective, Externalizing: positive
symptoms (8.9%), Comorbid positive refocusing, positive refocusing; Cognitive ER
internalizing and externalizing reappraisal, acceptance, and strategies explained more of
symptoms (4.8%), “No planning the variance for internalizing
problems” (38%) than externalizing symptoms
Table Abbreviations
ER self-report: Attentional Control Scale = ATTC, Brief COPE, Child Behavior Checklist = CBCL, Children’s Anger Management Scale = CAMS, Children’s Emotion Management Scale = CEMS,
Children’s Response Styles Questionnaire = CRSQ-Rumination, Children’s Sadness Management Scale = CSMS, Cognitions Checklist = CCL, Cognitive Emotion Regulation Questionnaire = CERQ,
COPE, Difficulties in Emotion Regulation Scale = DERS, Emotion Expression Scale for Children = EESC, Emotion Regulation Questionnaire = ERQ, Emotion Regulation Questionnaire for Children
and Adolescents = ERQ-CA, The Five Facet Mindfulness Questionnaire = FFMQ, Global Rumination Scale = GRS, modified Differential Emotions Scale = mDES, Positive and Negative Affect
Schedule = PANAS, Penn State Worry Questionnaire = PSWQ, Ruminative Response Scale = RRS, White Bear Suppression Inventory = WBSI
Symptom self-report: Anxiety Sensitivity Index = ASI, Bech-Rafaelsen Mania Scale = BRMS, Beck Anxiety Inventory = BAI, Beck Depression Inventory = BDI, The Binge-Eating Scale = BES, The Brief
Fear of Negative Evaluation = BFNE, Children’s Depression Inventory = CDI, Children’s Eating Attitudes Test = chEAT, Clinical Global Impression-Severity = CGI-S, Child Symptom Inventory = CSI,
Depression Anxiety and Stress Scale = DASS, The Eating Disorders Attitude Test = EAT-26, Eating Disorders Examination-Questionnaire (EDE-Q), Global Assessment of Functioning = GAF; DSM-IV Axis
V, Hamilton Anxiety Rating Scale = HAM-A, Hamilton Rating Scale for Depression = HRSD, Inventory of Depressive Symptomatology, IDS-C, Liebowitz Social Anxiety Scale = LSAS, Lifetime Interference
Measure = LIM, McLean Screening Instrument for Borderline Personality Disorder = MSI-BPD, Mood and Anxiety Symptom Questionnaire = MASQ, Mood and Anxiety Symptom Questionnaire-Short
form = MASQ-SF, Obsessive Compulsive Drinking Scale = OCDS, Overall Anxiety Severity and Impairment Scale = OASIS, Quick Inventory of Depressive Symptomology = QIDS, Revised Children’s
Anxiety and Depression Scales = RCADS/RCADS-Parent version, Revised Peer Experiences Questionnaire = RPEQ-aggressor version, The Short Michigan Alcohol Screening Test = SMAST-G, The Social
Interaction Anxiety Scale = SIAS, State-Trait Anxiety Inventory = STAI, Youth Self-Report = YSR
Semi-structured interviews: Anxiety Disorders Interview Schedule = ADIS-IV, Anxiety Disorders Interview Schedule–Child Version, Child and Parent report forms = ADIS-IV-C/P, Diagnostic Interview
Schedule for Children = DISC, Duke Structural Interview for Sleep Disorders = DSISD, Insomnia Diagnostic Interview = IDI, Structured Clinical Interview for DSM Disorders = SCID-I
FMRI and Physiological Measures: High Frequency heart rate variability = HRV-HF, Functional Magnetic Resonance Imaging = fMRI, Respiratory Sinus Arrhythmia = RSA, The Zephyr[TM]
BioHarness[TM] device = wireless physiological monitoring system
4
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rumination typically involves over-engagement with both present and past outcomes, which is
associated with both anxiety and depressive symptoms. Reappraisal’s specificity to depressive
symptoms might be related to the benefits of mindfulness, which can help individuals to adopt a
nonjudgmental stance and potentially disengage from their repetitive thinking.
Rumination and worry were examined with negative automatic thoughts in a study assessing
differences between euthymic bipolar I disorder (BP; n = 21), insomnia (INS; n = 19), and non-
clinical comparisons (NC; n = 20) (Gruber, Eidelman, & Harvey, 2008). While BP and INS par-
ticipants reported significantly more rumination and worry than NC participants, BP and INS
participants did not differ from one another in rumination and worry. The study also found that
the BP group reported significantly more negative automatic thoughts than the NC group; how-
ever, BP and INS groups again did not differ from one another in negative automatic thoughts.
In follow-up analysis, rumination and worry were no longer elevated in BP and INS compared
to NC after controlling for anxiety and depressive symptoms (Gruber et al., 2008). These results
highlight important methodological and conceptual issues when studying transdiagnostic pro-
cesses. Controlling for anxiety and depression may be important to adjust for any spurious effects
of general distress or symptom severity when comparing a mechanism across disorders. At the
same time, removing the effects of general distress may also be removing important explanatory
processes that may explain commonalities across disorders. We simply may not have the measures
that can adequately parse out the variance that is associated with unique transdiagnostic processes
from general distress.
Based on these studies (Aldao & Nolen-Hoeksema, 2010; Desrosiers et al., 2013), there is evi-
dence that some cognitive emotion regulation strategies might operate transdiagnostically, while
others might operate more uniquely to certain disorders. In particular, rumination might be a
transdiagnostic mechanism across depression and anxiety, whereas worry might relate more
closely to anxiety. The relationship between reappraisal and pathology may be more mixed. While
Aldao and Nolen-Hoeksema (2010) found that reappraisal was significantly related to anxiety
and depression, Desrosiers et al. (2013) found that reappraisal was significantly related to depres-
sion only. Another interesting finding discovered through latent class analysis was that the con-
struct of cognitive emotion regulation may be more strongly influenced by maladaptive cognitive
strategies than adaptive cognitive strategies. Adaptive strategies also appear to be helpful because
they decrease the use of maladaptive strategies more than because they are positive in-and-of
themselves.
Another way to examine emotion regulation difficulties across disorders is to investigate the
central facets of emotion regulation rather than certain constructs (e.g., rumination, worry).
Using the Difficulties in Emotion Regulation Scale (DERS), Brockmeyer et al. (2012) exam-
ined difficulties 1) experiencing and differentiating emotions (i.e., non-acceptance of emotional
responses, lack of emotional awareness, and lack of emotional clarity) and 2) attenuating and
modulating emotions (i.e., difficulties in engaging in goal-directed behavior, impulse control dif-
ficulties, and limited access to effective emotion regulation strategies) in women diagnosed with
major depression (MDD) or anorexia nervosa (AN), or considered healthy controls (N = 140).
Overall, individuals with both MDD and AN reported greater difficulty regarding the experience
and differentiation of emotions compared to healthy controls. However, difficulties in attenuating
and modulating emotions was significantly higher only in individuals with MDD, and there was
no significant difference between the AN or NC groups (Brockmeyer et al., 2012). These results
provide examples of both disorder-specific and transdiagnostic emotion regulation processes.
Research has also focused on how specific facets of emotion regulation mediate the relation-
ship between broader emotion regulation processes and psychopathology. Vine and Aldao (2014)
examined whether deficits in the broad construct of emotional clarity would correlate with
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dysregulation, or if it is something unique about the combination of anxiety and depression that
is of key importance. Further examination of expressive reluctance, emotional expression, and
emotional awareness may play an important role in the development or maintenance of comorbid
anxiety and depression.
