The Role of Emotion Regulation in the Treatment of Child Anxiety Disorders
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- Hannesdottir, D.K. & Ollendick, T.H. Clin Child Fam Psychol Rev (2007) 10: 275. doi:10.1007/s10567-007-0024-6
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In this review, we examine the role of emotion regulation in the treatment of children with anxiety disorders. Cognitive-behavioral therapy (CBT) has been shown to “work” for children with anxiety disorders and it has been categorized as an evidence-based treatment. However, most studies have shown that the treatment is effective for about 60–70% of children, leaving the remaining children symptomatic and oftentimes with persisting psychological disorders. Of importance, it has also been shown that many children with anxiety disorders demonstrate poor emotion regulation skills. Despite these findings, little attention has been directed toward incorporating emotion regulation strategies into these relatively effective cognitive-behavioral treatments. It is possible that CBT programs do not work as well for a portion of children because their emotion regulation deficits, if present, are not being targeted sufficiently. In this review, it is suggested that adding an emotion regulation component could increase treatment efficacy. In addition, strategies aimed at improving emotion regulation at the individual level and at the family level are introduced. Details of how improved emotion regulation skills could be beneficial in bringing about change are discussed. Finally, issues of measurement and the clinical implications for research and practice are considered.
KeywordsEmotion regulationAnxiety disordersCognitive behavioral treatmentChildren
Cognitive-behavioral therapy (CBT) has been widely used in clinical and research settings to treat children with anxiety disorders. Moreover, several large-scale studies have been conducted to investigate the efficacy of CBT for children and adolescents with various anxiety disorders, including separation anxiety disorder (e.g., Kendall 1994), obsessive-compulsive disorder (e.g., POTS team 2004), social anxiety disorder (e.g., Albano 1995), and specific phobia (e.g., Öst et al. 2001). Although these CBT programs vary somewhat, all use a common, underlying set of strategies including psychoeducation, cognitive restructuring, exposure, modeling, reinforcement, and homework assignments. Most have been shown to be effective and have been designated as “probably efficacious,” if not “well established,” treatments for the childhood anxiety and phobic disorders (Ollendick and King 1998).
Despite these successful efforts, most studies have shown that the currently available CBT programs are effective for about 60–70% of children (Kendall et al. 2005; Ollendick et al. 2006), leaving the remaining children symptomatic and oftentimes with persisting and refractory psychiatric difficulties. Most CBT programs for anxious children consist of strategies intended to alter both cognitive and behavioral symptoms of anxiety. Although some programs also focus on identifying fearful emotions, most do not focus on how children experience other emotions (e.g., sadness, anger, or happiness); moreover, there been little explicit focus on enhancing the emotion regulation skills of these youth. It is possible that CBT programs only work for some children because the affective component is not sufficiently targeted, especially for those youth who demonstrate poor emotion regulation skills from the outset. This is especially plausible since anxious children in general tend to evidence poor emotion regulation skills, report experiencing emotions more intensely than other children (Suveg and Zeman 2004), and show poor emotion understanding (Southam-Gerow and Kendall 2000). As noted by Vasey and MacLeod (2001), anxious children may possess just as much knowledge of good emotion regulation strategies as most non-anxious children. However, when faced with a difficult situation, they usually revert to maladaptive strategies such as avoidance and distraction.
It is expected that anxious children demonstrate some emotion regulation deficits since atypical emotional experiences have often been considered a defining characteristic of diverse forms of psychopathology (Cole et al. 1994). Despite these considerations, it is surprising that more treatment programs do not contain specific emotion regulation components. Some CBT programs for anxious children do include relaxation techniques, which are aimed at controlling the physiological sensation of anxiety, and others offer education on appropriate facial expressions associated with different feeling states. However, ways to regulate emotional states, both positive and negative emotions, in sync with the situation that the child is in are usually not the main focus of therapy and deserve more explicit attention. Although various authors have suggested the importance of targeting emotion regulation in treatment directly (e.g., Davis and Ollendick 2005; Kendall et al. 2000; Samoilov and Goldfried 2000; Southam-Gerow and Kendall 2002; Stark et al. 2005), changes in emotion regulation skills are typically not assessed nor specifically “tested” in clinical settings or in treatment outcome studies. If anxious children lack the skills or demonstrate dysfunctional skills to regulate their emotions in various situations, treatment should address these skills as well as the dysfunctional cognitions and behaviors associated with them.
The purpose of this review is to examine the potential role of emotion regulation in CBT and introduce strategies that might be incorporated into current treatment programs for children with anxiety. Some of the strategies discussed are already being utilized in treatment for anxiety in some form, while others are being used in treatment for other childhood disorders (e.g., anger management) or with adults. The mechanisms through which these regulatory processes could increase treatment efficacy are explored, as well as issues of measurement. Two anxiety disorders, social anxiety and panic disorder, are then reviewed from the perspective of possible emotion regulation difficulties and are used to highlight how emotion regulation strategies might be utilized in treatment. Finally, implications for therapy in clinical and research settings are highlighted.
Emotion and Emotion Regulation
Emotions organize much of a child´s experience and behavior, and are central to most relationships (Langlois 2004, p. 315)
The ability to control one’s emotions is a highly valued characteristic in today’s society. A child who is able to conceal her emotions when receiving a disappointing gift is usually better liked than a child who throws a tantrum or cries in response to receiving such a gift. Being able to regulate one’s emotions therefore increases flexibility in new situations and adjustment overall. Currently, researchers are focusing more and more on the development of emotions and the process of emotion regulation. Despite lack of consensus in the field about what constitutes “emotion” and “emotion regulation” (Cole et al. 2004; Thompson 1994), a number of studies have been conducted to examine the development of emotion regulation, emotion regulation in atypical populations, and biological indicators of emotion regulation.
Although the scientific study of emotion and emotion regulation is still in its infancy, these concepts are becoming increasingly important for the field of developmental psychopathology and clinical child and adolescent psychology. Since emotions organize children’s experience in many ways (Cole et al. 2004), introducing the concept of emotion regulation into clinical research and practice seems intuitive and may prove to be beneficial. As proposed by Eisenberg and Spinrad (2004), emotion regulation can be viewed as a voluntary and goal-directed process aimed at modifying emotional states to achieve social and biological adaptation, as well as individual goals. At its core, emotion regulation is a process triggered by emotional arousal in an attempt to modulate and manage the arousal. In light of the nature of psychopathology, therapy should aim at enhancing efficient emotion regulation skills elicited by intense negative emotions and the lack of positive affect.
Although it has been suggested that emotions cannot “exist in an unregulated manner” (Campos et al. 2004, p. 378), emotions and emotion regulation are defined here separately in order to provide a working definition of them. Emotions are defined as biologically endowed processes that allow for a quick appraisal of situations and appropriate responses in order to maintain favorable or to terminate unfavorable conditions (Cole et al. 2004). The nature of the appraisal determines the quality of the emotion (negative or positive emotions) and the degree of the appraisal determines the magnitude and duration of the emotional response (Campos et al. 2004; Thompson 1994).
Emotions can be distinguished along several dimensions. First, emotions vary in quality. Some emotional states are intrinsically unpleasant and negative, such as fear, pain, anger, sadness, and disgust (Cicchetti and Hesse 1982). Other emotions are, however, by nature more rewarding and positive, such as happiness and pride.
Second, emotions vary in intensity and duration (Thompson 1994). Not only is the quality or the type of emotion important for appraisal of events, but so is the intensity of the emotional arousal and the duration of it. An experience can have a different impact on an individual depending on the intensity of the emotion. For example, a child who experiences intense negative emotions for a long period of time when separating from her caretaker is more likely to experience the event as traumatic and to experience different consequences compared to a child who only briefly sheds a few tears when the caretaker leaves.
