Emotion regulation and psychopathology in children and adolescents ( PDFDrive )

Emotion Regulation and Psychopathology in Children and Adolescents

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iii Emotion Regulation and Psychopathology in Children and Adolescents Edited by Cecilia A. Essau Sara Leblanc Thomas H. Ollendick 1

iv 1 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries © Oxford University Press 2017 The moral rights of the authors‌have been asserted First Edition published in 2017 Impression: 1 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by licence or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this work in any other form and you must impose this same condition on any acquirer Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America British Library Cataloguing in Publication Data Data available Library of Congress Control Number: 2016963281 ISBN 978–0​ –1​ 9–8​ 76584–4​ Printed and bound by CPI Group (UK) Ltd, Croydon, CR0 4YY Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up-​to-​date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Except where otherwise stated, drug dosages and recommendations are for the non-p​ regnant adult who is not breast-​feeding Links to third party websites are provided by Oxford in good faith and for information only. Oxford disclaims any responsibility for the materials contained in any third party website referenced in this work.

v Preface This contemporary volume brings forefront research in emotion regulation and how processes underlying emotion regulation have a bearing on the field of child and adolescent psychopathol- ogy. The book shows continuity by initially introducing the topic of emotion and its regulation and then narrowing its scope, analyzing the role emotion regulation plays in specific disorders while critically examining current assessment and treatment strategies. In the concluding chap- ters, emotion regulation in high risk, targeted groups is assessed and intervention and prevention is explored. This book has brought together an array of leading international scholars who specialize in the emotional disorders. We have asked them to summarize the latest findings in their field while assessing intervention through a comparative, critical lens in order to pass on this cru- cial knowledge to the next generation of mental health professionals. Each chapter is unique, as authors expose the reader to different approaches and outlooks from diverse specialties for diverse problems. This 20-c╉hapter volume consists of four parts. In Part  1, broad issues are discussed such as the biological, physiological and cultural factors underlying and impacting emotion regulation and psychopathology in children and adolescents. In Part 2, specific disorders are delineated and current treatment programs are discussed, including Attention Deficit Hyperactivity Disorder, conduct disorder, anxiety disorders, depression, eating disorders, substance use disorders, autism spectrum disorder, borderline personality disorder, and severe irritability and disruptive mood dysregulation disorder. Part  3 assesses emotion dysregulation in specific targeted populations, including children of abuse and neglect, children of divorce, children with incarcerated parents, children exposed to traumatic stress, and adolescents who engage in nonsuicidal self-âi•‰njury. It investigates the interplay between environment, behavior and self-âr•‰egulation and the etiology, maintenance and propagation of psychopathology in these diverse environments. The final part of this book conceptualizes emotional regulation as a transdiagnostic process and discusses innova- tive approaches to treatment that arise when viewed through this lens. This book combines the latest research from leading academics on a variety of clinical top- ics with an emphasis on intervention from an applied perspective; this combination of appli- cation and theory makes it a suitable reference for mental health professionals by providing empirical review and current data on treatment efficacy. However, it was particularly designed for graduate students taking advanced courses in clinical psychology and psychiatry who want to remain abreast of current breakthroughs and leading treatment options for child and adolescent psychopathology. We wish to acknowledge the efforts of the contributors, whose expertise and dedication to the project have been outstanding. Without them, a comprehensive coverage of the various topics would not have been achieved. Additionally, we wish to acknowledge the support and cooperation of the staff at Oxford University Press. Cecilia A. Essau, Sara Leblanc, & Thomas H. Ollendick

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vi Acknowledgments I (Cecilia Essau) feel very honoured to have had this opportunity to co-e╉dit this volume with my highly respected colleague, Tom Ollendick, who’s been a great inspiration, mentor, scientist, clinician and very good, patient and understanding friend to me, and with Sara Leblanc, who introduced me to emotion regulation during her research. I wish to thank my family in Malaysia, Canada and Germany, especially my husband, Juergen, and our daughter, Anna, for their continu- ing support and inspiration. I dedicate this volume to my late parents, Essau Indit and Runyan Megat, whose courage, love and belief in me have made me become who I am; had they still been alive, they would have been most proud of this accomplishment and my choice of emotion regula- tion strategies. I (Sara LeBlanc) wish to express gratitude to my respected colleague Cecilia Essau for giving me the opportunity to serve as a co-e╉ ditor on this influential volume. Over the years Cecilia has served as a role model, mentor and inspiration due to her humility, grace and impeccable ethic; it was through her determination and vision that this work came to fruition. I also wish to express my deepest thanks to Professor Ollendick, I am humbled and inspired by your contribution to the field of Psychology, it was a privilege and honor to have the opportunity to work with you. I also wish to thank my family and friends for their unwavering dedication and support, especially my parents Blaine, Noreen and grandmother, Juanita. Finally, I also wish to thank my late sister Amanda for our countless adventures; her valuable insights taught me to see the humor in all things and have given me many memories I will eternally cherish, to her I dedicate this volume. I (Tom Ollendick) wish to give thanks to my good friend and colleague, Cecilia Essau, who invited me to serve as one of the co-âe•‰ ditors of this important volume with her. This has been a rewarding project and one that would not have been possible without her vision and dedication. I also wish to thank Sara LeBlanc whom I have met through this project and with whom I would very much like to work with in the future. Finally, I give thanks to my wife, Mary, our daughters, Laurie and Katie, and our sons-i╉n-l╉aw, David and Billy, as well as our six grandchildren, Braden, Ethan, Calvin, Addison, Victoria and William. Without them, my life would be much less interest- ing and enjoyable. I thank them for their love and support over the years. My own emotion regula- tion has been much the better with them at my side. To them, I dedicate this work.