In addition to emotion regulation strategies involving awareness and recognition of different
emotions, cognitive emotion regulation strategies have also been thought to influence disor-
der trajectories, and may be particularly important in youth given the vast changes to cognitive
capacity that occur between childhood and adolescence. Garnefski, Vivian Kraaij, and Marije van
Etten (2005), for example, compared a number of cognitive emotion regulation components (i.e.,
self and other blame, rumination, catastrophizing, putting into perspective, positive refocusing,
positive reappraisal, acceptance, and planning) among 271 12-to-18-year-old teens who demon-
strated internalizing symptoms, externalizing symptoms, comorbid internalizing, and external-
izing symptoms, or no significant symptoms. It was hypothesized that self-blame, rumination,
catastrophizing, and lack of positive reappraisal would be most highly associated with internal-
izing and externalizing symptoms. Regression analyses were completed to determine the relation-
ship between these cognitive strategies and internalizing problems (while controlling for gender,
age and number of externalizing symptoms), and between cognitive strategies and externaliz-
ing problems (while controlling for gender, age and number of internalizing symptoms). Results
showed that adolescents with internalizing problems (either alone or appearing with externaliz-
ing symptoms) reported significantly higher levels of self-blame and rumination than those with
externalizing problems alone or the healthy controls. No differences were found between inter-
nalizing and externalizing youth with regard to catastrophizing. Adolescents with externalizing
problems were more likely to report positive refocusing. With the exception of catastrophizing,
there was no overlap between the specific cognitive emotion regulation strategies that predicted
internalizing and externalizing problems, and cognitive emotion regulation strategies were able to
explain more of the variance of internalizing problems than of externalizing problems. This sug-
gests that cognitive emotion regulation strategies in general may play a larger role in contributing
to internalizing problems than to externalizing problems, and that these mechanisms may play a
key role in distinguishing between the two symptom profiles.
The results of these adult and youth cross-sectional studies highlight some of the ways in which
emotion regulation strategies can be conceptualized and how they might operate uniquely or
transdiagnostically across psychopathology. Emotion regulation mechanisms can be further
classified based on their hypothesized function, such as cognitive strategies (e.g., rumination,
worry, reappraisal), and adaptive or maladaptive strategies (e.g., Aldao & Nolen-Hoeksema,
2010; Desrosiers et al., 2013). Certain emotion regulation strategies have also been examined as
mediating variables (Vine & Aldao, 2014). One interesting takeaway from the adult studies seems
to be the greater link of maladaptive emotion regulation strategies to pathology than adaptive
emotion regulation strategies. These initial findings suggest that future research, and potentially
clinical work, should focus more on how the reduction of maladaptive strategies, rather than the
increase of adaptive strategies, relates to the development and maintenance of pathology over
time. Additionally, as it stands, the above studies suggest that cognitive emotion regulation strate-
gies may play an influential role in distinguishing between disorders within a youth population.
Overall, the strengths of these studies include examining an array of emotion regulation strategies
in both clinical and nonclinical populations, the use of multi-method assessments (diagnostic and
semi-structured interviews, such as the ADIS, SCID), and mixed methods (e.g., multiple media-
tion models, measurement, and structural models).
Unfortunately, there is a paucity of cross-sectional studies looking at emotion regulation
across disorders in youth, and additional research could help to further clarify specific emotion
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regulation strategies that may differentiate between or underlie multiple different disorders in
children and adolescents. With further assessment, this information may be beneficial in inform-
ing which mechanisms can be targeted to produce the most effective change in youth with dif-
ferent disorder profiles. It is important to note that while cross-╉sectional research can help detect
possible links between strategies and symptomatology, the design limits examination of how the
relationship between emotion regulation strategies and psychopathology might evolve over time.
Additionally, despite some use of multimodal assessment, there is heavy reliance on self-╉report
measures in the majority of cross-╉sectional studies, which lends itself to shared variance concerns
and does not provide any directions for specific behavioral or physiological indicators of emotion
regulation strategies or symptomology. Within both the adult and youth studies, recruitment of
nonclinical (e.g., undergraduate students, community youth) samples, which restricts the range
of psychopathology and might weaken the relationship to emotion regulation strategies. Overall,
however, these cross-╉sectional studies provide a foundation for future studies, especially prospec-
tive and experimental studies, which are needed to assess if these processes contribute to the
etiology or maintenance of disorders.
neural emotion responses to negative stimuli likely relates to deficits in emotion regulation capac-
ity. It is difficult to isolate the unique contributions of depression and anxiety disorders other than
SP here, but findings suggest that greater pathology contributes to greater amygdala upregulation,
which reflects greater emotion regulation dysregulation. It would take extra steps to determine the
magnitude and type of effects each disorder contributes to amygdala dysfunction.
Ball, Ramsawh, Campbell-Sills, Paulus, and Stein (2013) conducted an fMRI study including
participants with primary diagnoses of generalized anxiety disorder (GAD; n = 23), panic disor-
der (PD; n = 18), and healthy controls (HCs; n = 23). Participants completed self-report measures
and were scanned while completing a task that required them to reappraise or maintain their
emotional responses to negative images. The study was designed to test the hypothesis that GAD
and PD would evidence hypo-activation in the prefrontal cortex (PFC) during emotion regu-
lation attempts. Analyses of self-report measures revealed individuals with GAD reported the
least reappraisal use in daily life. Reappraisal use was inversely associated with anxiety severity
and functional impairment. fMRI data analyses showed that HCs had greater activation during
both reappraisal and maintenance in brain areas important for emotion regulation (i.e., dorsolat-
eral and dorsomedial PFC), whereas GAD and PD participants showed less activation in these
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areas, even as activation levels did not differ in the two clinical groups. Furthermore, those with
the least PFC activation reported the greatest anxiety severity and impairment. These results pro-
vide cross-╉method evidence that cognitive reappraisal and maintenance of emotional response
might have transdiagnostic properties across GAD and PD.
Although in nascent stages, heart rate and fMRI studies provide emerging evidence for physio-
logical and neural functions of emotion regulation processes. Gruber et al. (2015) demonstrated
that inconsistency in heart rate variability may be specifically linked to bipolar disorder, compared
to MDD or healthy controls, and additional studies suggest that some forms of neural reactiv-
ity is consistent across more severe symptoms of pathology. Burklund et al. (2015) found that
participants with comorbid anxiety and depression exhibited increased amygdala reactivity com-
pared to SP individuals without comorbidity (indicative of greater fear reactivity), and Ball et al.
(2013) found that individuals with GAD and PD exhibited less reactivity in prefrontal cortex areas
important for emotional regulation. These results provide evidence of several neural transdiag-
nostic mechanisms across anxiety and depression. Burklund et al. (2015) also found that there
are unique characteristics for individuals with comorbid depression, as they exhibited increased
amygdala activity compared to individuals with comorbid anxiety. Unfortunately, we could not
identify any youth-╉based studies that investigated biomarkers of emotion regulation processes
across multiple disorders. The more invasive assessment procedures used in this research may
make investigators cautious about using child and adolescent samples; investigators and human
subjects review boards may also expect a greater foundational evidence base before including a
youth population. As it stands, limited research exists to inform the field on developmental dif-
ferences of biological markers of emotion regulation. In summary, these studies underscore the
importance of expanding research to include physiological and neurological measures of emotion
regulation in order to gain greater specificity regarding potential transdiagnostic or disorder spe-
cific strategies across pathology.
Longitudinal designs
Cross-╉sectional studies can highlight important links between emotion regulation strategies and
disorders, but they do little to explain the development of regulation processes over time or their
reciprocal relations with socio-╉emotional distress. Longitudinal studies help explain how particu-
lar processes contribute to or maintain particular symptoms over time and clarify convergent and
divergent developmental trajectories (see Table 20.3).
McLaughlin, Hatzenbuehler, Mennin, and Nolen-╉Hoeksema (2011) conducted a longitudinal
assessment of the reciprocal relationship between psychopathology and emotion regulation skills.
Participants included 1065 sixth to eighth graders who completed self-╉report measures in school
at baseline and after seven months. Emotional understanding, adaptive expression of negative, and
cognitive emotion management strategies were targeted as emotion regulation processes. Results
demonstrated that all types of emotion regulation were inter-╉related and were positively associ-
ated with all four types of symptomology (anxiety, anger, eating pathology, depression), which
were also inter-╉related. Interestingly, analyses found that a one factor model best fit the data,
such that emotional understanding, dysregulated expression of sadness and anger, and ruminative
responses were better combined into one factor of emotion dysregulation rather than examined as
separate constructs. Using the single factor model, results showed that emotion dysregulation at
Time 1 predicted Time 2 anxiety, anger, and eating pathology, but not depression. However, Time
1 anxiety, anger, eating pathology, and depression did not predict emotion regulation at Time 2.