Third, appraisal of emotions can be based on internal or external information. In determining our own emotional states, we have privileged information to our strongly felt inner states and feelings. In determining others’ feelings, we can only base our judgment on their behavior, facial expressions, situational or contextual variables, language, and gestures (Cicchetti and Hesse 1982).
Emotional processes are therefore motivating for action (approach or inhibition), dynamically fluid with the environment, situationally responsive, and performance enhancing. Emotion is viewed as a multifaceted phenomenon that includes physiological arousal, neurological activation, cognitive appraisal, attention processes, and response tendencies (Thompson 1994). In a constantly changing environment, emotions are best viewed as a set of processes which define and organize our experiences.
The interplay of emotion and emotion regulation can be called “emotion dynamics.” Though discrete emotions may provide the content of an emotional experience, regulation processes significantly influence the quality, timing, intensity, and dynamic features of the experience (Thompson 1994). Emotion regulation can be defined as the modification of any processes, both extrinsic and intrinsic, in the system that generates emotion or its manifestation in behavior (e.g., expression) (Campos et al. 2004). Emotion regulation can involve change or maintenance of any aspect of emotional arousal mentioned previously, such as physiological and neurological activation, cognitive appraisal, and attention processes. Such processes are responsible for monitoring, evaluating, and modifying emotional reactions and can lead to a change in an activated emotion, including a change in intensity, valence, or time course (Thompson 1994). The concept of emotion regulation therefore attempts to explain how and why emotions facilitate or impair other psychological processes, such as attention, overcoming obstacles, problem solving behaviors, and overall adjustment (Cole et al. 2004). Thus, emotion regulation involves regulating both negative and positive emotions; moreover, the processes a person engages in to regulate emotion can be both adaptive and maladaptive, depending on the context (Campos et al. 2004).
Debates have evolved in the field regarding the scientific definition of emotion regulation. Some of the main issues focus on the possibility of separating emotion and emotion regulation well enough to be able to operationalize and measure these constructs in a valid and reliable manner. Part of the problem is whether emotion regulation should be defined as a two-factor process where emotion regulation is voluntary and follows when a “pure” emotion is triggered (i.e., without any regulation involved) or whether emotion regulation occurs concurrently or even before the emotional experience (Campos et al. 2004). For example, some theorists view emotion regulation as an automatic reaction to an emotion being triggered and that the regulatory process is an intrinsic part of the emotional experience (e.g., Cole et al. 2004). This suggests that any changes that result from the activated emotion can be viewed as an example of emotion regulation. Others (e.g., Eisenberg and Spinrad 2004) provide a more circumscribed definition of emotion regulation. In the opinion of Eisenberg and Spinrad, emotion regulation is an effortful, voluntary, and a goal-directed attempt to modulate and manage an activated emotion. In their view, emotion regulation is therefore not just a biologically based response to the emotion (e.g., crying when separating from caretaker), but an active attempt to change the elicited emotion (e.g., screaming loudly in attempt to bring the caretaker back) (Eisenberg and Spinrad 2004). Despite the goal-directed definition of emotion regulation, an attempt to regulate an emotional response qualifies as emotion regulation even though it may not be successful (Cole et al. 2004; Eisenberg and Spinrad 2004). Success in changing an emotional state cannot be the defining feature of emotion regulation since sometimes the strategies selected to regulate emotions may simply not work in a particular situation. For instance, if a child actively attempts to change her emotional state by engaging in specific strategies (e.g., distraction, seeking out parent, etc.) she is attempting to regulate although the strategy she selects may not work well enough to calm her down or to modify her emotional state. In this case, the process is a goal-directed attempt to try to modify or manage an emotion triggered by an event and thus qualifies as emotion regulation.
For the purpose of including emotion regulation skill building into therapy with anxious children, the goal-directed definition of Eisenberg and Spinrad will be used. Since the aim of emotion regulation skill building is to teach children adaptive ways of managing their emotions to improve adjustment, the strategies are by definition goal-directed. Although these skills may become more automatic with time and practice, they are still enacted in service of goal-directed actions and different from involuntary regulatory processes.
Emotion Regulation in Anxious Children
Individual differences in emotion and emotion regulation emerge early in childhood. Under certain conditions, however, basic emotion and emotion regulation patterns become maladaptive and impede functioning. When this occurs, these patterns are considered symptoms of childhood psychopathology (Cole et al. 1994). Although it is difficult to define optimal emotion regulation without examining it in its context, emotion dysregulation is generally referred to as limited ability to manage and modulate emotions to allow for interpersonal relatedness, prosocial initiative, personal assertiveness, sympathy toward others, and other indicators of successful functioning (Thompson 1994). Cicchetti et al. (1995) noted that emotion dysregulation develops as emotions become connected to deviant cognitive and action strategies, thus leading to difficulties in preventing the elicitation of certain emotions or managing emotions and expressions once they are elicited.
Many studies indicate that children with anxiety disorders demonstrate emotion dysregulation in various ways. For instance, anxious children frequently try to avoid events and situations which produce intense emotional arousal (Mash and Wolfe 2002). While avoidance may be an efficient emotion regulation strategy for reducing or preventing intense emotional reactions, it is often maladaptive. A child with social anxiety, for example, may engage in various avoidance behaviors to regulate her anxiety, but these behaviors may be maladaptive in terms of overall adjustment (e.g., failing an assignment because the child refuses to present it to the class).
When anxious children find themselves in emotionally arousing situations, they appear to have limited skills to manage their emotions. For example, Suveg and Zeman (2004) observed that anxious children reported experiencing emotions more intensely, had dysregulated expressions, showed less adaptive coping, and had lower self-efficacy in their ability to improve their mood than non-anxious children. Southam-Gerow and Kendall (2000) obtained similar findings in which anxious children demonstrated limited knowledge in their ability to change and hide their emotions to achieve interpersonal goals.
Based on a review of studies of selective attention, Vasey and MacLeod (2001) concluded that anxious children give higher processing priority to threatening information than non-anxious children. Anxious children have also demonstrated hypersensitivity and responsiveness to bodily cues that anticipate negative emotions (Thompson 2001). Anxious children also report having little control over external anxiety provoking events and their internal reactions to such events (Weems et al. 2003). In addition, anxious adolescents have been shown to report more negative memories than non-anxious controls (Miles et al. 2004). This suggests that anxious children may not only have deficiencies in their understanding and regulation of negative emotions, but also seek out information and interpret events in ways that make them more likely to experience associated negative moods.
The importance of emotion socialization among anxious children must also be considered. Since anxious children are likely to have anxious parents (e.g., Lieb et al. 2000; Turner et al. 1987; Van Beek and Griez 2003), children’s anxiety can become more intense through parental socialization processes if the parent models maladaptive emotion regulation skills. These hypotheses have certainly been supported by extant research. For example, families of anxious children tend to encourage or facilitate avoidance and threat interpretations of ambiguous situations (Barrett et al. 1996b). In addition, parents of anxious children appear to model anxious behavior (Whaley et al. 1999) and discourage discussion of negative emotional experiences (Suveg et al. 2005). These findings indicate that anxious children may learn through socialization processes that avoidance of difficult situations and discussions about emotions is the best emotion regulation strategy.
The dynamic interplay of children’s anxiety and parenting styles must also be considered. All too frequently, parents respond to their children’s fears and anxieties by removing their child from the situation and accommodating their fears. Results of various studies (e.g., Lieb et al. 2000; Rapee 1997) have indicated that parents of anxious children tend to exercise excessive control and protection over their children. The combination of anxiety in both the child and the parent seems to elicit excessive amounts of control compared to non-anxious parents or anxious parents of non-anxious children (Whaley et al. 1999). Due to removal from or shielding of emotionally arousing situations, children with anxiety disorders may have fewer opportunities to develop adaptive emotion regulation skills. In addition to these limited opportunities, these parents may model and approve of avoidance of situations which elicit intense emotions. Therefore, children with anxiety disorders may both experience more intense emotions and have fewer opportunities to develop skills and gain self-efficacy in being able to regulate their emotions.
