Skip to main content
SpringerLink
Log in

Reductions in Anxiety are Associated with Decreased Expressive Suppression and Increased Cognitive Reappraisal After Cognitive-Behavioral Treatment: A Naturalistic Study in Youth

  • Research
  • Published:
Child Psychiatry & Human Development Aims and scope Submit manuscript

Abstract

Broad deficits in emotion regulation skills have been observed in children with anxiety-related disorders. These deficits typically improve during cognitive-behavioral therapy (CBT), but few studies have examined changes in expressive suppression and cognitive reappraisal in youth with anxiety disorders and/or obsessive–compulsive disorder (OCD) during CBT, especially in real-world settings. In a naturalistic treatment-seeking sample, 123 youth completed measures of anxiety, depression, and emotion regulation strategy use before and after 15 sessions of CBT. For anxious youth, anxiety and expressive suppression decreased over treatment, while cognitive reappraisal increased. Reductions in expressive suppression and increases in cognitive reappraisal were significantly associated with improvements in anxiety and remained significantly associated with post-treatment anxiety after accounting for baseline anxiety and depression. Changes in expressive suppression and cognitive reappraisal over the course of treatment were not found for youth with primary OCD. Thus, CBT improves emotion regulation abilities in anxious youth, and these improvements are associated with anxiety reduction; improvements in emotion regulation do not appear to drive changes in OCD symptoms. Further research is needed to determine whether changes in emotion regulation strategies mediate changes in anxiety among youth receiving CBT.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

Data Availability

Data available upon request.

Notes

  1. 8 children in the dataset were below age 10. For these children, both ERQ-CA subscales demonstrated good internal consistency (Reappraisal \(\alpha\) = .94, Suppression \(\alpha\) = .85). Overall results did not change significantly when excluding these children from the dataset. Thus, we elected to include all children ages 8 and above to maximize sample size.

  2. In order to minimize the effects of missing data, mean imputation was used to calculate total scores on key study measures (MASC-2, CDI-2) if 10% or fewer scale items were missing. Given the brevity of the ERQ subscales, mean imputation was not used as the < 10% missing data threshold could not be met.

References

  1. Thompson RA (2011) Emotion and emotion regulation: two sides of the developing coin. Emot Rev 3(1):53–61. https://doi.org/10.1177/1754073910380969

    Article  Google Scholar 

  2. Gross JJ (2015) Emotion regulation: current status and future prospects. Psychol Inq 26(1):1–26. https://doi.org/10.1080/1047840X.2014.940781

    Article  Google Scholar 

  3. McRae K, Ciesielski B, Gross JJ (2012) Unpacking cognitive reappraisal: goals, tactics, and outcomes. Emotion 12:250–255. https://doi.org/10.1037/a0026351

    Article  PubMed  Google Scholar 

  4. Hofmann SG, Heering S, Sawyer AT, Asnaani A (2009) How to handle anxiety: the effects of reappraisal, acceptance, and suppression strategies on anxious arousal. Behav Res Ther 47(5):389–394. https://doi.org/10.1016/j.brat.2009.02.010

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cavicchioli M, Tobia V, Ogliari A (2023) Emotion regulation strategies as risk factors for developmental psychopathology: a meta-analytic review of longitudinal studies based on cross-lagged correlations and panel models. Res Child Adolesc Psychopathol 51(3):295–315. https://doi.org/10.1007/s10802-022-00980-8

    Article  PubMed  Google Scholar 

  6. Compas BE, Jaser SS, Bettis AH, Watson KH, Gruhn MA, Dunbar JP, Williams EK, Thigpen JC (2017) Coping, emotion regulation, and psychopathology in childhood and adolescence: a meta-analysis and narrative review. Psychol Bull 143(9):939–991. https://doi.org/10.1037/bul0000110

    Article  PubMed  PubMed Central  Google Scholar 

  7. Carthy T, Horesh N, Apter A, Gross JJ (2010) Patterns of emotional reactivity and regulation in children with anxiety disorders. J Psychopathol Behav Assess 32(1):23–36. https://doi.org/10.1007/s10862-009-9167-8