A number of interesting implications result. Unlike other studies that appear to find distinctions
between different elements of emotion regulation as they relate to different disorders, this study
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4
Table 20.3 Child longitudinal
Citation Sample Characteristics ER Measures ER components (all that Processes found to be Processes found to be
were assessed) universal disorder specific
McLaughlin et al. N = 1065; Ages 11–14 ER self-report: CAMS, CRSQ- Emotional understanding, Four ER components best T1 ER did not predict
(2011) with anxiety, depression, Rumination, CSMS, EESC expression of anger and fit into a single emotion depression at T2
agression, and eating -Assessment at T1 and T2 sadness, and cognitive dysregulation factor. T1 ER
pathology (7 months later) emotion management ratings predicted T2 anxiety,
strategies (rumination) aggression, and eating
pathology
Vasilev et al. (2009) N = 212; Ages 8–12 with ER physiological RSA, nonacceptance Higher DERS linked to greater Access to ER strategies,
conduct disorder (n = 30), measure: RSA ER self- of emotional response, emotional withdrawal (as impulse control, and
depression (n = 28), report: DERS -Assessment at difficulteis engaging in goal indicated by RSA) in response acceptance of emotional
comorbid conduct and 3 time points (each one year directed behaviors, impulse to sadness induction at Time response were most linked
depression (n = 80), control apart) control difficulties, lack of 1, but increased response at to reactivity
group (n = 69) emotional awarenes, limited Time 3. Lower DERS scores
access to ER strategies, lack of linked to stable reactivity
emotional clarity across all three time points
Pang & Beauchaine N = 159; Ages 8–12 with ER physiological RSA TI higher levels of depression T1 comorbid depression
(2013) conduct disorder (n = 30), measures: RSA -Assessment and conduct disorder and conduct disorder
depression (n = 28), at 3 time points (each one linked to lower baseline predicted lower baseline
comorbid conduct and year apart) RSA. Depression and RSA, over and above the
depression (n = 80), control conduct disorder samples main effects. Comorbid
group (n = 69) demonstrated elevated depression and conduct
emotional reactivity in disorder samples had
response to sadness induction highest RSA reactivity
at each of the time points
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4
suggests that one broad construct actually fit the data more accurately. This may be due, in part,
to the four particular inter-related elements of emotion regulation examined in this study; how-
ever, other ER constructs may not fit as well into a single factor. Dysregulation in emotion man-
agement also predicted subsequent symptomology at a later time point, but the reverse relation
was not found. Although a formal cross-panel analysis was not performed to rule out additional
confounding covariates, these results provide initial support for a prospective role of emotion
regulation strategies in promoting anxiety, anger, and eating pathology. Further research in why
depression was not predicted by earlier emotion regulation dysregulation is warranted.
Hoping to examine the relationship between self-reported emotion regulation and physiologi-
cal indices over time, Vasilev, Crowell, Beauchaine, Mead, and Gatzke-Kopp (2009) conducted
a three-year study with 212 eight to 12 year olds who were categorized in one of four groups:
non-clinical controls, conduct problems, depressive problems, or comorbid conduct and depres-
sive problems. Physiological assessment of emotion regulation consisted of measuring respira-
tory sinus arrhythmia (RSA), which captures changes in heart rate, and has been shown to be
related to symptoms of depression, anxiety, self-injury, and disruptive behavior (Beauchaine et
al., 2007; Crowell et al., 2005; Shannon, Beauchaine, Brenner, & Neuhaus, 2007; Silk, Steinberg, &
Morris, 2003). At each of the three time points, examiners assessed baseline and change in RSA
during a sadness induction task. The study aimed to link RSA at each assessment point to year
three self-reported difficulties in emotion regulation, assessed by the self-reported DERS (i.e.,
non-acceptance of emotional response, difficulties engaging in goal directed behaviors, impulse
control difficulties, lack of emotional awareness, limited access to emotion regulation strategies,
and lack of emotional clarity). It is normative for individuals to demonstrate increasing baseline
levels of RSA during adolescence, and results from this study found that increasing baseline levels
of RSA at each of the time points was associated with greater emotional awareness at year three.
In comparison, individuals with relatively stable baseline RSA at each time demonstrated greater
emotion regulation difficulties at year three. Regarding change in RSA rate following the sadness
induction task, those who scored higher on the DERS tended to have greater emotional with-
drawal (as indicated by RSA) in response to sadness induction at Time 1, but increased response
at Time 3. Those who scored low on the DERS demonstrated relatively stable reactivity across
all three time points. Authors suggested that low baseline RSA may actually be associated in
increased instability in emotional reaction in response to triggers.
Additional analysis found that access to emotion regulation strategies, impulse control, and
acceptance of emotional response were most linked to reactivity. In related work, Pang and
Beauchaine (2013) looked at baseline RSA and changes in RSA across the different disorder
groups. At Time 1, higher levels of depression and conduct disorder were linked to lower RSA at
baseline, indicating increased emotional withdrawal. The interaction of depression and conduct
disorder also predicted lower baseline RSA, over and above the main effects. Individuals with
depression and conduct disorder also demonstrated greater emotional reactivity in response to
sadness induction at each of the time points, though individuals with comorbid depression and
conducted disorder displayed the highest levels of reactivity. None of the disorder profiles were
linked to trajectory changes in baseline RSA or RSA reactivity over time.
Collectively, these studies demonstrate the ability of researchers to begin exploring how emo-
tion regulation can impact change over time. The first study provides support for the notion that
poor ER plays a temporal role in the development of symptomology, such that emotion regula-
tion dysregulation precedes distress. Longitudinal studies using physiological markers of distress
have found a link between RSA and specific self-reported emotion regulation strategies, such as
emotional awareness and acceptance, impulse control, and access to emotion regulation strate-
gies. The studies demonstrated that while both depression and conduct disorder were linked to
34
greater difficulties, comorbidity was associated with even higher levels of deficit. It appears that
individuals who demonstrated developmentally normative rates of RSA over adolescence may
actually respond most appropriately to emotional cues. In contrast, individuals with blunted base-
line levels of RSA demonstrate difficulty with emotion regulation when presented with triggers.
Interestingly, all of these studies have been conducted with youth.
and used samples with comorbidities or multiple disorders were included. The literature search
resulted in 14 articles, ten of which reported results from open trials or randomized controlled
trials (RCTs) and four reported small n case studies. Effect sizes were (i.e., Cohen’s d) calculated at
post-╉treatment and follow-╉up to evaluate the effects of transdiagnostic treatments on diagnostic
status, emotion-╉related measures such as positive and negative affect, and anxiety and depressive
symptoms (Table 4) A Cohen’s d value of 0.20 indicates a small effect size, 0.50 a medium effect
size and 0.80 or greater a large effect size.
Unified protocol
Twelve of the studies focused on the Unified Protocol (UP) for treating emotional disorders.
Originally developed by Barlow, Allen, and Choate (2004), the UP protocol integrates cognitive
behavior therapy (CBT) and emotion regulation principles (Wilamowska et al., 2010). It con-
sists of five core principles that include: (1) Increasing present-╉focused awareness of emotions,
(2) increasing cognitive flexibility, (3) identifying and preventing emotional avoidance and mal-
adaptive emotion-╉driven behaviors, (4) increasing awareness and tolerance of emotion-╉related
physiological sensations, (5) exposing to bodily and environmental triggers of emotional experi-
ences (Farchione et al., 2012). The aim of UP is to treat the symptoms of anxiety and mood dis-
orders through tolerance of emotions and modifying maladaptive emotion regulation strategies
(Wilamowska et al., 2010). A summary of these studies is presented in Table 20.4. The effects of
UP have been studied mostly as an individual treatment for adults with a principal anxiety or uni-
polar depressive disorder (above 18 years old; Bullis, Fortune, Farchione, & Barlow, 2014; Ellard,
Fairholme, Boisseau, Farchione, & Barlow, 2010; Farchione et al., 2012). There are also studies
using participants with chronic pain (Allen, Tsao, Seidman, Ehrenreich-╉May, & Zeltzer, 2012),
Bipolar Disorder, and Borderline Personality Disorder (Ellard, Deckersbach, Sylvia, Nierenberg,
& Barlow, 2012; Sauer-╉Zavala, Bentley, & Wilner, 2015). The UP has been applied to children
(seven to 12 years old; Bilek & Ehrenreich-╉May, 2012), adolescents (12–╉17 years old; Trosper,
Buzzella, Bennett, & Ehrenreich, 2009; Ehrenreich, Goldstein, Wright, & Barlow, 2009; Queen,
Barlow, & Ehrenreich-╉May, 2014) and adults (Bullis et al., 2015; Ornelas Maia, Braga, Nunes,
Nardi, & Silva, 2013) in group format.