It seems evident then that based on these various findings children with anxiety disorders may have difficulties in regulating their emotions above and beyond their anxieties and fears. These findings emphasize the necessity of giving emotion regulation skills more explicit attention in treatment programs that are currently being offered to these children, and a need for investigating specific improvements in emotion regulation that occur in the functioning of these children following treatment. Therefore, a review of ways to measure emotion and emotion regulation for clinical and research purposes would be especially helpful to investigate such specific effects in emotion regulation based cognitive-behavioral treatment for anxious children.
Measurement of Emotion Regulation
Although emotion and emotion regulation are dynamic processes that are difficult to capture operationally (Cole et al. 2004), various methods have been devised to measure these processes separately. Most methods include a task which is designed to activate emotions in the child. The processes which occur as the child attempts to “manage” these emotions is then measured based on the assumption that emotion regulation is taking place. Thus, it is possible to measure and compare affect when the child is relaxed (baseline), when emotions are elicited (stressful or pleasant task), and then the time it takes the child to return to baseline (recovery) with regard to physiology, frequency of behavior, facial expressions, or other measures of affect. For example, Calkins and her colleagues (e.g., Calkins 1997; Calkins and Keane 2004) have utilized experimental tasks designed to elicit positive affect (a game of peek-a-boo), empathy (a film clip of child experiencing death of a pet), or frustration (attempting to open a box with a set of keys which does not include the right key). During these tasks, children’s physiology is measured, as well as their behavior, for coding of affective displays and behavior regulation. In this section, a review of emotion regulation measures is offered for purposes of measuring change in this ability after treatment. In general, a multi-method approach to measurement is recommended in which emotion regulation is assessed through a combination of a variety of methods such as behavioral, cognitive, and physiological measures (Ollendick and Hersen 1993).
Autonomic Nervous System Arousal
Although no physiological indices have been identified that represent a perfect relation to the regulation of an emotional state (Davidson et al. 2000), various processes seem to be associated with emotion regulation. When an organism experiences excitement or fear, the sympathetic nervous system increases blood flow and energy to the skeletal muscles preparing it for fight or flight. The parasympathetic nervous system, however, controls activities that occur during relaxation when heart rate decreases and restorative processes take over (Carlson 1998). Therefore, a change from heightened sympathetic activity to heightened parasympathetic activity in a stressful situation likely indicates that the organism is calming down and gaining control of the emotional experience.
Various developmental studies offer support for this assumption. For example, infants who become easily frustrated and engage in few regulatory behaviors demonstrate less suppression of cardiac activity (respiratory sinus arrhythmia) than less fussier infants (Stifter et al. 1999). Specifically, suppression of respiratory sinus arrhythmia (RSA) is considered indicative of emotional and behavioral regulation in challenging situations and seems to reflect physiological processes that allow the child to shift and focus attention on the challenging task (Calkins and Keane 2004). In addition, anxiety and fear have, in particular, been linked to low cardiac vagal tone (an index of the impulses from the vagus nerve producing inhibition of the heartbeat) (Kagan 1994; see also Stifter et al. 1999). High vagal tone, on the other hand, seems to be a marker for physiological and psychological flexibility (Friedman and Thayer 1998) and serves as a buffer against a sympathetic threat response (Porges 1995). Thus, changes in vagal tone in response to challenging tasks before and after treatment that focuses on emotion regulation, could be used as an indicator that the child is capable of better regulating their affect (e.g., fear or frustration) to be able to complete the task.
It is important to consider the state a child is in when physiological measures are obtained. For example, vagal regulation measured during baseline periods when the child is minimally engaged and not challenged (e.g., watching a neutral film clip) has been associated with temperamental reactivity to negative and positive tasks among preschoolers. Suppression of vagal regulation, on the other hand, has been related to emotional and behavioral regulation during challenging tasks (Calkins 1997). Finally, Fredrickson and Levenson (1998) have demonstrated that speed of cardiovascular recovery after an emotionally arousing event is related to the use of adaptive coping strategies, such as the elicitation of positive affect. These findings suggest that vagal regulation measured during baseline is indicative of temperament, while regulation during or after an emotionally arousing event are indicative of a person’s ability to regulate emotions and behavior.
It has been suggested that cognition and emotion are intricately bound. Recent findings indicate that the same underlying neural mechanisms direct both emotion regulation and higher cognitive processes, such as working memory and sustained volitional attention (Bell and Wolfe 2004). In fact, several studies support the notion that emotional arousal (e.g., anxiety) can impede cognitive processes such as attention and working memory. For example, Eisenberg et al. (2001) observed that children with internalizing disorders demonstrated low attention regulation. In another study of attention allocation, socially anxious adults showed increased self-focused attention and decreased external attention in feared social situations (Mansell et al. 2003). Also, Ladouceur et al. (2005) observed that children with comorbid anxiety and depressive disorders were significantly more distracted on a working memory task when presented with negative emotional stimuli compared to low-risk controls. Therefore, increased ability to regulate one’s emotions may be evident in increased attention and working memory capabilities and this may be measured directly before and after treatment.
Due to the increased cognitive load during emotionally arousing events, it is possible to examine enhanced emotion regulation skills through experimental attention tasks. Using a modified Stroop Color-naming Task, Matthews and MacLeod (1985) found that anxious subjects responded slower when presented with threat related words (physical or social threat) compared to controls. These effects have also been observed in children with anxiety disorders (e.g., Martin et al. 1992). This suggests that slower performance on the Emotional Stroop Task may be attributable to a loss in information processing capacity due to emotional arousal. Therefore, increased emotion regulation skills should lead to increased information processing capacity after successful therapy. Finally, self-report measures of emotion regulation skills have been utilized frequently with children. Assessment instruments such as the Children’s Emotion Management Scales (Zeman et al. 2001; Suveg and Zeman 2004) and the Emotion Regulation Interview (Suveg and Zeman 2004) may offer additional insights into children’s perceptions of their ability to regulate their own emotions.
Developmental psychologists have devised various methods to measure emotion regulation through specific behavioral observation systems. For example, by observing facial and vocal responses to emotionally arousing events it is possible to measure the latency, persistence, recovery time, and intensity of an emotional reaction (Thompson 1994).
Although initially designed for young children, the “disappointment task” (Cole et al. 1994) can offer valuable insights into children’s behavioral regulation in response to negative emotions at any age. In this task, the child is asked to rank-order prizes and then is led to believe she will receive her preferred toy. When given the least preferred toy, the child’s emotional reactions can be coded. Various affective behaviors (e.g., anger, sadness, worry, smiling, etc.) and self-regulatory behaviors (active, passive, and smiling) can be reliably coded during this task (e.g., Forbes et al. 2006). If direct behavioral observations are not feasible, parent reports of their children’s emotion regulation skills can be obtained using the Emotion Regulation Checklist (Shields and Cicchetti 1997).
Anxiety in Childhood
It also appears to be the case that anxious children may display biases in the ways they anticipate the future, cope with the present and remember the past. (Vasey and MacLeod 2001, p. 256)
When discussing poor emotion regulation skills among anxious children, it is necessary to examine the basic symptomatology of anxiety and how emotion regulation is intertwined with the anxiety disorders. The following section provides a brief overview of how poor emotion regulation could be a core feature in developing and maintaining anxiety and how it can impede functioning when the child is not able to adjust her emotional state according to the situation.
