The Role of Emotion Regulation in the Treatment of Child Anxiety ...

Clin Child Fam Psychol Rev (2007) 10:275–293 

DOI 10.1007/s10567-007-0024-6 

The Role of Emotion Regulation in the Treatment of Child 

Anxiety Disorders 

Dagmar Kristin Hannesdottir · Thomas H. Ollendick 

Published online: 20 August 2007 

© Springer Science+Business Media, LLC 2007 

Abstract 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 

becausetheir emotion regulation deficits, if present, are 

notbeing targeted sufficiently. In this review, it is suggestedthat 

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. 

Keywords Emotion regulation · Anxiety disorders · 

Cognitive behavioral treatment · Children 

D. K. Hannesdottir (&) · T. H. Ollendick 

Department of Psychology, Child Study Center, 

Virginia Polytechnic Institute and State University, Suite 207, 

460 Turner Street, Blacksburg, VA, 24061, USA 

e-mail: dkh@vt.edu 

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 anxietydisorders, including separation 

anxiety disorder (e.g., Kendall 1994), obsessivecompulsive 

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 

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276 Clin Child Fam Psychol Rev (2007) 10:275–293 

emotions more intensely than other children (Suveg 

andZeman 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 

andpanic disorder, are then reviewed from the perspective 

of possible emotion regulation difficulties 

andare usedto highlight how emotion regulation strategies 

mightbe 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. 

Emotion 

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 

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Clin Child Fam Psychol Rev (2007) 10:275–293 277 

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. 

Emotion Regulation 

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. 

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For the purpose of including emotion regulation skill 

building into therapy with anxious children, the goaldirected 

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 goaldirected. 

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 

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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 peeka-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. 

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Cognitive Indicators 

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. 

Behavioral Indicators 

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 

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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 Disorder 

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; 

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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. 

Psychoeducation 

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. 

Affect Education 

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 insituations 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. 

Relaxation 

Through relaxation training, the child learns to develop 

awareness and control over her physical reactions to 

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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 cognitivebehavioral 

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. 

Cognitive Restructuring 

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. 

Exposure 

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 

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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 

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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 insituations 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 

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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 

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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 nonstressful 

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 

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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 

123


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 selfefficacy. 

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 

123


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. 

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