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

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280 Clin Child Fam Psychol Rev (2007) 10:275–293 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 123
Clin Child Fam Psychol Rev (2007) 10:275–293 281 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; 123
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