    Article  Google Scholar 

  8. Mathews BL, Koehn AJ, Abtahi MM, Kerns KA (2016) Emotional competence and anxiety in childhood and adolescence: a meta-analytic review. Clin Child Fam Psychol Rev 19(2):162–184. https://doi.org/10.1007/s10567-016-0204-3

    Article  PubMed  Google Scholar 

  9. See CC, Tan JM, Tan VS, Sündermann O (2022) A systematic review on the links between emotion regulation difficulties and obsessive-compulsive disorder. J Psychiatr Res 154:341–353. https://doi.org/10.1016/j.jpsychires.2022.07.023

    Article  PubMed  Google Scholar 

  10. Berman NC, Shaw AM, Curley EE, Wilhelm S (2018) Emotion regulation and obsessive-compulsive phenomena in youth. J Obsessive Compuls Relat Dis 19:44–49. https://doi.org/10.1016/j.jocrd.2018.07.005

    Article  Google Scholar 

  11. McKenzie ML, Donovan CL, Mathieu SL, Hyland WJ, Farrell LJ (2020) Variability in emotion regulation in paediatric obsessive-compulsive disorder: associations with symptom presentation and response to treatment. J Obsessive Compuls Relat Dis 24:100502. https://doi.org/10.1016/j.jocrd.2019.100502

    Article  Google Scholar 

  12. Stein DJ, Fineberg NA, Bienvenu OJ, Denys D, Lochner C, Nestadt G, Phillips KA (2010) Should OCD be classified as an anxiety disorder in DSM-V? Depress Anxiety 27(6):495–506. https://doi.org/10.1002/da.20699

    Article  PubMed  Google Scholar 

  13. Clark DA (2022) Cognitive reappraisal. Cogn Behav Pract 29(3):564–566. https://doi.org/10.1016/j.cbpra.2022.02.018

    Article  Google Scholar 

  14. Suveg C, Sood E, Comer JS, Kendall PC (2009) Changes in emotion regulation following cognitive-behavioral therapy for anxious youth. J Clin Child Adolesc Psychol 38(3):390–401. https://doi.org/10.1080/15374410902851721

    Article  PubMed  Google Scholar 

  15. Helland SS, Baardstu S, Kjøbli J, Aalberg M, Neumer SP (2022) Exploring the mechanisms in cognitive behavioural therapy for anxious children: does change in emotion regulation explain treatment effect? Prev Sci 24(2):214–225. https://doi.org/10.1007/s11121-022-01341-z

    Article  PubMed  Google Scholar 

  16. Gioia GA, Isquith PK, Guy SC, Kenworthy L (2000) Behavior rating inventory of executive function: BRIEF. Psychological Assessment Resources Odessa, Lutz

    Google Scholar 

  17. Afshari A, Neshat-Doost HT, Maracy MR, Ahmady MK, Amiri S (2014) The effective comparison between emotion-focused cognitive behavioral group therapy and cognitive behavioral group therapy in children with separation anxiety disorder. J Res Med Sci 19(3):221–227

    PubMed  PubMed Central  Google Scholar 

  18. Suveg C, Jones A, Davis M, Jacob ML, Morelen D, Thomassin K, Whitehead M (2018) Emotion-focused cognitive-behavioral therapy for youth with anxiety disorders: a randomized trial. J Abnorm Child Psychol 46(3):569–580. https://doi.org/10.1007/s10802-017-0319-0

    Article  PubMed  Google Scholar 

  19. Ehrenreich-May J, Kennedy SM, Sherman JA, Bilek EL, Buzzella BA, Bennett SM, Barlow DH (2018) Unified protocols for transdiagnostic treatment of emotional disorders in children and adolescents: therapist guide. Unified protocols for transdiagnostic treatment of emotional disorders in children and adolescents. Oxford University Press, Oxford

    Google Scholar 

  20. Kennedy SM, Bilek EL, Ehrenreich-May J (2019) A randomized controlled pilot trial of the unified protocol for transdiagnostic treatment of emotional disorders in children. Behav Modif 43(3):330–360. https://doi.org/10.1177/0145445517753940