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ix Table of Contents List of Abbreviations╇ xi List of Contributors╇ xv Part I╇ Emotion Regulation: General Issues 1 Emotion Regulation: An Introduction╇ 3 Sara LeBlanc, Cecilia A. Essau, & Thomas H. Ollendick 2 The Relation of Self-âR•‰ egulation to Children’s Externalizing and Internalizing Problems╇ 18 Nancy Eisenberg, Maciel M. Hernández, & Tracy L. Spinrad 3 Biological and Physiological Aspects of Emotion Regulation╇ 43 Kateri McRae & Michelle Shiota 4 Cultural and Social Aspects of Emotion Regulation╇ 60 Selda Koydemir & Cecilia A. Essau 5 Research Domain Criteria (RDoC) and Emotion Regulation╇ 79 Michael Sun, Meghan Vinograd, Gregory A. Miller, & Michelle G. Craske Part II╇E motion Regulation and Child and Adolescent Psychopathology 6 Emotion Regulation and Attention Deficit Hyperactivity Disorder╇ 113 Blossom Fernandes, Roseann Tan-M╉ ansukhani, & Cecilia A. Essau 7 Emotion Regulation and Conduct Disorder: The Role of Callous-âU•‰ nemotional Traits╇ 129 Nicholas D. Thomson, Luna C. M. Centifanti, & Elizabeth A. Lemerise 8 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment╇ 154 Dagmar Kr. Hannesdóttir & Thomas H. Ollendick 9 Emotion Regulation and Depression: Maintaining Equilibrium between Positive and Negative Affect╇ 171 Frances Rice, Shiri Davidovich, & Sandra Dunsmuir 10 Emotion Regulation and Eating Disorders╇ 196 Julian Baudinet, Lisa Dawson, Sloane Madden, & Phillipa Hay 11 Emotion Regulation and Substance Use Disorders in Adolescents╇ 210 Thomas A. Wills, Jeffrey S. Simons, Olivia Manayan, & M. Koa Robinson 12 Emotion Regulation in Autism Spectrum Disorder╇ 235 Jonathan A. Weiss, Priscilla Burnham Riosa, Carla A. Mazefsky, & Renae Beaumont 13 Emotion Dysregulation in Adolescents with Borderline Personality Disorder╇ 259 Carla Sharp & Timothy J. Trull

x x Table of Contents 14 Emotion Regulation in Severe Irritability and Disruptive Mood Dysregulation Disorder  281 Katharina Kircanski, Ellen Leibenluft, & Melissa A. Brotman Part III  Emotion Regulation in Specific Behavior/P​ opulation 15 Children of Abuse and Neglect  305 Faye Riley, Anna Bokszczanin, & Cecilia A. Essau 16 Children of Divorce  331 Maria Caridad H. Tarroja, Ma. Araceli Balajadia-​Alcala, & Maria Aurora Assumpta D. Catipon 17 Children’s and Adolescents’ Emotion Regulation in the Context of Parental Incarceration  351 Janice Zeman & Danielle Dallaire 18 Children Exposed to Traumatic Stress  374 Brandon G. Scott & Carl F. Weems 19 Adolescents who Engage in Nonsuicidal Self-i​njury (NSSI)  398 David Voon & Penelope Hasking Part IV Epilogue 20 Transdiagnostic Approaches to Emotion Regulation: Basic Mechanisms and Treatment Research  419 Brian C. Chu, Junwen Chen, Christina Mele, Andrea Temkin, & Justine Xue Index  453