Citation Sample Characteristics and Assessments ER components (all Treatment Effect size (Cohen’s d)
Design that were assessed)
Pre-posttreatment Pre-follow-up
Allen et al Case study: N = 2, 14–17 years Pain interview, Children’s Somatization Lack of emotion UP for the Treatment N/A N/A
(2012) old, chronic pain with comorbid Inventory (CSI), Emotion Expression awareness, reluctance of Emotional
anxiety and depression. Scale for Children (EESC), Faces Pain to express negative Disorders in Youth
Assessment at posttreatment Scale-Revised (FPS-R), Functional emotion with Pain (UP-YP)
and 3 month follow-up Disability Inventory (FDI), RCADS
Bilek & Open trial, intent-to-treat ADIS-IV-C/P, Screen for Child Anxiety N/A Emotion Detectives Within-group ESs: N/A
Ehrenreich-May (ITT): N = 22, 7–12 years old Related Emotional Disorders-Child and Treatment Protocol Principal diagnosis
(2012) (M = 9.79 years), anxiety Parent Reports (SCARED), Children’s severity = 1.38
disorder and comorbid Depression Inventory-Child and Total severity of depression and
depressive disorder. Within Parent Reports (CDI), parent and child anxiety = 1.07
group comparison at satisfaction with treatment Parent-report anxiety = 0.49
posttreatment and 3 month Self-report anxiety = 0.47
follow-up Parent-report depression = 0.54
Self-report depression
(ITT) = 0.34
Self-report depression
(completers) = 0.65
Bullis et al. Open trial: N = 15, 20–52 years ADIS-IV-L, BDI-II, BAI, PANAS, PSWQ, Positive and negative Individual UP Within-group ESs: Within-group ESs:
(2014) old (M = 32.27 years), anxiety SIAS, WSAS, OCI-R, Albany Panic and affect Principal diagnosis Principal diagnosis
disorders (M = 2.47 diagnoses; Phobia Questionnaire (APPQ) severity = 1.74 severity = 1.98
7 with comorbid depressive Self-report anxiety = 1.72 Self-report anxiety = 0.96
disorder). Within group Self-report depression = 1.19 Self-report
comparison of treatment Positive affect = 0.39 depression = 0.38
completers at posttreatment and Negative affect = 1.00 Positive affect = 0.41
18 month follow-up Negative affect = 0.31
Bullis et al. Open trial: N = 11, 20–69 years ADIS-IV-L, Overall Anxiety Severity Total experiential Group UP Within-group ESs: N/A
(2015) old (M = 44.55 years), anxiety and Impairment Scale (OASIS), Overall avoidance, Behavioral Self-report anxiety = 1.36
disorders (M = 1.27 diagnoses, Depression Severity and Impairment avoidance, Self-report depression = 0.66
n = 8 with comorbidity). Scale (ODSIS), Multidimensional distress aversion, Total experiential
Within group comparison at Experiential Avoidance Questionnaire procrastination, avoidance = 1.12
posttreatment (MEAQ), WSAS, Quality of Life distraction and
Enjoyment and Satisfaction suppression,
Questionnaire (Q-LES-Q) repression and denial,
distress endurance
(continued)
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Table 20.4 Continued
Citation Sample Characteristics and Assessments ER components (all Treatment Effect size (Cohen’s d)
Design that were assessed)
Pre-posttreatment Pre-follow-up
Ehrenreich, Open trial: N = 12, 12–17 years ADIS-IV-C/P, Revised Child Anxiety and Emotion regulation of UP-Y None reported None reported
Buzzella et al. old, anxiety (42%) or comorbid Depression Scale (RCADS), Children’s sadness, anger and
(2009) anxiety and depressive Emotion Management Scales (CEMS) worry
disorder (58%). Assessment at
posttreatment, 3 and 6 month
follow-up
Ehrenreich et al. Multiple baseline design: N = 3, Anxiety Disorders Interview Schedule N/A UP-Y N/A N/A
(2009) 12–16 years old, principal for DSM-IV Child and Parent Versions
diagnosis of anxiety or (ADIS-IV-C/P)
mood disorder. 2–8 week
baseline phase. Assessment at
posttreatment and 6 month
follow-up
Ellard et al. Clinical replication series: N = 3, MINI, Hamilton Depression Rating N/A Individual UP N/A N/A
(2012) 23–62 years old, bipolar disorder Scale, Montgomery Asberg Depression
with comorbid anxiety disorder. Rating Scale (MADRS), Young Mania
Assessment at posttreatment Rating Scale (YMRS), Clinical Global
Impression Severity and Improvement
(CGI-S, CGI-I), BDI-II, BAI
Ellard et al. Open trial #1: N = 18, 18– Clinician assessed Anxiety Disorders Positive and negative Individual UP Within-group ESs: N/A
(2010) 54 years old (M = 30 years), Interview Schedule for DSM-IV Lifetime affect Principal diagnosis
anxiety or major depressive version (ADIS-IV-L), Beck Depression severity = 1.20
disorder (M = 1.94 diagnoses). Inventory-II (BDI-II), Beck Anxiety Self-report anxiety = 0.60
Within group comparison at Inventory (BAI), Positive and Negative Self-report depression = 0.50
posttreatment Affect Scale (PANAS), Obsessive- Positive affect = 0.30
Compulsive Inventory-Revised (OCI-R), Negative affect = 0.53
Panic Disorder Severity Scale (PDSS-
SR), Penn State Worry Questionnaire
(PSWQ), Social Interaction Anxiety
Inventory (SIAS), Work and Social
Adjustment Scale (WSAS)
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4
Open trial #2: N = 15, 18– ADIS-IV-L, clinician rated structured Individual UP Winthin-group ESs: Within-group ESs:
44 years old (M = 29.73 years), interview guides for the Hamilton Principal diagnosis Principal diagnosis
principal anxiety disorder Anxiety and Depression Rating Scales severity = 1.84 severity = 2.13
(M = 2.2 diagnoses). Within (SIGH-A, SIGH-D), BDI-II, BAI, PANAS, Self-report anxiety = 0.62 Self-report anxiety = 0.64
group comparison at Yale-Brown Obsessive Compulsive Self-report depression = 0.43 Self-report
posttreatment and 6 month Scale (Y-BOCS), PDSS-SR, PSWQ, SIAS, Positive affect = 0.53 depression = 0.65
follow-up WSAS Negative affect = 0.75 Positive affect = 0.27
Negative affect = 0.78
Farchione et al. Randomized controlled ADIS-IV-L, SIGH-A, SIGH-D, BDI-II, BAI, Positive and negative Individual UP Between-group ESs: N/A
(2012) trial: N = 37, anxiety disorders PANAS, Y-BOCS, PDSS-SR, PSWQ, affect Principal diagnosis
(M = 2.16 diagnoses; 12 with SIAS, WSAS severity = 2.27
comorbid depressive disorder) Self-report anxiety = 0.43
Between group comparison of Self-report depression = 0.87
treatment group (n = 26, 19– Positive affect = 0.87
52 years old, M = 29.38 years) Negative affect = 0.42
with 16 week waitlist control
group (n = 11, 19-43 years
old, M = 30.64 years) at
posttreatment
(continued)
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Table 20.4 Continued
Citation Sample Characteristics and Assessments ER components (all Treatment Effect size (Cohen’s d)
Design that were assessed)
Pre-posttreatment Pre-follow-up
Mennin et al. Open trial, ITT: N = 21 ADIS-IV-L, modified CGI, PSWQ, Emotional intensity, Emotion Regulation Within-group ESs: Within-group ESs:
(2015) (M = 35.25 years), generalized BDI-II, Mood and Anxiety Symptom decentering, Therapy (ERT) GAD severity = 3.60 GAD severity_3m = 3.55
anxiety disorder (GAD) with Questionnaire-Short Form (MASQ), nonacceptance of MDD severity = 0.54 GAD severity_9m = 3.60
comorbid major depressive State-Trait Anxiety Inventory (STAI), negative emotions, Self-report worry = MDD severity_3m = 0.65
disorder (MDD; n = 11). Sheehan Disability Scale (SDS), Quality difficulty in emotional Self-report depression = 1.28 MDD severity_9m = 0.80
Within group comparison at of Life Inventory (QOLI), Negative situations with Emotional intensity = 0.55 Self-report worry_3m = 1.48
posttreatment, 3 and 9 month Intensity scale from Affect Intensity pursuing goal- Decentering = 1.18 Self-report worry_9m = 1.77
follow-up Measure (AIM), Decentering subscale directed behaviors, Emotion regulation = 0.71 Self-report depression_
from Experiences Questionnaire, DERS, controlling impulses, Reappraisal = 1.26 3m = 1.22
Emotion Regulation Questionnaire lack of regulation Trait mindfulness = 0.62 Self-report depression_
(ERQ), Five Facet Mindfulness strategies, problems 9m = 1.41
Questionnaire (FFMQ) with emotional Emotional intensity_
awareness, emotional 3m = 0.25
clarity, reappraisal, Emotional intensity_
trait mindfulness 9m = 0.64
Decentering_3m = 1.01
Decentering_9m = 1.35
Emotion regulation_
3m = 0.72
Emotion regulation_
9m = 0.99
Reappraisal_3m = 1.35
Reappraisal_9m = 1.06
Trait mindfulness_3m = 0.32
Trait mindfulness_9m = 0.76
Neacsiu et al. Randomized controlled DERS, DBT Skills subscale of DBT Ways Nonacceptance of Dialectical Behavior Between-group Ess: Between-group ESs:
(2014) trial, ITT: N = 44, high on of Coping Checklist (DBT-WCCL), negative emotions, Therapy- Skills Self-report anxiety = 0.86 Self-report anxiety = 0.70
emotion disorder, at least Patient Health Questionnaire-9 difficulty in emotional Training group Self-report depression = 0.39 Self-report
one anxiety or depressive (PHQ-9), OASIS, Brief Treatment situations with (DBT-ST) Emotion regulation = 0.99 depression = 0.39
disorder (DBT-ST: M = 2.68; History Interview (B-THI), Addiction pursuing goal- DBT skills = 0.75 Emotion regulation = 0.63
ASG: M = 2.59). Between Severity Index Self-Report Form (ASI- directed behaviors, DBT skills = 0.27
group comparison of treatment SR), Credibility and Expectancy of controlling impulses,
group (M = 32.27 years old) Improvement Scales (CEIS) lack of regulation
with 16 sessions, 120 min, strategies, problems
Activities-Based Support Group with emotional
(ASG, M = 38.82 years old) at awareness, emotional
posttreatment and 2 month clarity
follow-up
9
3
4
Ornelas et al. Open trial: N = 16, 18-58 years Mini International Psychiatric Nil Group UP Within-group ESs: N/A
(2013) old (M = 35.63 years), unipolar Interview (MINI 5.0), BDI, BAI, World Self-report anxiety = 0.95
mood disorder comorbid Health Organisation Quality of Life Self-report depression = 1.34
with anxiety. Within group (WHOQOL-BREF), ARIZONA scale of
comparison at posttreatment sexual function
Queen et al. Piecewise latent growth curve ADIS-IV-C/P, RCADS, Revised Child Nil Individual UP-Y Within-group ESs: Within-group ESs:
(2014) modelling: N = 59, 12-17 years Anxiety and Depression Scale—Parent Self-report anxiety = 0.81 Self-report anxiety_
old (M = 15.42 years), ≥ 8 Version Self-report depression = 0.65 3m = 1.29
sessions in previous open trial or Parent-report anxiety = 0.48 Self-report anxiety_
RCT, anxiety (79.9%), unipolar Parent-report depression = 0.63 6m = 1.34
depressive (15.3%) disorder or Self-report depression_
both (5.1%). Test trajectories 3m = 0.97
of anxiety and depressive Self-report depression_
symptoms over the course of 6m = 0.80
the UP-Y (data from an open Parent-report anxiety_
trial or an RCT were analysed). 3m = 1.11
Within group comparison at Parent-report anxiety_
posttreatment, 3 and 6 month 6m = 1.07
follow-up Parent-report depression_
3m = 0.87
Parent-report depression_
6m = 0.60
Sauer-Zavala Clinical replication series: N = 5, Diagnostic Interview for Personality Nonacceptance of Individual UP N/A N/A
et al. (2015) borderline personality disorder Disorders-4th Edition (DIPD-IV), negative emotions,
with comorbid anxiety and ADIS-IV, The Zanarini Rating Scale difficulty in emotional
mood disorders. Assessment at for Borderline Personality Disorder situations with
posttreatment (ZAN-BPD), Depression, Anxiety and pursuing goal-
Stress Scales, Difficulties in Emotion directed behaviors,
Regulation Scale (DERS) controlling impulses,
lack of regulation
strategies, problems
with emotional
awareness, emotional
clarity
0
4
were identified as treatment responders based on their principal diagnosis and 71% based on their
comorbid diagnoses. Thirty-three percent of participants gained high end-state functioning based
on their principal diagnosis and 50% based on their comorbid diagnosis.
However, the authors considered the effects as “modest,” given that 67% of the sample remained
at the clinical level at post-treatment. To enhance the UP, the protocol was extended to 18 ses-
sions and this was further tested in 15 participants with a principal diagnosis of anxiety disor-
der in a second pilot trial (Ellard et al., 2010). Participants had at least two comorbid anxiety or
depressive disorders and they attended an average of 17 sessions of the treatment. There were
significant improvements in clinical severity ratings of principal diagnosis, self-reported anxiety
symptoms, negative affect and functional impairment. However, self-reported depressive symp-
toms and positive affect did not show significant changes. The percentage of responders increased
to 71% compared to the first pilot trial (56%) based on their principal diagnosis and 64% based on
their comorbid diagnoses. Similarly, based on both principal and comorbid diagnoses, high end-
state functioning increased from 32% and 50% in the first pilot trial to 60% and 64%, respectively.
A higher proportion of participants were classified as within the normal range of negative affect
(67%). At six-month follow-up, only clinical severity ratings of principal diagnosis, negative affect
and functional impairment showed significant improvements. Eleven participants (73%) showed
further gains in responder status and high end-state functioning based on their principal diagnosis
while only 50% showed improvements based on their comorbid diagnosis. However, the results
from these two trials were preliminary, given the small sample size and absence of a control group.
Subsequently, Farchione et al. (2012) conducted an RCT to investigate the efficacy of the UP and
its effects at six-month follow-up. The study involved 37 participants with a principal diagnosis of
anxiety disorders and at least two comorbid diagnoses. Twelve of these participants had comor-
bid depressive disorders. The UP used in this study was different from Ellard et al. (2010), which
included motivational techniques to assess for readiness for change and engagement in treatment,
additional optional emotion-focused exposure exercises, and treatment review and relapse pre-
vention (see details in Barlow et al., 2011). Participants received a maximum of 18 sessions of
treatment. The study used the same assessment measures as Ellard et al. (2010). Compared to the
waitlist control, participants in the UP group demonstrated significantly greater improvement in
self-reported and independent evaluator-rated anxiety and depressive symptoms, positive and
negative affect, and functional impairment. Between groups, effect sizes ranged from 0.42 to 2.27
(Table 20.4). Responders were defined as either ≥ 30% change or ≤ 3 in clinical severity rating
of principal diagnosis plus ≥ 30% change in at least diagnosis-specific or functional impairment
measures. The definition of high end state functioning was the same as Ellard et al. (2010). None
of the participants in the waitlist control were identified as responders or at high end state func-
tioning. In contrast, 59% participants in the UP group were identified as responders and 50%
of them at high end-state functioning. The study also analyzed results of the treatment initiator
sample which included waitlist control participants who completed treatment after the waitlist
period (n = 35; average of 15.26 sessions completed). Within group effect sizes of clinical severity
ratings of principal diagnosis, anxiety and depressive symptoms, positive and negative affect and
functional impairment ranged from moderate to large (Table 20.4). Forty five percent of the treat-
ment initiators no longer met criteria of any clinical diagnoses at post-treatment and 64% at six
month follow-up. Similarly, the proportion of the participants who were identified as responders
(59%) and at high end state functioning (52%) at post-treatment based on principal diagnosis
increased to 71% and 64% at follow-up. Regarding comorbid diagnoses, there was an increase in
the percentage of participants who were identified as responders and at high end state functioning
at follow-up compared to post-treatment, from 38% to 62%, and 41% to 72%, respectively. It was
highlighted that 67% of participants with comorbid depressive disorders no longer met criteria
1
4
for any clinical diagnoses, and were identified as responders and at high end state functioning at
post-╉treatment and this increased to 89% at follow-╉up. These results demonstrated the efficacy of
UP on anxiety and depressive disorders, with further symptom improvements at six month fol-
low-╉up. The authors suggested that the effects of the UP on positive and negative affect were likely
achieved through improving individuals’ reactions toward negative emotions and their engage-
ments in positive emotional experiences. However, there were limitations including small sample
size and the lack of reliability and fidelity checks. Furthermore, given that the comparison group
was not an active treatment, conclusions on the processes of the UP in relation to therapeutic
effects cannot be drawn.