Anxiety disorders are among the most prevalent problems in childhood and adolescence (Anderson et al. 1987). Some common symptoms of anxiety include intrusive and catastrophic thoughts, uncontrollable worry, avoidance behavior, and increased activation of the sympathetic nervous system (e.g., increased heart rate, sweating, shortness of breath). The presence of an anxiety disorder can lead to considerable distress and interference for children and their families. For instance, the avoidance of certain social activities can impede normal social development and even lead to peer rejection (Ollendick and Hirshfeld-Becker 2002; Strauss et al. 1987). Being consumed with uncontrollable worry and anxiety can also lead to attention problems (Kendall and Pimentel 2003), low self-esteem (Mash and Wolfe 2002), and poor academic achievement (Ialongo et al. 1995).
In this section, we provide brief descriptions of two anxiety disorders, social anxiety disorder and panic disorder, along with hypothesized emotion regulation difficulties characteristic for each disorder. Due to the dearth of research on emotion regulation among anxious children, initial support for these hypotheses is gleaned from the adult literature.
Social Anxiety Disorder
This disorder is characterized by marked and persistent fear of situations in which the person feels she is being evaluated or is the focus of attention. For children, this fear is present in peer settings and not just with adults (American Psychiatric Association 1994). Children with social anxiety may try to avoid socially distressing events (e.g., birthday parties, school activity nights, or playing on a sports team) because they fear they will embarrass themselves or others might laugh at them. If they find themselves in a stressful social situation, they are likely to experience an immediate anxiety response that will likely be evident in both physiological (e.g., nausea and shortness of breath), and behavioral symptoms (e.g., poor eye contact, stuttering, and nail biting) (Beidel and Turner 1998; Ollendick and Hirsfeld-Becker 2002) or catastrophic thoughts, although these are less common for younger children with social anxiety disorder (Ollendick and Ingman 2001).
Some studies have supported the notion that socially anxious individuals may have considerable difficulty regulating their affect in social situations. Such individuals have been found to focus their attention on their physiological arousal and catastrophic cognitions instead of focusing on subtle but important cues from their interaction partners (e.g., Mansell et al. 2003). In addition, children with internalizing disorders tend to exhibit poor attention regulation (Eisenberg et al. 2001) and shy children, in particular, have demonstrated difficulties regulating emotions and coping with stress (Eisenberg et al. 1998). Preliminary findings have also shown that socially anxious children avoid attending to negative facial expressions (Stirling et al. 2006), and might thus be more likely to adjust their behavior to try to please others and limit negative feedback. Studies have also indicated that emotion regulation abilities are associated with the quality of social functioning among children (Eisenberg et al. 2000; Nowicki and Duke 1994) and adults (Lopes et al. 2005). This suggests that one of the primary difficulties for socially anxious children may be managing their negative emotions well enough to allow them to perform effectively in socially demanding situations. Key factors in successfully interacting with others include being able to send and receive subtle messages regarding ones own and others’ emotional states (Halberstadt et al. 2001). Difficulty in these processes may therefore impede children who are socially anxious from receiving and sending subtle affective messages effectively during interactions and thus lead to poor performance in social situations. In fact, children who score highly on social anxiety scales show avoidance of negative facial expressions in others, especially fear and anger (Stirling et al. 2006).
Panic attacks are generally referred to as discrete periods of time when the individual experiences intense fear or discomfort (APA 1994). Physiological symptoms may include accelerated heart rate, sweating, nausea, shortness of breath, and dizziness while catastrophic thoughts that accompany these symptoms may be fears of dying or going crazy (Ollendick 1998). To obtain a diagnosis of a panic disorder, individuals must experience recurrent unexpected panic attacks and be persistently concerned about future panic attacks and/or avoiding situations or activities they believe might lead to a panic attack (APA 1994). Thus, catastrophic thoughts and misattribution of physiological symptoms seem to be central to the maintenance of panic disorder (Clark 1986).
Panic disorder among adolescents tends to resemble panic among adults with regard to physiological symptoms and accompanying cognitions (Ollendick 1998) and panic attacks are fairly frequent at this age (Beidel and Turner 2005). Although panic disorder is somewhat rare among children, it does occur and the expression of the disorder may vary depending on the child’s age and maturity level (Birmaher and Ollendick 2004; Ollendick 1998).
It seems then that children and adolescents with panic disorder have low-self efficacy of coping with intense emotions. Youngsters who experience frequent and intense panic attacks have reported doubts about their ability to handle such intense emotions and therefore avoid activities that might trigger an attack or situations in which they have experienced panic attacks in the past (Ollendick 1995). This low efficacy may manifest itself in a belief that the presence of a certain safety signal, for example a caretaker, protects the person from an impending attack. In fact, some evidence suggests that young adults and adolescents with panic disorder have suffered from separation anxiety in early childhood (e.g., Mattis and Ollendick 1997; Silove et al. 1996). It is possible that before developing panic disorder, these children experienced occasional panic attacks or intense physiological arousal but felt safer and less anxious when their caretaker was present and therefore felt they could better cope. This view is supported by findings that indicate that a common basis for both separation anxiety and panic disorder may be high anxiety sensitivity (e.g., Hannesdottir and Ollendick 2006; Ollendick 1995), the tendency to interpret anxiety symptoms as dangerous and aversive (Silverman et al. 1991). Thus it seems that children and adolescents who develop panic disorder may have little faith in their ability to handle intense emotionally arousing situations, use safety signals to regulate their emotions, and find physiological symptoms of anxiety highly aversive and even dangerous.
CBT for Children with Anxiety
Several CBT programs are available for children with anxiety. For example, the “Coping Cat” program is frequently applied when working with children with generalized anxiety, separation anxiety, or social anxiety (Kendall 1992), “How I ran OCD off my land” is a program for children with obsessive-compulsive disorder (March and Mulle 1998), One-Session Treatment is used to treat children with specific phobias (Öst and Ollendick 1999) and Panic Disorder Treatment for Adolescents is used to treat panic disorder (Mattis and Ollendick 2002), to indicate a few.
In these programs, a change in cognition and behavior is attempted through various strategies. Cognitive restructuring is attempted through testing the child’s catastrophic thoughts during graduated exposures to the feared situations. For example, if a child believes that a dog will bite her if she approaches it, the child will be allowed to discover that this does not occur when dogs are approached and petted in a skillful way. Before the exposure stage of treatment, the child is often educated about the nature of fear and physiological arousal, sometimes taught relaxation skills and non-negative self-talk, and the interplay of thoughts, behavior, and physiological arousal is explained and illustrated. During exposure, various behavioral techniques are applied to elicit an increase in approach behavior and extinction of avoidance. The therapist may model the behavior for the child, provide positive reinforcement (social or tangible rewards) if the child is able to complete the behavior (or at least some steps towards it), and ask the child to monitor their progress outside of session via homework assignments (Marx and Gross 1998). Although the therapist may assist the child in the initial stages of therapy, the ultimate goal is to enhance the child’s ability to recognize and manage their anxiety, self-regulate, and not allow themselves to avoid or escape stressful situations. Thus, self-efficacy is engendered.
Although current CBT programs focus mostly on changing cognitions and behavior, some include references to emotions or emotion regulation, However, given extensive emotion regulation difficulties among anxious children (e.g., Southam-Gerow and Kendall 2000; Suveg and Zeman 2004) for various emotional states (not only fear and anxiety), emotions and emotion regulation strategies may need to receive more explicit attention in CBT programs than they are currently receiving. Before introducing emotion regulation strategies specifically, a brief overview of the most common techniques currently used in CBT with anxious children will illustrate this state of affairs. These techniques will be reviewed in light of how they address the affective component of anxiety and whether they can be viewed as techniques sufficiently robust to enhance emotion regulation.