xi List of Abbreviations ACC anterior cingulate cortex DBT Dialectical Behavior Therapy ACEs adverse child experiences DBT-​ST Dialectical Behavior Therapy Skills Training ADHD Attention Deficit Hyperactivity Disorder DERS Difficulties in Emotion Regulation Scale AG Agoraphobia DMDD disruptive mood dysregulation ALS Affective Lability Scales disorder AM autobiographical memory DSM Diagnostic and Statistical Manual of Mental Disorders AN Anorexia Nervosa ANS autonomic nervous system DTS Distress Tolerance Scale APA American Psychiatric EA experiential avoidance Association EABT Emotion Acceptance Behavior ARFID Avoidant/​Restrictive Food Therapy Intake Disorder ECBT Emotion-F​ ocused Cognitive-​ ASD Autism spectrum disorder Behavioral Therapy BA behavioural activation ED emotional dysregulation BABCP British Association of EF executive function Behavioural and Cognitive Psychotherapies EMA Ecological Momentary Assessment BP bipolar I disorder EMDR eye-​movement sensitization BPD borderline personality disorder processing BPS British Psychological Society EMG electromyography BSI Brief Symptom Inventory EPM Extended Process Model CAT Cognitive analytic therapy ERPs event-​related potentials CBITS Cognitive Behavioral ERT Emotion Regulation Training Intervention for Trauma in Schools EUC Enhanced Usual Care CBT cognitive behaviour therapy FBT family based treatment CD conduct disorder FFCWB Fragile Families and Child Well Being CDC Centers for Disease Control and Prevention FFT Functional family therapy CERQ Cognitive Emotion Regulation fMRI functional magnetic resonance Questionnaire, imaging CGI Clinical Global Impression GAD generalized anxiety disorder CIDI Composite International HCPC Health and Care Professions Diagnostic Interview Council CODIP Children of Divorce HED heavy episodic drinking Intervention Program HF-H​ RV high-f​ requency heart rate variability CP conduct problems HFASD high-f​ unctioning autism CSR clinical severity ratings spectrum disorder CU callous-u​ nemotional HPA hypothalamic–p​ ituitary–a​ drenal CVR cardiovascular reactivity

xi xii List of abbreviations HRV heart rate variability PCMC-​A Parents and Children Making Connections—H​ ighlighting ICD-6​ Sixth edition of the Attention International Classification of Diseases PD Panic Disorder ID Intellectual disability PDs personality disorders INS insomnia PFC prefrontal cortex IPPA Inventory of Parent and Peer pgACC pregenual anterior Attachment Inventory cingulate cortex ISRE incarceration-​specific risk PMT Parent management training experiences PNS peripheral nervous system IY The Incredible Years PSST Problem-​Solving Skills LHPA limbic-h​ ypothalamic-p​ ituitary-​ Training adrenal PTS posttraumatic stress LPE Limited Prosocial Emotions symptoms LPP late positive potential PTSD posttraumatic stress disorder MAAS Mindfulness Attention Scale RCTs randomized controlled trials MACT Manual Assisted Cognitive-​ RDoC Research Domain Criteria Behavioural Therapy RSA respiratory sinus arrhythmia MANTRA Maudsley Model of Anorexia Nervosa Treatment for Adults RVLPFC right ventral lateral prefrontal cortex MBT mentalization based therapy RO-​DBT Radically-O​ pen DBT MBT-​A MBT for adolescents SA sinoartial MBT-F​ MBT for families SAD Separation Anxiety Disorder MDD major depressive disorder SAS-O​ R Secret Agent Society-​Operation MEAQ multi-d​ imensional experiential Regulation avoidance questionnaire SDQ Strengths and Difficulties MPC medial prefrontal cortex Questionnaire MST Multisystemic Therapy SHAPS Snaith-​Hamilton Pleasure Scale MTF The Monitoring the Future SIB self-​injurious behavior NBP New Beginnings Program SM Selective Mutism NC non-​clinical comparisons SMD severe mood dysregulation NICE The National Institute of Clinical Excellence SNS sympathetic nervous system NIMH National Institute for Mental SP Specific Phobias Health’s SPACE Supportive Parenting for NSDUH The National Survey on Drug Anxious Childhood Use and Health Emotions NSPCC National Society for the SSRIs selective serotonin reuptake Prevention of Cruelty to inhibitors Children SSRT Stop Signal Reaction NSSI non-s​ uicidal self-​injury Time Task ODD oppositional defiant disorder STAIR Skills Training in Affect and Interpersonal Regulation OGM overgeneral autobiographical memory STEPPS Systems Training for Emotional Predictability and Problem OST One-s​ ession treatment Solving PATHS Promoting Alternative SUD substance use disorder Thinking Strategies

xi TAU treatment-​as-​usual UP-Y​ List of abbreviations xiii TFP transference-​focused psychotherapy WHO Unified Protocol for the TRY Thinking about Reward in WPVA Treatment of Emotional Young People Disorders in Youth UP Unified Protocol World Health Organization Word, Perception, Valuation, Action