A follow-╉up study by Bullis, Fortune, Farchione, and Barlow (2014) aimed to explore the out-
comes of participants in the Farchione et al. (2012) study at 18 months after treatment (i.e., long-╉
term follow-╉up; n = 15). The results showed a significant improvement in clinical severity ratings
of principal diagnosis, number of clinical diagnoses, and clinician-╉rated and self-╉report functional
impairment at long-╉term follow-╉up in 15 treatment completers with anxiety disorders. Although
53% of participants did not meet criteria for any clinical diagnosis at long term follow-╉up, there
was no evidence of further improvements from six months to 18-╉month follow-╉up. Participants
who were identified as responders and at high end state functioning at six months maintained
their functioning at 18-╉month follow-╉up. While there was an increase in participants’ depressive
symptoms, negative affect and clinician-╉rated functional impairment from 6 months to long-╉term
follow-╉up, the average scores in these domains remained at the normal to mild range. The results
suggest that gains in treatment were maintained up to 18 month follow-╉up. However, the small
sample made it impossible to generalize the results to other diagnoses and populations.
To sum up, the three studies reviewed above revealed that UP focuses primarily on increasing
emotional awareness and changing maladaptive emotion regulation strategies. Although emotion
regulation was not directly measured in these studies, there is evidence that targeting emotion
regulation in adults could lead to improvements in anxiety and depressive symptoms, and nega-
tive or positive affect concurrently.
avoidance questionnaire (MEAQ: Gamez, Chmielewski, Kotov, Ruggero, & Watson, 2011) was
administered to assess the tendency to avoid negative internal experiences. This measure consisted
of six subscales including behavioral avoidance, distress aversion, procrastination, distraction and
suppression, repression and denial, and distress endurance. In addition, anxiety, depression, func-
tional impairment, and satisfaction and enjoyment in daily living were also measured.
Results showed that the UP demonstrated a strong effect on anxiety (d = 1.36) and experi-
ential avoidance (d = 1.12) and a moderate effect on depressive symptoms (d = 0.66). UP was
mostly rated as “very” or “extremely” acceptable and participants were satisfied. The group format
provided opportunities for participants to increase their confidence in practicing skills, through
involvement in other participants’ exposure and small group exercises. Although the efficacy of
UP was demonstrated in a group intervention, the authors noted difficulties in training and moni-
toring the understanding of treatment concepts in the group setting, especially with participants
who require extensive direction. Moreover, the small sample size, reliance on self-╉report meas-
ures, and lack of control group and follow-╉up failed to ascertain the causal inferences or modera-
tors of treatment efficacy. Therefore, it was suggested to improve the treatment by devoting more
time to homework review, limiting to one objective per session, including brief individual meet-
ings with participants, and using the group intervention as a step towards intensive treatment.
In sum, the group format of the UP protocol shows promising results. Specifically, Bullis et al.
(2015) measured multiple dimensions of experiential avoidance in a study of adults with multiple
disorders. Group UP showed large effects on six domains of emotion regulation as well as anxi-
ety and depressive symptoms. Future research should include control conditions and long-╉term
follow-╉up to consolidate the efficacy of UP on emotion regulation as a group intervention for
adults with emotional disorders.
improvement in worry, sadness, and overall emotion dysregulation, as well as coping with anger at
post-╉treatment. At three month follow-╉up, there was significant improvements in overall emotion
coping and dysregulation of sadness. However, there was generally no significant difference in
emotion dysregulation and coping between three and six months. These results showed that UP-╉
Y is effective in improving emotion regulation and coping with emotions in adolescents. Similar
to Ehrenreich et al. (2009), the sample was small (n = 12) and did not include participants with a
principal depressive disorder. Moreover, emotion regulation was not specifically measured.
Although anxiety and depression share similar vulnerabilities, studies have demonstrated that
anxiety and depression are also distinct from each other (Anderson & Hope, 2008). As such, to
compare the trajectory of the changes in self and parent reported anxiety and depressive symp-
toms in adolescents up to six months following UP-╉Y treatment, Queen, Barlow, and Ehrenreich-╉
May (2014) analyzed the results of 59 adolescents who completed at least eight sessions of UP-╉Y
from a total sample of 67 participants in either an open trial or an RCT. Emotion regulation was
not examined in the analysis. Participants were 12–╉17 year old adolescents with an anxiety disor-
der (79.9%), unipolar depressive disorder (15.3%) or co-╉principal anxiety and depressive disor-
ders (5.1%). Twenty-╉three participants (38.98%) were assigned a secondary comorbid depressive
disorder. The UP was flexibly conducted between eight to 21 sessions with optional parenting
skills training, motivational interviewing and safety planning depending on the needs of the indi-
vidual participant. By the end of treatment, mean scores of self and parent-╉reported anxiety and
depressive symptoms fell into the normal range. Symptom trajectories showed that self-╉reported
anxiety symptoms decreased significantly by 4.76 units every eight weeks during treatment and
1.48 units every eight weeks during three to six month follow-╉up period. The rate of change of
self-╉reported anxiety symptoms during treatment was significantly associated with the rate of
change during the follow-╉up period. Although self-╉reported depressive symptoms significantly
decreased during treatment at a similar rate of change as self-╉reported anxiety symptoms, there
were no significant reductions at follow-╉up. The rate of change of self-╉reported depressive symp-
toms during treatment was not significantly related with the rate of change during the follow-╉up
period. Parent-╉reported anxiety and depressive symptoms also demonstrated significant improve-
ment during treatment. However, similar to the adolescents’ self-╉reported depressive symptoms,
both parent-╉reported anxiety and depressive symptoms revealed no significant reduction from
post treatment to three to six month follow-╉up. Participants and parents who reported greater
severity in both anxiety and depressive symptoms at baseline demonstrated a greater rate of
improvement of symptoms during treatment but only self-╉reported anxiety symptoms showed a
reduction in rate of improvement at follow-╉up. The preliminary evidence from this study needs to
be further replicated with a larger sample with a diverse population in order to obtain trajectories
of improvement in symptoms.
parent training after individual reviews with their child at the beginning of the session. It was
hypothesized that participants would show improvement in severity of their principal diagnosis
regardless of the severity of their depressive symptoms at pre-╉treatment. Seventy-╉three percent
of the sample was identified as treatment completers who completed 11 or more sessions. At
post-╉treatment, 77.8% and 80% of the participants no longer met criteria for an anxiety and a
depressive disorder, respectively. There was a significant improvement in clinical severity rat-
ings of both principal diagnosis and the total scores of the clinical severity ratings of anxi-
ety and depressive disorders, self-╉reported anxiety symptoms and parent-╉reported depressive
symptoms. Effect sizes ranged from 0.47 to 1.38. A significant improvement in self-╉reported
depressive symptoms was only seen in the treatment completers. Both self-╉and parent-╉reported
depressive symptoms at baseline did not significantly predict change in clinical severity ratings
of principal diagnosis at post-╉treatment. Satisfaction of the child (M = 5.5 on an eight point
Likert Scale) and the parent with the treatment were high (M = 7.7). The Emotion Detectives
Treatment Protocol was shown to be efficacious and feasible in children with a diagnosis of a
principal anxiety disorder who also had comorbid depressive symptoms. However, analysis was
not conducted to determine effects on those with or without comorbid depression. The sample
was ethnically diverse, but the study was limited by the small sample size, lack of control group,
and lack of control for Type I errors. The small sample also did not allow for group and therapist
effects to be analyzed. More studies are required to test the efficacy of the Emotion Detectives
Treatment Protocol with other emotional disorders.
