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

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284 Clin Child Fam Psychol Rev (2007) 10:275–293 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 123
Clin Child Fam Psychol Rev (2007) 10:275–293 285 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 123
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