    Article  PubMed  Google Scholar 

  21. Ehrenreich-May J, Bilek EL (2012) The development of a transdiagnostic, cognitive behavioral group intervention for childhood anxiety disorders and cooccurring depression symptoms. Cogn Behav Pract 19:41–55. https://doi.org/10.1016/j.cbpra.2011.02.003

    Article  Google Scholar 

  22. Rothwell PM (2005) External validity of randomised controlled trials: “To whom do the results of this trial apply?” Lancet 365(9453):82–93. https://doi.org/10.1016/S0140-6736(04)17670-8

    Article  PubMed  Google Scholar 

  23. Kendall PC, Hedtke KA (2006) Cognitive-behavioral therapy for anxious children: therapist manual, 3rd edn. Workbook Publishing, Ardmore

    Google Scholar 

  24. Piacentini JC, Peris TS, March JS, Franklin ME (2012) Obsessive-compulsive disorder. In: Kendall PC (ed) Child and adolescent therapy: cognitive-behavioral procedures. The Guilford Press, pp 259–282

    Google Scholar 

  25. Cisler JM, Olatunji BO, Feldner MT, Forsyth JP (2010) Emotion regulation and the anxiety disorders: an integrative review. J Psychopathol Behav Assess 32(1):68–82. https://doi.org/10.1007/s10862-009-9161-1

    Article  PubMed  PubMed Central  Google Scholar 

  26. Garnefski N, Kraaij V (2018) Specificity of relations between adolescents’ cognitive emotion regulation strategies and symptoms of depression and anxiety. Cogn Emot 32(7):1401–1408. https://doi.org/10.1080/02699931.2016.1232698

    Article  PubMed  Google Scholar 

  27. Tolin DF, Sain KS, Davis E, Gilliam C, Hannan SE, Springer KS, Serchuk MD (2023) The DIAMOND-KID: psychometric properties of a structured diagnostic interview for DSM-5 anxiety, mood, and obsessive-compulsive and related disorders in children and adolescents. Assessment. https://doi.org/10.1177/10731911221143994

    Article  PubMed  Google Scholar 

  28. Gullone E, Taffe J (2012) The emotion regulation questionnaire for children and adolescents (ERQ-CA): a psychometric evaluation. Psychol Assess 24(2):409–417. https://doi.org/10.1037/a0025777

    Article  PubMed  Google Scholar 

  29. Gross JJ, John OP (2003) Individual differences in two emotion regulation processes: implications for affect, relationships, and well-being. J Pers Soc Psychol 85(2):348–362. https://doi.org/10.1037/0022-3514.85.2.348

    Article  PubMed  Google Scholar 

  30. March JS (2013) Multidimensional anxiety scale for children, 2nd edn. Multi-Health Systems, Toronto

    Google Scholar 

  31. Kovacs M (2010) Children’s depression inventory (CDI), 2nd edn. Multi-Health Systems, Toronto

    Google Scholar 

  32. Beck AT, Rush AJ, Shaw BF, Emery G (1979) Cognitive therapy of depression. Guilford Press, New York

    Google Scholar 

  33. Smits JA, Julian K, Rosenfield D, Powers MB (2012) Threat reappraisal as a mediator of symptom change in cognitive-behavioral treatment of anxiety disorders: a systematic review. J Consult Clin Psychol 80(4):624–635. https://doi.org/10.1037/a0028957

    Article  PubMed  PubMed Central  Google Scholar 

  34. Franklin ME, Freeman JB, March JS (2018) Treating OCD in children and adolescents: a cognitive-behavioral approach. Guilford Publications, New York

    Google Scholar 

  35. Peris TS, Compton SN, Kendall PC, Birmaher B, Sherrill J, March J, Gosch E, Ginsburg G, Rynn M, McCracken JT, Keeton CP, Sakolsky D, Suveg C, Aschenbrand S, Almirall D, Iyengar S, Walkup JT, Albano AM, Piacentini J (2015) Trajectories of change in youth anxiety during cognitive-behavior therapy. J Consult Clin Psychol 83(2):239–252. https://doi.org/10.1037/a0038402