In sum, there is only limited research of UP with child and adolescent samples. In the three stud-
ies reviewed above, emotion regulation was not directly assessed despite the fact that UP retained
its focus on emotions and dysregulation of emotions and coping. Nevertheless, the improvements
in both anxiety and depressive symptoms based on self-╉and parent-╉reports provided beneficial,
albeit only preliminary, evidence for the UP as a transdiagnostic approach for emotion regulation
across emotion disorders.
exposure exercises. Although similar in length (i.e., eight to 21 sessions) as the UP-Y, the 50-
minute sessions were conducted within six months and were flexible to be fortnightly delivered
sessions at the end of the treatment. Results of the treatment protocol were presented in two cases
with emotion awareness and expression of negative emotions measured. In one case, there was a
decline in functional impairment, anxiety symptoms, somatization, and an increase in emotional
awareness and expression while the level of pain remained stable. There were further gains at three
month follow-up and pain was at its lowest level. However, in the other case, no change was seen
in depressive symptoms and there were increases in somatization, pain and functional impair-
ment despite an increase in emotion regulation scores. Although results suggest that the emphasis
of increasing awareness of both physical and emotional symptoms in the UP-YP may contribute
to its effectiveness, future study is warranted to consolidate the findings.
Given that neuroticism (i.e., the tendency to experience negative emotions uncontrollably)
has been proposed as one common underlying trait in borderline personality disorder (BPD),
anxiety and depressive disorders, Sauer-Zavala, Bentley, and Wilner (2015) used the UP as a
relatively brief treatment to target neuroticism in participants with less severe symptoms of BPD.
Using the same UP protocol as Farchione et al. (2012), this study evaluated symptom levels and
emotion regulation skills in five BPD patients with comorbid anxiety and depressive disorder.
Effect sizes were reported as standardized mean gain (ESsg). Results showed the improvements in
BPD symptoms (ESsg = 1.06) and emotion regulation skills (ESsg = 1.29) were large in magnitude
while moderate in anxiety (ESsg =.51) and depressive symptoms (ESsg =.70). Although the UP
showed promise in treating BPD with comorbid emotional disorders, the heterogeneity in BPD
made it difficult for the protocol to be appropriate for everyone. Therefore, the authors suggested
that more studies with a larger sample size and including other personality traits are required to
further investigate the moderators and efficacy of the UP for managing BPD. In sum, given that
these studies have included measures related to emotion regulation, they provided further sup-
port for the potential of UP to improve symptoms and skills in emotion regulation in multiple
disorders.
Taken together, our review reveals that the UP has been used to treat a variety of emotion-
related disorders, with a majority focusing on principal anxiety and depressive disorders and their
comorbidities. Overall, the UP protocol demonstrated promising effects on anxiety and depres-
sive symptoms in adults, children and adolescents, either in an individual or a group treatment
format. These results suggest the potential of the UP as a transdiagnostic approach that targets
emotion regulation across emotion disorders, which in turn leads to improvements in anxiety
and depressive symptoms, and negative or positive affect in these disorders. However, the reli-
ability of the results of these studies on the UP is limited by small sample size and few comparison
conditions. It should also be noted that in some studies, especially those conducted in children
and adolescents, the majority of the participants had a principle diagnosis of an anxiety disorder
but not a depressive disorder. The exclusion of individuals with Major Depressive Disorder (e.g.,
Bilek & Ehrenreich-May, 2012) and a relatively small number of participants with comorbid anxi-
ety and depression symptoms require future research to include participants with a diversity of
diagnoses. This will allow a more solid conclusion for the effects of the UP as a transdiagnostic
approach. In addition, only three of the studies directly measured changes in emotion regula-
tion in their samples (Allen et al., 2012; Ehrenreich et al., 2009; Sauer-Zavala et al., 2015). Future
research including a controlled design with larger samples, assessments of emotion regulation,
and participants with different types of emotional disorders are warranted. Furthermore, longer
duration of follow-up, as well as more detailed analysis of outcomes, and investigating potential
moderators and mediators would increase the validity of UP as a transdiagnostic treatment tar-
geting emotion regulation.
6
4
motivational mechanisms (i.e., the functional and directional properties of an emotional response
tendency), regulatory mechanisms (i.e., controlling emotional responses using a variety of elabora-
tive systems); and contextual learning consequences (i.e., promoting broad and flexible behavioral
strategies). Emotion Regulation Therapy, which integrates principles of CBT with experiential
therapy, targets deficits in these mechanisms that maintain GAD. Given that GAD with comorbid
major depressive disorder (MDD) is associated with severe functional impairments compared to
GAD or MDD alone, Mennin et al. (2015) conducted the first study to test the efficacy of Emotion
Regulation Therapy for GAD with comorbid depressive symptoms. Emotion Regulation Therapy
focuses on increasing awareness of properties of emotion response tendencies, developing less
and more elaborate emotion regulation strategies and exposure to different contexts, which allow
participants to develop a variety of flexible behaviors. Participants were 21 adults with principal
diagnosis of GAD, among which 11 had comorbid MDD. The treatment protocol consisted of 20
weekly sessions with each session lasting for 60 minutes, except for Sessions 11–╉16, which lasted
90 minutes for participants to practice exposure exercises. In the first half of the treatment pro-
gram, participants were taught emotion regulation strategies to respond “counteractively” rather
than “reactively”. In the second half of the treatment, they were encouraged to become more “pro-
active” in using regulation skills through in-╉session and out-╉session exposure exercises.
Results revealed significant improvements in clinical severity ratings of GAD and MDD, self-╉
reported worry and depressive symptoms, and quality of life at post-╉treatment, three and nine
months follow-╉up. This study also assessed for emotional intensity, decentering, emotion reg-
ulation skills, reappraisal and trait mindfulness associated with the model of emotion regula-
tion therapy, all of which improved significantly at post-╉treatment and nine months follow-╉up. At
three months follow-╉up, only changes in emotion regulation skills, decentering and reappraisal
were significant. High end-╉state functioning was defined as falling in the normal range on four
of six measures of GAD and three of four MDD measures. At post-╉treatment, 66.7% and 45.5%
achieved high end-╉state functioning on GAD and MDD, respectively with the proportion increas-
ing to 75% in GAD and 70% in MDD at three months follow-╉up. At nine months follow-╉up, 85%
of the sample were at high end-╉state functioning on GAD and 80% on MDD. This study provided
preliminary evidence for the efficacy of Emotion Regulation Therapy for GAD participants with
significant depressive symptoms. In addition to improvement in severity of anxiety and depres-
sive symptoms, Emotion Regulation Therapy showed large effects on different aspects of emotion
regulation. Despite these findings, ERT requires refinement to differentiate the intervention from
other interventions with similar components. Future research should include larger RCTs and
objective assessments of symptoms to determine the mechanisms targeted. Notably, this interven-
tion has not yet been used with children and adolescents.
ERT appear to provide good examples of treatment evaluations that actively assess and report
outcomes in emotion regulation—╉each has shown positive short-╉and long-╉term benefits of treat-
ment on improving individuals’ ability to regulate distress. This appears consistent across multiple
presenting problems.
Our review highlights the nascent stage of investigating emotion regulation processes across
disorders and problem ╉sets and with children and adolescents. Research designs, assessment
tools, and analytic approaches differ considerably across studies, making comparisons difficult. It
is recommended that future emotion regulation research make concerted efforts to recruit multi-╉
problem samples, as comparisons can aid a more refined understanding of specific and common
regulation deficits and strengths. This review has identified several model approaches, but it has
also revealed multiple areas for future growth. Greater use of prospective designs, utilizing multi-╉
domain and multi-╉source assessment, would improve experimental, longitudinal, and treatment
research.