At the outset of most CBT programs, the child is provided with a rationale of treatment and education about the nature of fear and anxiety. The therapist informs the child that anxiety is a natural, necessary, and, for the most part, a harmless part of being human (Mattis and Ollendick 2002). The three-component model of anxiety (thoughts, behavior, and physical feelings) is explained and the role of avoidance is explained in maintaining anxiety. The purpose of the psychoeducational component is to demystify the disorder (e.g., “OCD is just a hiccup of the brain”) and reduce the fear of experiencing anxiety. In a way, the educational component addresses concerns the child may have about her disorder and her feelings of abnormality and shame. Although the affective component is not targeted directly, the educational component provides some reassurance to the child that anxiety is harmless and, in at least some situations, might be beneficial. However, education about experiencing other negative or positive emotions (e.g., sadness, anger, or happiness) is usually not targeted specifically in treatments for anxiety.
Many CBT programs include a brief overview of affective education (e.g., Beidel et al. 1998; Kendall et al. 2000). This involves learning how facial expressions and postures are related to certain emotions. In addition, the child learns about what emotions are likely to be elicited in various situations. The aim of affective education can be to enhance the child’s social skills or help her identify her feelings in situations and use them as cues for initiating relaxation or some other coping strategy. Despite this brief introduction to affect, an anxious child is still left with a poor understanding of how to change or manage emotions once they are experienced.
Through relaxation training, the child learns to develop awareness and control over her physical reactions to anxiety. This awareness will allow the child to detect somatic symptoms of anxiety early and initiate relaxation before anxiety increases (Kendall et al. 2000; Ollendick and Cerny 1981). Relaxation can be considered a form of emotion regulation because it allows the child to modulate her physical response to an anxiety-provoking event. If successful, this modulation of the physical response should help her achieve goals that increase adaptation. For example, a socially anxious child who is able to modulate her anxiety through relaxation while reading a report in front of the class is likely to perform better academically than a child who is completely debilitated by her anxiety. However, relaxation only targets the physiological component of emotion and emotion regulation. Moreover, it is an active treatment ingredient in only some cognitive-behavioral programs for anxiety disorders (e.g., Kendall 1992; Mattis and Ollendick 2002).
Problem Solving Training
Some treatment programs for childhood anxiety include problem solving training (e.g., Kendall 1992). This includes teaching the child to identify the problem, think of various solutions, anticipate the outcome of each solution, and finally select the best strategy (Marx and Gross 1998). Oftentimes the identified problem includes how to respond in a particular situation (e.g., when another child is being a bully) or how to become better at the use of particular skills (e.g., approaching a new child in class). This strategy could be considered an emotion regulation strategy if the focus of the problem solving is to identify emotionally challenging situations and ways to respond to them. Then the child can prepare for experiencing certain emotions and use previously decided responses when they feel overwhelmed in the situation.
As with adults, the purpose of cognitive restructuring is to examine catastrophic and faulty cognitions through “experiments,” either imagined or in vivo. The purpose of these experiments is for the child to discover that her belief system is faulty and that she needs to learn new and adaptive ways of thinking. These experiments can either be behavioral, where the child tests out what happens when she faces a feared situation, or they can be cognitive, where the child learns how to work through maladaptive thought patterns and change her automatic thoughts. In regard to emotion and emotion regulation, cognitive restructuring can bring about change in affect through decreased anxiety due to changed thinking patterns. Cognitive restructuring can in some sense be viewed as an emotion regulation strategy because it involves a change in cognitive appraisal and can lead to change in affect as a byproduct of changed thinking. However, the strategy is very logical and requires the child to effectively evaluate evidence independent of previously biased schemas. This technique can therefore require a great deal of effort for children to be able to utilize it when attempting to calm down in an emotionally challenging situation.
After a child identifies her catastrophic thoughts, she is gradually exposed to the feared situation. The purpose of exposure is to help the child acclimate to the distressing situation, realize that she can cope with it, and discover that the feared consequences do not occur (Öst and Ollendick 1999). Exposure is therefore an essential technique to help a child experience decreased distress in the situation, enhance self-efficacy of coping, and change faulty cognitions. With regard to emotion and emotion regulation, exposure seems to be an important procedure in activating the emotion network and giving the child an opportunity to learn to regulate her emotions while in an emotionally arousing situation. So far, research has not revealed whether exposure works through helping the child cope with the situation or with the emotions stirred up by it (Southam-Gerow and Kendall 2002). As suggested by Davis and Ollendick (2005), exposure allows for new information to be entered into the emotional network, which should lead to improvement. However, few CBT programs target emotion regulation and emotion understanding explicitly during exposures. For example, the therapist does not necessarily reframe emotional experiences, attribute the child’s success to their ability to control their emotions, or emphasize emotional cues during exposures. More importantly, getting a child to enter an exposure situation or proceed to the next step of the exposure can often be difficult because she may feel she cannot handle such an emotionally arousing situation. Therefore, adding specific emotion and emotion regulation components to regular CBT programs might enhance the efficacy of exposures and other valid techniques considerably.
Based on this brief overview of various techniques used in CBT, it is evident that emotion and emotion regulation need to be more directly addressed in therapy for anxious children, especially for those who demonstrate such poor regulation skills. Although many programs provide the opportunity for emotion education and increased regulation skills (e.g., exposure), and others address one component of emotion (e.g., relaxation), these opportunities need to be fully utilized in sessions. Since emotional dysregulation and poor understanding of emotions appear to characterize children with most anxiety disorders, it would seem beneficial to place more emphasis on emotion regulation techniques in these treatment approaches.
Efficacy of Current CBT Programs
A number of large-scale studies have been conducted on the efficacy of CBT for children with various anxiety disorders. Although most programs do not focus on emotion and emotion regulation directly, approximately 60–70% of the children generally improve and their symptoms are reduced to subclinical levels (Kendall et al. 2005; Ollendick et al. 2006). However, many children are still left symptomatic and could possibly benefit more from treatment that focuses on changes in emotion and emotion regulation skills, as well as cognitive and behavioral skills.
The first randomized clinical study of CBT with anxious youth (Kendall 1994) revealed promising findings. After treatment, children who received CBT improved significantly compared to a wait-list control group. In addition, 65% of children (age 9–13) no longer met criteria for their primary anxiety disorder based on self-reports, parent reports and behavioral observations (Kendall et al. 2005). Moreover, treatment gains were maintained or had increased at 1-year follow-up (Kendall 1994).
Since the first clinical CBT study demonstrated efficacy for anxious children, others have followed and demonstrated efficacy of CBT for OCD (e.g., POTS team 2004), social anxiety disorder (e.g., Albano 1995; Spence et al. 2000) and specific phobia (e.g., Öst et al. 2001). A recent review of 10 controlled CBT studies on child anxiety indicated that there is a 56.5% chance of remission for a child receiving CBT compared to a 34.8% chance of remission for a child in the control groups (Cartwright-Hatton et al. 2004). These findings and other such reviews (e.g., Compton et al. 2004) support the efficacy of using cognitive-behavioral techniques for treating specific anxiety problems.
The Missing Component
Despite efforts to incorporate additional components into current CBT programs for anxious children, emotion and emotion regulation skills need to receive concerted attention, as suggested above. In contrast, various treatment programs for depressed youth (e.g., Stark and Kendall 1996; TADS 2000) already include specific emotion regulation components aimed at improving interpersonal skills, identifying feelings in specific situations, and monitoring and changing mood.
