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

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