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xv List of Contributors Ma. Araceli Balajadia-​Alcala Blossom Fernandes De La Salle University-​Manila, Philippines University of Roehampton, London, UK Julian Baudinet Dagmar Kr. Hannesdóttir Sydney Children’s Hospital Network Throska-​og hegdunarstod, Reykjavik, Iceland (Westmead Campus), Sydney, Australia Penelope Hasking Renae Beaumont Curtin University, Perth, Australia University of Queensland, Australia Phillipa Hay Anna Bokszczanin Western Sydney University, Sydney, Australia University of Opole, Poland Maciel M. Hernández Melissa A. Brotman Arizona State University,USA National Institute of Mental Health, National Katharina Kircanski Institutes of Health, Bethesda, MD, USA National Institute of Mental Health, National Maria Aurora Assumpta D. Catipon Institutes of Health, Bethesda, MD, USA InTouch Community Services, Makati City, Selda Koydemir Philippines Middle East Technical University, Luna C. M. Centifanti Northern Cyprus University of Liverpool,UK Sara Leblanc Junwen Chen College of New Caledonia, Quesnel, Canada Flinders University, Adelaide, Australia Ellen Leibenluft Brian C. Chu National Institute of Mental Health, National Rutgers, The State University Institutes of Health, Bethesda, MD, USA of New Jersey, USA Elizabeth A. Lemerise Michelle G. Craske Western Kentucky University, USA University of California, Los Angeles, USA Sloane Madden Danielle Dallaire Sydney Children’s Hospital Network College of William and Mary, USA (Westmead Campus), Sydney, Australia Shiri Davidovich Olivia Manayan University College London, London, UK University of Hawaii Cancer Center, Lisa Dawson Honolulu, Hawaii, USA University of Sydney, Sydney, Australia Carla A. Mazefsky Sandra Dunsmuir University of Pittsburgh School of University College London, London, UK Medicine,USA Nancy Eisenberg Kateri McRae Arizona State University, USA University of Denver, USA Cecilia A. Essau University of Roehampton, London, UK

xvi xvi List of Contributors Christina Mele Michael Sun Rutgers, The State University University of California, Los Angeles, USA of New Jersey, USA Roseann Tan-M​ ansukhani Gregory A. Miller De La Salle University-​Manila, Philippines University of California, Los Angeles, USA Maria Caridad H. Tarroja Thomas H. Ollendick De La Salle University-​Manila, Philippines Virginia Polytechnic Institute and State Andrea Temkin University, USA Rutgers, The State University Frances Rice of New Jersey, USA Cardiff University, UK & University College Nicholas D. Thomson London, UK University of Durham, UK Faye Riley Timothy J. Trull University of Roehampton, London, UK University of Missouri, Columbia, Priscilla Burnham Riosa Missouri, USA York University, Canada Meghan Vinograd M. Koa Robinson University of California, Los Angeles, USA University of Hawaii Cancer Center, David Voon Honolulu, Hawaii, USA Monash University, Melbourne, Australia Brandon G. Scott Carl F. Weems Arizona State University, REACH Iowa State University, USA Institute, USA Jonathan A. Weiss Carla Sharp York University, Canada University of Houston, Houston, Texas, USA Thomas A. Wills Michelle Shiota University of Hawaii Cancer Center, Arizona State University, USA Honolulu, Hawaii, USA Jeffrey S. Simons Justine Xue University of South Dakota, USA Flinders University, Adelaide, Australia Tracy L. Spinrad Janice Zeman Arizona State University, USA College of William and Mary, USA

Part I Emotion Regulation: General Issues

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3 Chapter 1 Emotion Regulation: An Introduction Sara LeBlanc, Cecilia A. Essau, & Thomas H. Ollendick Human emotions Human emotions are an integral component of everyday life that influence cognitive functioning (Bebko, Franconeri, Ochsner, & Chiao, 2011; Eysenck, 2004; Gross, 2013) memory (Christianson, 2014) and overall wellbeing (Kotsou, Gregoire, & Mikolajczak, 2011). Emotions impact both intra- personal and interpersonal processes, and, when dysregulated, they may become destructive and intrusive in daily life (Frijda, 1986; Slee, Arensman, Garnefski, & Spinhoven, 2007), contributing to the development, maintenance, and propagation of psychopathology (Castella et al., 2013). In general, emotion regulation competencies become differentiated as a function of develop- ment. Children tend to seek support from adults or use behavioral techniques to regulate emo- tions. As children reach adolescence, they become increasingly self-âr•‰eliant, engaging in planful problem solving and utilizing cognitive strategies (for example, reappraisal) more frequently when faced with stressful life events (Zimmer-âG•‰ embeck & Skinner, 2011). Although the majority of children and adolescents will successfully navigate these developmental stages by cultivating adaptive coping skills, for some, this marks the beginning of lifelong challenges with emotion regulation and resultant dysregulation (Kessler et al., 2005). This introductory chapter will begin by discussing both the definition and functionality of emo- tions; it will then turn to a discussion of emotion regulation and associated processes. Critically, it will consider the importance of this topic as it pertains to emotional wellbeing, whilst also examin- ing the crucial link between emotion dysregulation and psychopathology in children and adoles- cents. Later in the chapter, various emotion regulation strategies will be described and categorized according to their utility, emphasizing strategies that demonstrate adaptive social, cognitive and physiological benefits. This information is critical in delineating the underlying mechanisms leading to the development and propagation of psychopathology, which is crucial when tailoring effective treatment and prevention programs specifically suited to both the child and adolescent populace. Definition and function of emotions Emotion is a dynamic and convoluted construct. A comprehensive definition of emotions must consider three key aspects, which include:  The conscious experience elicited via the emotion; the underlying neurological processes involved in emotion generation and finally, the observable behavior and facial expression evoked by the emotion (Izard, 2013). Universally accepted within the literature, emotion has been broadly defined as “[a]â•„person-s╉ ituation transaction that compels attention, has particular meaning to an individual, and gives rise to a coordinated, yet flexible, multi-s╉ ystem response to the on-g╉ oing person-s╉ ituation transaction” (Thompson, 2007, p. 5). Emotions are important due to their relative influence on cognition, appraisal processes, per- ception, and ultimately, behavior. They impact decision-m╉ aking (Cassotti, Habib, Poirel, Aïte, & Moutier, 2012; Mikels, Maglio, Reed, & Kaplowitz, 2011; Oatley & Johnson-L╉ aird, 1987), learning (Ahmed, van der Werf, Kuyper, & Minnaert, 2013; Cahill, Prins, Weber, & McGaugh, 1994) and