Despite the incorporation of emotion regulation components, changes in emotion regulation have not been specifically examined in these treatment programs either. Unfortunately, outcome measures in these studies include only broad measures of depression, social skills, automatic thoughts, and measures of global functioning (Stark et al. 2005; TADS 2004). The specific impact of incorporating emotion regulation components into therapy for children and adolescents is therefore largely unexplored at this time. A few studies, however, have examined changes in emotion regulation skills following emotion regulation therapy for adults (e.g., Clyne and Blampied 2004; Mennin 2004). In the Clyne and Blampied (2004) study with bulimic women, for example, the recognition of emotion and bodily sensations improved significantly following treatment. A non-significant increase in emotional intelligence was also observed. Such results lend some credence to the potential benefits of including emotion regulation components when treating complex emotional problems. Unfortunately, this study lacked an appropriate control group and it is therefore difficult to know whether enhanced emotional competence resulted from the emphasis on emotion regulation or another treatment component.
Many researchers have emphasized the need to address subjective feelings and emotion regulation skills in therapy (e.g., Davis and Ollendick 2005; Southam-Gerow and Kendall 2002; Stark et al. 2005). Fortunately, Suveg and et al. (2006) have started investigating the effects of including emotion regulation strategies in treatment for anxious youth. In a pilot study of emotion focused CBT, 6 children with anxiety disorders received 16 sessions of regular CBT (Coping Cat, 1992) which also included components on enhanced emotion understanding, emotion awareness, and emotion regulation beyond feelings of anxiety. Results indicated improvement for all children and after treatment four children no longer met diagnostic criteria for their respective disorder. More importantly, Suveg and colleagues measured and observed changes in emotion regulation skills. The children showed improvements in regulating, in emotion understanding (hiding and changing emotions), and they showed an increase in the use of emotion related language. These promising findings highlight the importance of moving in the direction of giving emotions and emotion regulation more explicit attention in the future and the need to further assess the efficacy of such treatment above and beyond the effects of currently used treatments.
Based on these arguments, it appears important to explore the benefits and possible effects of incorporating more emotion regulation components into current treatment programs. Our goal is to highlight the potential beneficial effects of including emotion and emotion regulation components into the programs available and to examine if such a strategy could result in enhanced outcomes, as has been suggested by Suveg et al. (2006). Some of the emotion regulation strategies we offer here have been utilized in other treatment programs, while others are new and are based on recent studies on emotion regulation difficulties among anxious children. As in traditional CBT programs, these strategies are intended for school aged children in as much as they require a level of cognitive sophistication for their use.
Emotion Regulation in CBT for Children with Anxiety
Based on our review, it is evident that anxious children experience intense emotions, often lack understanding of emotional change, and have low self-efficacy in their ability to improve and control their emotions. Moreover, they are likely to have parents who are anxious themselves and who may inadvertently model anxious behavior, demonstrate poor regulation skills (e.g., avoidance) themselves, and discourage expression and discussion of emotions.
Various strategies are available that can improve anxious children’s ability and understanding of regulating their emotions. These strategies are based on studies that have clarified the course of emotional development in normative populations. Moreover, these strategies aim to modify and improve emotion understanding and regulation skills at the individual level and at the family level.
The Individual Level
It appears that anxious children could benefit from strategies that aim at modifying emotion regulation skills at the individual level. As noted, anxious children can be hypervigilant toward negative information, may frame information in a negative or threatening way, lack understanding of changing and hiding emotions, and finally lack self-efficacy in their ability to manage intense emotional experiences.
Education of Emotion
In most treatment programs that include emotion regulation components, education on emotion is generally offered. For example, in the ACTION program (Stark and Kendall 1996) for depressed youngsters, children and adolescents are taught how to identify their emotions by examining their thoughts, physiological reactions, and behavior. In addition, the participants are given various scenarios and they are asked to identify what emotion the situation might elicit. Finally, participants are informed that by thinking negative thoughts they are more likely to experience negative emotions.
This approach is highly beneficial for children with anxiety disorders as well. As previously discussed, there is already a great deal of education of emotion offered in anxiety treatment programs, but most of the focus is typically on anxiety and fear and not necessarily on other emotions. By making emotion education more extensive, children can be taught about the impact of various emotions, both positive and negative. It is, for example, important for these children to realize that negative thinking elicits negative emotions, such as sadness, anger, shame, and guilt, as well as fear, anxiety, and avoidance. By teaching them to label emotions correctly, they can learn how to steer away from negative emotions that cause them to become upset and can interfere with their daily activities. Being aware of what emotions they are likely to experience when entering a situation helps children prepare themselves and learn how to manage these emotions without feeling overwhelmed. For example, a child with panic disorder may expect to feel negative emotions before entering a situation in which they have had a panic attack in the past. Thus, when a child expects to experience these emotions, she can prepare how to respond to these emotions and handle the situation more successfully.
Correctly identifying emotions in situations also allows children to gain some control over their emotions and a sense of being able to change their emotional state by altering the situation. Finally, anxious children should receive education about how to change their emotions when they feel worried and fearful. In the ACTION program, children are taught how to bring themselves out of the down mood by engaging in fun activities. It should be noted that this strategy should not be used as an avoidance strategy of an anxiety provoking situation, but as a way of teaching children that they can bring themselves out of the worry or anxiety state by taking control of their emotions and making themselves feel better. Even a simple game of putting on different colored sunglasses demonstrate for children how easily they can change their mood and see the world as “dark” or “bright” (Stark and Kendall 1996). This strategy could be especially beneficial for children with panic disorder. Learning how to correctly identify their emotions and situations which elicit certain emotions may help them feel more in control of their emotions without feeling overwhelmed with a fear of panicking and not being able to control the onset or course of the panic.
The Effects of Hot and Cold Cognitions
The tendency for anxious children to experience more negative thoughts and feelings than positive or neutral ones should be addressed. According to the Broaden-and-Build Theory of Positive Emotions (Fredrickson 2001), positive emotions broaden people’s thought repertoires and allow them to discover novel lines of thought or action by enhancing flexibility and creativity. This is the opposite effect of negative emotions, which tend to narrow people’s focus causing them to become rigidly stuck on certain solutions, as often happens among anxious and depressed people (Fredrickson and Branigan 2005). Another line of evidence comes from neuroscience where it has been suggested that the same neural mechanisms are underlying emotion regulation and higher order cognitive processes, especially working memory and volitional sustained attention (Bell and Wolfe 2004). Evidence for this interconnectedness can be observed on a Stroop task, in which a person’s performance depends on how much emotional distress she experiences during the task (Vasey and MacLeod 2001).
These findings have important implications for treatment. In treatment, children are usually taught strategies to solve problems and think of alternative options in difficult situations. For example, a child with social anxiety may be encouraged to think of different topics of conversation or ways to initiate conversation during an interaction instead of remaining quiet or leaving the situation. However, it is one thing to teach children strategies when they are in a relaxed atmosphere at the therapist’s office and quite another to expect them to remember these strategies and to actually use them when in a stressful situation. This problem has also been referred to as the difference between hot cognitions (i.e., affect loaded cognitions) and cold cognitions (i.e., the rational mind). According to the Broaden-and-Build theory, people have limited ability to think of and evaluate different solutions when they are overwhelmed by negative emotions in a stressful situation. In fact, Vasey and MacLeod (2001) concluded that although anxious children demonstrate equivalent knowledge of various coping strategies as other children, they select distraction and avoidance responses more frequently as ways of solving problems.
Due to the adverse effects of negative emotions, anxious children are especially unlikely to succeed in stressful situations if they only receive didactic training. Thus, exposure sessions are ideal for practicing these skills. Although the goal of exposure is generally to reduce anxiety and discomfort, these findings imply that it could be beneficial to go beyond reducing negative emotions and induce positive emotions. This strategy is especially important for youth with social anxiety, who may be required to perform in anxiety provoking situations and therefore have to bring their anxiety under control. Since experience of positive emotions should, theoretically, elicit the broadening of thought repertoires and help the child think of and select adaptive coping responses and solutions to problems, the socially anxious child in the example above should be able to think of more conversation starters when interacting with peers after an exposure session that concluded with the experience of positive emotions.