    Article  PubMed  Google Scholar 

  36. Whiteside SP, Ale CM, Young B, Dammann JE, Tiede MS, Biggs BK (2015) The feasibility of improving CBT for childhood anxiety disorders through a dismantling study. Behav Res Ther 73:83–89. https://doi.org/10.1016/j.brat.2015.07.011

    Article  PubMed  Google Scholar 

  37. Whiteside SPH, Sim LA, Morrow AS, Farah WH, Hilliker DR, Murad MH, Wang Z (2020) A meta-analysis to guide the enhancement of CBT for childhood anxiety: exposure over anxiety management. Clin Child Fam Psychol Rev 23(1):102–121. https://doi.org/10.1007/s10567-019-00303-2

    Article  PubMed  PubMed Central  Google Scholar 

  38. Gross JT, Cassidy J (2019) Expressive suppression of negative emotions in children and adolescents: theory, data, and a guide for future research. Dev Psychol 55(9):1938–1950. https://doi.org/10.1037/dev0000722

    Article  PubMed  Google Scholar 

  39. Schäfer JÖ, Naumann E, Holmes EA, Tuschen-Caffier B, Samson AC (2017) Emotion regulation strategies in depressive and anxiety symptoms in youth: a meta-analytic review. J Youth Adolesc 46:261–276. https://doi.org/10.1007/s10964-016-0585-0

    Article  PubMed  Google Scholar 

  40. Asnaani A, Tyler J, McCann J, Brown L, Zang Y (2020) Anxiety sensitivity and emotion regulation as mechanisms of successful CBT outcome for anxiety-related disorders in a naturalistic treatment setting. J Affect Disord 267:86–95. https://doi.org/10.1016/j.jad.2020.01.160

    Article  PubMed  Google Scholar 

  41. Sendzik L, Schäfer JÖ, Samson AC, Naumann E, Tuschen-Caffier B (2017) Emotional awareness in depressive and anxiety symptoms in youth: a meta-analytic review. J Youth Adolesc 46(4):687–700. https://doi.org/10.1007/s10964-017-0629-0

    Article  PubMed  Google Scholar 

  42. Wald N, Carthy T, Shenaar-Golan V, Tadmor-Zisman Y, Ziskind M (2018) Influence of maternal negative emotion reactivity and cognitive reappraisal on child anxiety disorder. Depress Anxiety 35(4):353–359. https://doi.org/10.1002/da.22745

    Article  PubMed  Google Scholar 

  43. De Los Reyes A, Augenstein TM, Wang M, Thomas SA, Drabick DAG, Burgers DE, Rabinowitz J (2015) The validity of the multi-informant approach to assessing child and adolescent mental health. Psychol Bull 141(4):858–900. https://doi.org/10.1037/a0038498

    Article  PubMed Central  Google Scholar 

  44. Hope TL, Adams C, Reynolds L, Powers D, Perez RA, Kelley ML (1999) Parent vs. self-report: contributions toward diagnosis of adolescent psychopathology. J Psychopathol Behav Assess 21(4):349–363. https://doi.org/10.1023/A:1022124900328

    Article  Google Scholar 

Download references

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Anxiety Disorders Center, The Institute of Living/Hartford Hospital, 200 Retreat Avenue, Hartford, CT, 06106, USA

    Kelly A. Knowles & David F. Tolin

  2. Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA

    David F. Tolin

Authors
  1. Kelly A. Knowles
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. David F. Tolin
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Dr. Tolin initiated data collection, conceptualized the initial research question, and edited the manuscript. Dr. Knowles refined the research question, conducted the analyses, and wrote the first draft of the manuscript. All authors contributed to and have approved the final manuscript.

Corresponding author

Correspondence to Kelly A. Knowles.

Ethics declarations

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Ethical Approval

All study procedures were approved by the Hartford Hospital IRB.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Knowles, K.A., Tolin, D.F. Reductions in Anxiety are Associated with Decreased Expressive Suppression and Increased Cognitive Reappraisal After Cognitive-Behavioral Treatment: A Naturalistic Study in Youth. Child Psychiatry Hum Dev (2024). https://doi.org/10.1007/s10578-024-01684-4

Download citation

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s10578-024-01684-4

Keywords

Search

Navigation