4 4 Emotion Regulation: An Introduction drive goal pursuits (Koole, 2009; Tice, Bratslavsky, & Baumeister, 2001). It has been hypothesized that emotions evolved to promote the species by eliciting specific action patterned responses to life threatening circumstance, thereby increasing the likelihood of survival. From this stand-âp•‰ oint a negative bias would be adaptive; for example, in prehistoric times hearing a rustling in the bush if one was likely to interpret this as a threat, feel fear, and ultimately flee, one would be more likely to survive than if a more positive appraisal was made, viewing the sound as innocuous, rather than life threatening (Sapolsky, 2007). However, in post-i╉ndustrial societies humans are often faced with psycho-âs•‰ocial stressors, which activate the fight-âo•‰ r-f╉light response (Hypothalamic–╉ pituitary–a╉ drenal axis: HPA axis) in the same manner even though they are no longer placed in life threatening circumstances. This chronic activation can have a deleterious impact on overall wellbeing if stress levels are not regulated. In terms of adaptive function, the positive emotions may be facilitative, as they broaden atten- tional focus (Derryberry & Tucker, 1994) whilst concurrently enhancing the scope of cognition. For example, a series of classical experiments demonstrated that when compared with a control condition, those in a positive state were able to make more unique associations with neutral words (Isen, Johnson, Mertz, & Robinson, 1985). This led researchers to conclude that positive affect enhances cognitive processing via the promotion of cognitive flexibility, elaboration, and integra- tion, whilst concomitantly fostering relatedness and interconnection between cognition, ideas, and action (Isen, 1987; Isen & Daubman, 1984). Emotions in childhood and adolescence In terms of development, infants will vary in individual difference with regards to the intensity and frequency at which they express emotion. Additionally, the way caregivers respond to their expression of emotion is critical in the development of their emotion regulation competencies and their attachment style (Izard, 2013). The famous strange situation experiment (Ainsworth & Wittig, 1969) demonstrated varying attachment styles of children between the ages of 12 and 24 months based on their emotional response when placed in various stressful situations. Their behavior towards their caregiver in these situations allowed their attachment to be categorized as either secure, insecure avoidant, and insecure ambivalent/âr•‰ esistant. Insecure attachment occurred when the infant’s emotional needs were not adequately met by the caregiver, this transactional process impacted both the behavior of the child and caregiver. Accordingly, insecure attachment has been associated with an increased risk of emotional, interpersonal, and behavioral problems (Dang & Gorzalka, 2015; Kobak et al., 1993). In terms of development, emotions impact personality development two-âf•‰old (John & Gross, 2004). Firstly, genetic predisposition plays an integral role in establishing core traits, propensities, and thresholds for various emotive states (Hariri & Forbes 2007). The second key feature is the child’s experiences (Campos, Walle, Dahl, & Main 2011) and key learnings relating to their emo- tional health with particular importance placed on how the expression of emotion and regulation is socialized (Izard, 2013). In addition, an individual’s development of their emotional traits will play a critical role in their social development such that the child who is quick to anger, frightens easily, frequently smiles, will attract and receive differentiated responses based on their behav- ior (Van Reekum & Scherer, 1997). Thus, emotional development influences social development and also plays a critical role in intellectual development. An infant who is frequently distressed or afraid will be far less likely to explore their environment when compared with a child who is content and curious. Tomkins (1962) asserts that the emotion “interest” is a critical component required for intellectual development. Thus, adaptive emotional development serves a myriad of functions that influence social, intellectual and interpersonal growth.