The Upward Spiral of Positive Emotions
The Broaden-and-Build theory not only proposes a broadening of thought repertoires following positive emotions, but also a restorative effect. A series of studies have indicated that elicitation of positive emotions following a negative event helps a person recover from adverse effects of negative emotions. In one study, the effects of experimentally elicited fear were mollified by subsequently inducing positive emotions. Participants who watched a film that elicited happiness or contentment recovered more quickly in terms of cardiovascular activity after watching a fear inducing film, compared to people who subsequently watched a neutral or sadness eliciting film (Fredrickson and Levenson 1998). These findings suggest that positive emotions may not only allow the person to feel better, but also allow her to recover quickly from negative emotions and restore balance. Although minor changes in physiology for non-anxious individuals in a laboratory setting through positive emotions may not signal major reductions in symptomatology for anxious children, it is worthwhile to examine whether it may be beneficial to focus more on enhancing positive emotions in therapy.
In fact, the TADS program includes a component in which depressed adolescents are encouraged to engage in pleasant activities because they will lead to an upward spiral of positive thoughts and feelings. Similarly, engaging in unpleasant activities leads to a downward spiral of negative thoughts and emotions. Although it has been suggested that anxious children need to engage in less negative or more neutral thinking to become less anxious (Kendall and Treadwell 2007; Treadwell and Kendall 1996), it may be worthwhile inducing positive emotions in treatment for anxious children. If positive emotions can in fact “repair” the effects of negative emotions and speed up recovery, as suggested by Fredrickson and her colleagues, these effects are highly relevant for CBT programs. The findings can be utilized in treatment for anxious children, who have few opportunities to experience the effects of positive emotions because of chronic worry and fear. Ideally, the therapist would find a way for anxious children to engage in pleasant activities that can be incorporated into situations they are generally fearful of. For example, an adolescent with panic disorder who frequently experiences panic attacks in large crowds might enjoy going to see her favorite movie at the theater while practicing being in a large group of people or a separation anxious child might enjoy listening to her favorite story on tape when going to bed at night alone. This pleasant activity might activate positive emotions, which in turn may undo the effects of experiencing panic in a crowd.
Refocusing of Attention
Good emotion regulation abilities include being able to disengage and redirect attention away from emotion eliciting stimuli. Normative studies on children’s development of coping strategies indicate that they frequently use distraction as a way of managing their emotions (Stark et al. 2000). As a part of their psychopathology, anxious children tend to become hyperfocused on negative information and have difficulty disengaging. For instance, they frequently give high processing priority to threatening information. This includes both bodily sensations in response to negative emotions (Thompson 2001) and environmental cues (Vasey and MacLeod 2001). Other studies have indicated that children with comorbid anxiety and depressive disorders become more distracted on a working memory task when presented with negative emotional stimuli compared to controls, who on the other hand become distracted when presented with positive emotional stimuli (Ladouceur et al. 2005). This threat bias causes anxious children to focus on information that elicits negative emotions.
Learning how to shift attention to positive or neutral emotional stimuli when attempting to regulate negative emotional states seems to be an important lesson for anxious children. For socially anxious children, this strategy could be beneficial since they can become hyperfocused on a single episode of negative feedback they have received in the past and ignore the multiple times they have received positive feedback from peers or adults for their performance or interaction attempts. As suggested by Ladouceur et al. (2005), teaching attention control strategies through games could be beneficial for this group of children. For example, it is possible to design a computer game in which children are reinforced for quickly identifying a scene that would lead to positive emotions (e.g., a child being applauded for her performance) amid various negative or neutral scenes (e.g., a child being laughed at by her peers). If such computer programs are not available for children, reallocation of attention could also be accomplished through more traditional and pragmatic methods, such as having them identify, memorize, and document at the end of the day positive events that occurred and examine how these events made them feel.
The problem that anxious children, as well as adults, tend to be hypersensitive and hyperfocused on physiological symptoms of distress (Mansell et al. 2003; Thompson 2001) needs to be addressed in terms of reallocation of attention. Children need to receive training in focusing their attention outward and away from their physiological response to avoid further escalation of anxiety. In fact, attention retraining programs away from threatening stimuli have been devised for adults with anxiety disorders. MacLeod and Bridle (2006) have demonstrated that adults who are trained on a dot probe task no longer show an attentional threat bias after treatment, and show reduced symptoms of anxiety. The efficacy of these methods still needs to be tested among anxious children.
Allocating attention outwards is also important for obtaining information from the environment, especially for children with social anxiety disorder who need to attend to other people to interact effectively and for youth with panic disorder who frequently misinterpret bodily symptoms of anxiety. This training could first be accomplished in a non-stressful situation using a biofeedback system. As children become more skilled at ignoring signs of physiological arousal, this skill can be utilized during exposure when children may experience heightened arousal.
It should be noted that encouraging children to ignore physiological signs of distress is somewhat contradictory to treatment programs in which they learn to identify signs of distress and use them as cues to initiate relaxation (e.g., Kendall 1992) or in other programs that actively encourage exposure to the threatening stimuli, whether it is physiological arousal or external phobic objects (Öst and Ollendick 1999). However, many situations in life require a person to effectively accomplish tasks despite feeling anxious. It may be unrealistic to expect children to initiate relaxation or to take a deep breath in the midst of a difficult situation (e.g., taking an oral test or performing in front of others) in which they need to be able to focus and pay attention. Learning how to disengage from signs of distress is therefore a good emotion regulation strategy that can be potentially applied in many situations.
Reframing Emotional Experiences
One way to manage emotions is by altering interpretations of emotionally arousing events to decrease distress. Framing emotionally arousing events in a positive light has been shown to be a powerful coping mechanism that allows people to recover more quickly from stressful experiences (e.g., Tugade and Fredrickson 2004). Being able to reframe stressful experiences becomes especially important for children with anxiety disorders given their tendency to interpret even mildly negative or neutral events as stressful, as well as having a bias for negative memories.
Children often receive external regulatory assistance during stressful times (Thompson 1994). For example, a mother might help her child reinterpret a failed attempt to perform in public by saying that the act was too difficult. In exposure therapy such reinterpretation of events is sometimes offered by the therapist who points out to a socially anxious child that a child in the front row yawned because he was tired and not because her presentation was boring. In a similar fashion, children can be taught how to interpret physiological symptoms of anxiety in less threatening ways. In fact, this is an important strategy in most treatment programs for panic disorders (e.g., Mattis and Ollendick 2002) and has been utilized in other anxiety programs as well (e.g., Kendall 1992). Teaching anxious children to reinterpret emotionally arousing events in a more positive light than they tend to do and normalizing the experience for them can therefore help reduce distress and the threat they often experience in everyday life. Ideally children learn how to reinterpret events in a positive light by themselves and do not need external help or prompts to initiate this process.
There is some evidence that reframing and recoding memories of stressful events can reduce anxiety and distress. In one study, children who had received numerous painful lumbar punctures as part of cancer treatment were assisted in correctly recollecting their ability to cope during their last procedure. Previous findings had indicated that the more distressed children were during this procedure, the less accurate and more negative their memories were of it (Chen et al. 2000). As children were assisted in recollecting correctly their ability to cope during the last procedure and realistically appraise their responses (e.g., how much they seemed distressed), they showed a greater decrease in anticipatory heart rate, lower levels of cortisol, and were rated as less distressed compared to a control group which received no intervention before the lumbar puncture (Chen et al. 1999). Reframing of negative events may thus be a beneficial strategy for children with most anxiety disorders, provided that they have experienced events that they interpreted as traumatic or negative (e.g., someone yawned while a socially phobic child presented in the class).