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Index
454 Index
Index 455
456 Index
Index 457
Attention Deficit Hyperactivity Disorder 113, 114 protective factors for adjustment to parental
autism spectrum disorder 235 separation 341
borderline personality disorder 259–61 risk factors for adjustment to parental separation 341
conduct disorder 129, 130, 131 dopamine receptors 97
depression 171 drug abuse see substance use disorders
disruptive mood dysregulation disorder 281, 282 dual-process theory 221
history of mental health/disorder 80
nonsuicidal self-injury 398 E
posttraumatic stress disorder 379, 389 Early Adolescent Temperament Scale-Revised 360
Research Domain Criteria 90, 91, 102 eating disorders 196–207
substance use disorders 211, 212 abused/neglected children and adolescents 311
transdiagnostic approaches 420 case example 204–6
traumatic stress exposure 374–5, 379, 389 central facets of emotion regulation 425
Dialectical Behavior Therapy (DBT) 446 emotion regulation 196–8, 200, 421–4
abused/neglected children and adolescents 318 emotional clarity 426
borderline personality disorder 270, 406, 407 longitudinal research 430, 432
Research Domain Criteria 98 treatments 198–203
eating disorders 200, 206–7 Children’s Hospital at Westmead program 201–3
nonsuicidal self-injury 406–7, 408, 409 evidence-based 198–200
Dialectical Behavior Therapy Skills Training Ecological Momentary Assessment (EMA)
(DBT-ST) 446 methodology 267
Difficulties in Emotion Regulation Scale (DERS) educational attainment see academic achievement
borderline personality disorder 267–8, 269 effortful control 19–20, 34
substance use disorders 217, 219 biological measures 48–51
transdiagnostic approaches 425, 426, 432 co-occurring externalizing and internalizing
dimensional models 420–1 problems 32
disabilities 307, 308 externalizing problems 23–4, 26
disappointment display rule paradigm 362–3 internalizing problems 27, 28, 29, 30, 31
disruptive mood dysregulation disorder (DMDD) 281–96 ego depletion effects 48
diagnosis 281 ego-resiliency 31
differential diagnosis 282–3 electromyography 46
emotion (dys)regulation 283–91 emotion 3
interventions 291–5 as action preparation 81–3
labeling irritable emotion 295 bioinformational model 82–3
parental contingencies for behavior, consistency in 295 biphasic model 82
prevalence 282 in childhood and adolescence 4
severe mood dysregulation 281–2 definitions 3, 263, 378
distraction functions 3–4, 132, 133
nonsuicidal self-injury 408, 409 perspectives 81–7
vs. reappraisal 52–3 three-systems view 83, 84
substance use disorders 217 Emotion Acceptance Behavior Therapy (EABT) 200
traumatic stress exposure 381 emotion awareness 238, 249
distress management emotion coaching 359
anorexia nervosa 201–2, 203 Emotion Detectives Treatment Protocol
case example 204 anxiety disorders 163
Dialectical Behavior Therapy Skills Training 446 Unified Protocol 443–4
emotion regulation strategies 424 emotion dysregulation see emotion regulation
nonsuicidal self-injury 401 Emotion-Focused Cognitive-Behavioral Therapy
distress thermometers 202 (ECBT) 162, 164, 165
distress tolerance 215 emotion regulation (ER) 5–6
borderline personality disorder 267, 268 as action change 81–3
substance use disorders 216, 218, 219, 224 benefits 79
Distress Tolerance Scale (DTS) 219 in children and adolescents 9–11
divalproex definitions 5, 43, 62, 237, 263–4, 359, 378
Attention Deficit Hyperactivity Disorder 293 development 8–9, 132–3
disruptive mood dysregulation disorder 293 and executive function 7
severe mood dysregulation 293 extended process model (EPM) 85–8
divorce, children of 331–46 Research Domain Criteria 98, 99–101
effects 331 function 6–7
emotion regulation 337 group therapy 408, 409
for at-risk children 337–8 influencing factors 7–8
as protective adjustment 340 process model see process model of emotion regulation
impact of parental separation 332–6 research methods 43–5
influential factors 338–40 strategies 237
interventions 341–4 cross-sectional research 421, 427
mediating factors 336–7 as transdiagnostic mechanism 433
prevalence 331–2 Emotion Regulation Checklist 360, 363
8
5
4
458 Index
Index 459
460 Index
J depression 176–7
James, William 81, 82 posttraumatic stress disorder 380
working 116
K mental health and disorder, history of 79–81
Kids First 344 mentalization based therapy (MBT)
Kids First Center 344 for adolescents (MBT-A) 271–3
Kids’ Turn program 343 borderline personality disorder 271–3
for families (MBT-F) 271
L nonsuicidal self-injury 407–8, 409
language development 132, 133 methylphenidate 122
LAST Project 385 mindfulness
late positive potentials (LPPs) 48 anorexia nervosa 201, 205
limbic-hypothalamic-pituitary-adrenal (LHPA) axis Attention Deficit Hyperactivity Disorder 122
autism spectrum disorder 240 autism spectrum disorder 243
traumatic stress exposure 379, 381 Secret Agent Society-Operation Regulation
Limited Prosocial Emotions (LPE) see callous program 245, 248, 249, 250
unemotional (CU) traits depression 424–5
lithium 293 Dialectical Behavior Therapy Skills Training 446
longitudinal research designs 430–47 emotion regulation strategies 424
nonsuicidal self-injury 408, 409
M substance use disorders 214, 218, 220–1
major depressive disorder (MDD) training 122
central facets of emotion regulation 425 traumatic stress exposure 387
comorbidity Mindfulness Attention Scale (MAAS) 220
generalized anxiety disorder 447 substance use disorders 221
oppositional defiant disorder 282 MINI International Neuropsychiatric Interview 441
decision making 178 Monitoring the Future (MTF) survey 210–11
diagnosis 171, 172 motivational interviewing 409
Emotion Regulation Therapy 447 Movie Task for the Assessment of Social Cognition 272
executive functioning 180 multi-dimensional experiential avoidance questionnaire
genetic factors 92, 97 (MEAQ) 441–2
heart rate variability 428, 430 Multisystemic Therapy (MST) 139
memory 177 conduct disorder 139–40
neural mechanisms 289
prevalence 172 N
Research Domain Criteria 92, 97, 98 narrow phenotype bipolar disorder (NP-BD) 282,
risk factors 173, 174 283, 190
traumatic stress exposure 378 attention-emotion interactions, dysregulated 286
Unified Protocol 445 context-sensitive regulation, decreased 284–5
Manual Assisted Cognitive-Behavioral Therapy interventions 292–3
(MACT) 405–6 social-emotional stimuli, misinterpretation of 288
Manualized Cognitive-Behavioral Therapy 406 National Institute for Mental Health (NIMG), Research
marijuana use Domain Criteria 80, 88, 90, 420–1
distress tolerance 219 National Longitudinal Study of Youth 366
emotion dysregulation 219 National Survey on Drug Use and Health
intervention example 223 (NSDUH) 211, 212
prevalence 211, 212 natural disaster exposure
mass trauma exposure see traumatic stress exposure emotion regulation mechanisms 383
maternal factors lifetime risk 375
abuse and neglect 308, 309, 313 posttraumatic stress disorder 376
anxiety disorders 161 see also traumatic stress exposure
Attention Deficit Hyperactivity Disorder 114 negative automatic thoughts 425
cultural scripts 69 negative divorce effect 334
divorce, children of 336, 339, 340, 341 neglect
incarceration 352–4, 366 definition 306
attachment 356, 357, 358 emotion regulation problems, development of 313,
emotion regulation 360, 361, 363 314, 315
psychopathology 10 nonsuicidal self-injury 400
socialization 62, 63, 132–3 outcomes 311
see also parental factors prevalence 306
Maudsley Model of Anorexia Nervosa Treatment for risk factors 308, 309–10
Adults (MANTRA) 200 see also abuse and neglect
medication see pharmacotherapy neural measures of emotional reactivity 48, 50
meditation 243 reappraisal 48, 50
memory detached vs. positive 53–4
autobiographical (AM) 176–7, 181 vs. suppression 51–2
1
6
4
Index 461
462 Index
Index 463
464 Index