5 Emotion regulation 5 Emotion regulation Emotions are complex and dynamic: They can be useful or deleterious. Thus, the key to optimum emotional functioning is adaptive emotion regulation, which is characterized by implementing effective strategies that are contextually appropriate and account for individual difference and personal preference (Gross & John, 2003). Varying definitions of emotion regulation exist within the developmental literature (Cole, Martin & Dennis, 2004). For example, according to Gross (1998) emotion regulation refers to the heterogeneous set of processes individuals implement to modulate their emotional experiences. This definition subsumes both the “up” and “down” regulation of emotions, as an individual may decrease, increase or maintain negative and positive emotions (Erber, Wegner, & Therriault, 1996; Parrott, 1993). Alternatively, emotion regulation has been defined as a “[p]râ•„ocess used to man- age and change if, when, and how (e.g., how intensely) one experiences emotions and emotion-╉ related motivational and physiological states, as well as how emotions are expressed behaviorally” (Eisenberg et al. 2007, p. 288). Eisenberg and Spinrad (2004) posit that although intrinsic and extrinsic factors play a role in emotion regulation, it is advantageous to distinguish between exter- nal and internal regulation. External regulation refers to external forces, such as parents, teachers, and peers, which influence emotion regulation. This may be particularly pertinent in the early childhood years, when support seeking from adults is a primary form of affect regulation in nor- mative development (Zimmer-G╉ embeck & Skinner, 2011). In contrast, internal regulation refers to effortful, self-âr•‰ egulation, which may include a variety of cognitive and behavioral strategies an individual chooses to implement to modulate their emotional response. The primary focus of this chapter will be internal self-âr•‰egulation, as this type of regulation is within the individual’s control and can be shaped through directed intervention, a topic that will be discussed in greater detail in Chapter 2. The definition utilized within this chapter will be consistent with the aforementioned definition put forth by Gross (1998), who views emotion regulation as a varied set of processes individuals engage in to modify their emotional experience. The ability to effectively regulate emotions is a critical and common place activity (Oschner & Gross, 2005). Various strategies may be employed that are broadly categorized as antecedent-╉ focused or response-âf•‰ocused strategies (Gross, 1998). Antecedent strategies occur early in the emotion generative process, altering the impact of emotion-âe•‰liciting cues; whereas, response-╉ focused emotion regulation occurs later in the process, impacting behavioral responses (Gross & Thompson, 2007). Emotion regulation influences the intensity, duration, and expression of emotions (Gross, 1999), occurring on a continuum from controlled to automatic, conscious to unconscious (Koole, 2009). Research has demonstrated the vast majority of emotional experience can be regulated (Canli, Ferri & Dunman, 2009). There are a variety of different strategies which can be employed to regu- late emotions which include: Reappraisal of the event (Hofmann, Heering, Sawyer, & Asnaani, 2009), situation modification (Gross, 1998), change of attentional focus (Rothermund, Voss, & Wentura, 2008), and suppression (Dalgleish, Schweizer, & Dunn, 2009). The two strategies that will be primarily focused on in this chapter are reappraisal and emotional suppression, as they have received the most attention in the literature, with reappraisal primarily associated with posi- tive health outcomes and suppression, primarily associated with negative health outcomes (Gross & John, 2003). Cognitive reappraisal is an antecedent technique that involves changing the interpretation of a situation in order to reduce the emotional impact (Gross & Thompson, 2007). Perception is real- ity and our thoughts are linked to our actions, which are linked to our behavior: Every situation can be interpreted in a variety of different ways, and it is this interpretation, rather than the event

