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

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