The Family Level
Although self-sufficiency in emotion regulation is eventually encouraged, it appears that these skills initially develop within the parent–child relationship (Malatesta and Haviland 1982). As children age, they become more adept at maintaining or modifying emotional states to achieve interpersonal goals. However, it appears that children with anxiety disorders may be at a disadvantage in developing emotion regulation skills that allow them to adjust to their environment. As previously noted, parents of anxious children tend to encourage avoidance, model anxious behavior, discourage discussion of negative emotional experiences, and frequently accommodate their children’s fears by shielding them from emotionally arousing situations. To address these issues, parents of anxious children need to receive direct training as part of their children’s treatment. This training should consist of parent management skills and reflective listening, as is frequently involved in CBT programs with parent involvement (e.g., Barrett et al. 1996a), but the focus should also be on discussion of emotional experiences and the modeling of emotional responses.
First, parents could be educated about the effects of projecting or placing their own fears onto their child. By modeling anxious behavior (e.g., avoiding or catastrophizing situations), and interpreting or anticipating situations as dangerous and threatening, they are inadvertently fueling their children’s anxiety and maintaining the disorder. Thus, parents are preventing their children from developing more adaptive emotion regulation skills when faced with stressful situations. Programs (e.g., Wood et al. 2006) which have included family anxiety management have shown promising results, especially for younger children (Barrett et al. 1996a).
Second, parents could receive guidance in how to discuss emotions with their children and be educated about the importance of letting children express their emotions. Studies have indicated that parental practices that encourage children’s expression of emotion are associated with positive outcomes (Eisenberg 1998). As suggested by Suveg et al. (2005), asking parents to engage in discussions about emotionally arousing events with children during treatment could be beneficial, provided they receive constructive feedback from the therapist. Allowing children with anxiety disorders to discuss their emotional experiences, without being discouraged or ignored, may help them develop better skills to manage their emotions. Parents could even utilize reflective listening (rewording and reflecting back what the child said without questioning or passing judgment) when helping their children express themselves.
Specifically, parents of anxious children should engage in an emotion-coaching parenting style, as opposed to an emotion-dismissing parenting style. Emotion coaching entails parents’ awareness of emotions in themselves and their children, and their ability to use this knowledge to enhance their children’s socialization. As emotion coaches, parents tolerate their children’s negative mood states without becoming upset or impatient and use these events as opportunities to offer guidance on how to regulate the emotions (Lagacé-Séguin and Coplan 2005). Since this parenting style has been associated with better emotion regulation, increased trust in one’s feelings and improved problem-solving skills (Gottman et al. 1997), anxious children could most certainly benefit from emotion coaching. However, parents should be careful to structure the emotion discussions so that the child does not perceive this as a time to obtain constant reassurance and reinforcement for her excessive worries.
Third, the bidirectional effect of the anxious child-anxious parent dyad needs to be addressed. Anxious parents frequently remove their children from emotionally arousing situations. Whether they do this to reduce their own anxiety or the child’s anxiety is unclear, however. By asking parents to observe their child in a mildly anxiety provoking situation and resisting the urge to remove the child from the situation, they are gradually exposed to the anxiety this situation elicits in them. In turn, allowing the child to see that their parent is observing them in this situation affords the child confidence in their ability to cope with the situation and, in turn, may enhance their self-efficacy. This way, parents can send the message that the situation is not dangerous and that they trust their child to be independent.
In light of the findings that many parents of anxious children help to maintain and exacerbate their children’s anxiety, it seems important to address familial effects on children’s regulation skills in therapy. This will be especially important for younger children since parents appear to be an integral part of the development of emotion regulation skills in early childhood.
Conclusion and Future Directions for Research and Practice
This review has presented findings on emotion regulation difficulties among children with anxiety disorders and the possible benefits of enhancing current cognitive-behavioral treatment programs by focusing more explicitly on emotion regulation skills training. The efficacy of CBT programs for child anxiety was examined, as well as the direct and indirect emotion regulation effects of strategies currently used in CBT. Emotion regulation strategies were presented in light of how they could modify anxiety at the individual level and the family level, and examples for treatment of social anxiety disorder and panic disorder were used to demonstrate the use of these strategies. Finally, measurement of treatment efficacy and developmental implications of therapy were discussed.
It seems especially important to examine the possible benefits of incorporating emotion regulation training into treatment for anxious youth. In as much as approximately 30–40% of anxious children remain symptomatic after traditional therapy (Kendall et al. 2005; Ollendick et al. 2006) and in light of the accumulating evidence of specific emotion regulation difficulties which characterize these children, new avenues in therapy should be considered to enhance treatment efficacy. It is recommended that the emotion regulation components discussed in this paper be added to the currently available treatment programs, tailored to the specific disorders, and evaluated for their incremental value in efficacy. Still, further study is required at this time to identify what specific emotion regulation difficulties characterize each disorder. Although the anxiety disorders all have common elements, they vary in terms of low self-efficacy of emotion regulation, difficulties in preventing negative emotions (e.g., interpretative threat bias, difficulties reframing and redirecting attention, etc.), and difficulties managing emotions or their expression (e.g., experiencing intense emotions, hiding emotions for interpersonal purposes, etc.).
The developmental appropriateness of the emotion regulation strategies also needs to be considered. Several authors have discussed the importance of incorporating developmental theory into CBT with children (e.g., Barrett 2000; Grave and Blissett 2004; Kinney 1991; Ollendick and Vasey 1999; Ollendick et al. 2001). It has been suggested that many CBT strategies require children to have attained a certain maturity level, such as being able to understand causal reasoning and use language to mediate and control behavior (Grave and Blissett 2004). Similarly, the developmental requirements and appropriateness of emotion regulation strategies must be considered before implementing them routinely in therapy.
It also goes without saying that the selection of certain emotion regulation treatment modules depends entirely on the nature of the child’s disorder. In this review, examples of social anxiety and panic disorder have been used to demonstrate the possible usefulness of incorporating emotion regulation strategies into therapy. However, these strategies can be applied for any anxiety disorder if they target the nature of the problem or the demonstrated maintenance factors. Whether the family is included in treatment would also depend on the nature of the disorder. For instance, it would seem especially beneficial to include emotion regulation strategies at the family level for children with separation anxiety. Although focusing on emotion regulation issues at both the individual and the family level might be useful, therapeutic efforts should probably also be focused on poor emotion regulation at the individual level if no family issues are present.
Before new components are added to treatment programs, logistical issues such as time constraints and availability need to be considered. Since most programs already include approximately 10–15 one hour weekly sessions (e.g., Kendall 1992; Mattis and Ollendick 2002), it would be best if these new treatment components could be incorporated into these existing sessions. For example, a child could practice diverting her attention away from her physiological arousal through a biofeedback system during a regular exposure session. A child could even play a computer game aimed at training attention toward positive information for 10 min at the end of each session. Similarly, the therapist could work with parents separately on the aforementioned parenting skills and children could practice sending, experiencing, and receiving affective messages in group therapy with other anxious children. Before these strategies are implemented in a clinical setting or in private practice, their efficacy needs to be examined in controlled clinical treatment trials and change in emotion regulation needs to be directly measured to determine if such processes truly mediate change. The pilot study on Emotion Focused Cognitive Behavioral Therapy (Suveg et al. 2006) suggests that incorporating more emotion regulation skills into therapy is promising, although this program still needs to be compared with traditional CBT to examine whether treatment gains are above and beyond usual outcomes.
It is expected that inclusion of specific emotion regulation components will soon become reality in treatment of child anxiety, as is already happening in the area of adult psychopathology (e.g., Clyne and Blampied 2004; Mennin 2004). This overview of emotion regulation difficulties and strategies to modify them hopefully will serve as a catalyst for designing treatments for children that address more explicitly the emotion regulation component of psychopathology, as well as the cognitive and behavioral components.