6 6 Emotion Regulation: An Introduction itself, that impacts thoughts, behaviors, and emotions (Malooly, Genet, & Siemer, 2013; Wilding & Milne, 2010). In children, reappraisal has been shown to be an adaptive method of managing emotions, when compared to other strategies, such as suppression (Carthy et al., 2010; Garnefski & Kraaij, 2009; McKrae, et  al., 2012). In addition, both longitudinally and cross-s╉ectionally, Garnefski and colleagues have demonstrated a strong negative relationship between the reported use of reappraisal and depression in both adolescent and adult populations (Garnefski & Kraaij, 2006; Garnefski, Kraaij, & Spinhoven, 2001; Kraaij, Pruymboom, & Garnefski, 2002). Similarly, research has shown children possessing a secure attachment style are more empathetic due to their superior emotion regulation competencies (Panfile & Laible, 2012). These findings are mir- rored in the adolescent populace, as adolescents demonstrating adaptive emotional regulation competencies are more likely to achieve their goals and form strong interpersonal relationships; whereas, adolescents with impaired emotion regulation skills, often manifest behavioral problems and are less likely to achieve both long and short-ât•‰erm goals (Hum & Lewis, 2013). In contrast to reappraisal, emotional suppression has been shown to have negative health out- comes, as studies have linked the frequent use of suppression with depressive symptomology in both children and adolescents (Betts, Gullone, & Allan, 2009; Hughes, Gullone, & Watson, 2011; Larsen et  al., 2013). Relatedly, in adolescents, deficits in emotion regulation have been associated with substance abuse (Wilens et al., 2013), aggressive behavior (Herts, McLaughlin, & Hatzenbuehler, 2012) and pathological gambling (Potenza, et al., 2011), topics which will be dis- cussed in greater detail in subsequent chapters. In general, suppression has been associated with increased negative affect (Srivastava et al., 2009), decreased positive affect (Gross & John 2003), decreased social functioning (English & John, 2013), and enhanced levels of depressive sympto- mology and obsessive thinking (Corcoran & Woody, 2009; Marcks & Woods, 2005). Furthermore, suppression has been linked to decreased life satisfaction (Kashdan & Steger, 2006), decreased interpersonal skills (Butler et al., 2003), enhanced sympathetic nervous-s╉ ystem activation (Egloff, Schmuckle, Burns, & Schwerdtfeger, 2006), increased stress-âr•‰elated symptomology (Moore, Zoellner, & Mollenholt, 2008)  and decreased memory recall (Richards, Butler, & Gross, 2003; Richards & Gross, 2000). In conclusion, the frequent and inflexible use of emotional suppression may be damaging as it prolongs the experience of negative affect (Campbell-âS•‰ ills & Barlow, 2007), makes excessive use of cognitive resources (Gross & John, 2003) and keeps physiological arousal chronically activated (Eglof et al., 2006; Ohira et al., 2006). Thus, the cultivation of adaptive strat- egies, such as cognitive reappraisal, is imperative during the formative years so that the use of emotional suppression is minimized. Function of ER Historically, it was hypothesized that emotion regulation functioned to satisfy hedonic needs, such that pleasure was maximized and pain minimized (Larsen, 2000; Westen, 1994). This may be due in part to the realization that negative emotions drain an extensive amount of an individual’s physical and mental resources (Sapolsky, 2004; 2007). However, even though hedonic needs may fuel emotion-âr•‰ egulation in some circumstances, they are not the sole motivation for all regulatory function (Erber & Erber, 2000; Erber, Wegner, & Therriault, 1996). For example, if one deems their emotions to be beneficial they may choose to stay in that emotional state even though it is associated with negative and unpleasant feelings (Gross, 2007). Relatedly, goal pursuits may influence emotion regulation tendencies, leading to short-ât•‰erm discomfort in the quest towards delayed gratification based on a strong commitment to long-t╉erm goals (Mischel et al., 2010; Mischel & Ayduk, 2004). Delayed gratification is a common paradigm employed in the investigation of emotion regulation competencies in children dating back to the

7 FACTORS INFLUENCING EMOTION REGULATION DEVELOPMENT 7 1970’s. Early research showed that some children were able to practice emotion-âr•‰ egulation strate- gies, such as reframing and distraction, to delay gratification in the interest of garnering a greater reward at a later time. A recent follow-âu•‰ p of the original studies conducted by Mischel and col- leagues, demonstrated the predictive validity of the delayed gratification test across a wide range of social, cognitive, and mental health indicators (Casey et al., 2011). Thus, one can infer from this research that the absence of delayed gratification in children can be an early sign of emotion dysregulation. In support, a study by Krueger and colleagues (1996) determined that, in pre-╉ adolescents, the inability to delay gratification was linked to the externalizing disorders. Relatedly, the work of Shoda et al. (1990), determined that preschoolers’ performance on the delayed grati- fication task accurately predicted behavioral problems from age five to eight. In part, this may be attributed to deficiencies in attentional control and executive function. Executive function and emotion regulation Attentional processes play a key role in one’s ability to regulate motivation and emotional arousal; therefore, executive function is considered a key component of effective emotion regulation. Executive function (EF) is a multidimensional construct relating to the processes that exercise control over cognition, attention, and behaviors (Blair, Zelazo, & Greenberg, 2005). EF is goal oriented and involves higher order, self-r╉egulatory processes (Nelson, Thomas, & Hann, 2006). EF emerges during the end of infancy and shows striking changes during the preschool years, continuing to develop throughout adolescence (Zelazo et al., 2008). The literature on EF asserts that an important corollary of cognitive development in early childhood is the ability to diminish the emotional impact of disruptive and distractive stimuli. A study by Ursache, Blair, Stifter, and Voegtline (2013), for example, determined that high levels of executive function were associated with children who exhibited high levels of emotional reactivity in conjunction with high levels of emotion regulation competencies. In addition, children that rated high in both emotional reactiv- ity and emotion regulation where more likely to have increased levels of adaptive parenting. In adolescence, the cultivation of emotion regulation strategies shows an increase in the use of reappraisal and a reduction in the use of suppression, a progression that mirrors developmental changes occurring in executive functions during this period (Lantrip, Isquith, Koven, Welsh, & Roth, 2015). More specifically, these researchers determined that the increased use of reappraisal was associated with improved executive function; whereas, the increased use of suppression was associated with worsened executive function in an adolescent sample. Deficiencies in EF are criti- cal during this period, as they have been associated with a plethora of early onset psychiatric disorders, such as conduct disorder and attention deficit/âh•‰ yperactivity disorder (Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005), in addition to behavioral problems such as substance abuse and physical aggression (Séguin & Zelazo, 2005). Thus, EF is intimately tied to emotion regulation. Factors influencing emotion regulation development Emotion regulation is influenced by a variety of genetic, biological and environmental factors. Children demonstrate enhanced control of both affect and behavior, shifting control from the brain’s orienting neuronal network during infancy to greater use of executive functions by the age of three to four years. From infancy to toddlerhood connectivity changes in the following way: During the early years, parietal and frontal areas play a crucial role in orienting; whereas, executive function and emotion regulation is regulated via the midfrontal and anterior cingu- late regions of the brain in the later years (Rothbart, Sheese, Rueda, & Posner, 2011). On a neu- robiological level, individual variations in serotonin levels have been identified, which impact

8 8 Emotion Regulation: An Introduction an individual’s emotional expressivity and regulation (Hariri & Forbes, 2007). Concordantly, dysregulation of the dopaminergic system has been associated with major depressive disorder (Kennedy, Koeppe, Young, & Zubieta, 2006). Moreover, there seems to be a distinct genetic com- ponent to emotion regulation, as evidenced by twin studies, which have shown that identical twins are more similar in emotional control, when compared with fraternal twins (Goldsmith, Buss, & Lemery, 1997). From a neurobiological stand-p​ oint, the development of the prefrontal cortex, hippocampus, and amygdala is associated with higher decision making processes, sustained attentional control and the enhanced capacity to regulate one’s emotions (Ochsner & Gross, 2007) (see Chapter 3). Environmental factors also play a key role in the development of emotion regulation competen- cies, particularly in infancy and early childhood. By six months of age an infant’s primary form of emotion regulation occurs through relative interactions with caregivers (Crockenberg & Leerkes, 2004). However, as the child ages, they are influenced by numerous factors such as the parents’ regulatory style, social referencing, peer influence, and parental reactions to their children’s dis- plays of emotion (Zeman, Cassano, Perry-​Parrish, & Stegall, 2006). Furthermore, culture impacts emotion regulation in a myriad of ways, by determining what is valued (i.e., saving face, personal autonomy, etc.), which behaviors are socially acceptable and what is deemed appropriate behavior in varying contexts (see Chapter 4). This was illustrated in a study by Kagan (2003) who compared cultural norms in American and Chinese cultures. This study determined that children in the American sample were socialized to be outgoing, assertive, and bold; thus, children were taught to be highly expressive of both positive and negative affect. In contrast, in the Chinese sample, shyness was seen as a positive attribute, as it demonstrated the child was studious, hard-​working, and willing to prescribe to social norms. Relatedly, in some Asian cultures, emotional suppression is considered an adaptive emotion-​regulation strategy, unlike in autonomous cultures (e.g., Australia, America, and the UK); therefore, its consequences do not manifest negatively in these cultures (Butler, Lee, & Gross, 2007) the way they do in cul- tures subscribing to Western-E​ uropean value systems. Thus, adaptive emotion regulation is con- textually specific and culturally motivated. Emotion regulation development during childhood and adolescence Changes in emotion regulation strategies become evident during the first few years of life. At this time, regulation becomes less reflexive (i.e., newborns) and more intentional, involving behav- ioral control in the absence of external input or monitoring from parents (i.e., self-​regulation, see Kopp & Neufeld, 2003). In young infants and toddlers, behavior such as self-​soothing (e.g., thumb sucking; Ekas, Lickenbrock, Braungart-​Rieker, 2013), reorienting attention (Wiebe et al., 2011), and distracting one’s gaze from negative stimuli (Crockenberg & Leerkes 2004) have been shown to reduce negative affect. In addition, as noted, research has shown an increase in both executive function and effortful self-​regulation as children age (Eisenberg et al., 2010). As noted above, a common measure of emotional control in children is their ability to delay gratification. Improvements in the ability to delay gratification are found from 24 months to four years (Li-G​ rining, 2007). Further improvements in self-​control and executive function occur dur- ing the late pre-s​ chool years (Mezzacappa, 2004); moreover, substantial development in emotion regulation is manifested between six to ten years of age (Stegge & Terwogt, 2007). At this stage of development, critical changes in regulatory competencies occur, as children learn to identify, understand, and analyze emotion-e​ liciting situations in a cause and effect way, whilst also discov- ering alternative ways of expressing their feelings (Stegge & Terwogt, 2007). Thus, a large body

9 Emotion regulation and psychopathology in children and adolescents 9 of literature has demonstrated that a healthier emotion regulation profile is demonstrated as a function of age and maturation (John & Gross, 2004; Silvers, McRae, Gabrieli, Gross, Remy, & Ochsner, 2012; Tottenham, Hare, & Casey, 2011). Sex differences in emotion regulation strategies also occur in line with the adult literature, which have demonstrated that males employ emotional suppression more frequently than females (Eisenberg, Spinrad, & Eggum, 2010). In part, this may be due to socialization processes. Adolescent emotional development may be influenced by a variety of factors, such as interactions with peers, parents, and teachers, as well as societal influences such as the Internet, media, and contemporary culture (Klimes-​Dougan et al., 2007; Morris et al., 2007). One line of scientific inquiry has investigated the importance of parental influence on ado- lescents’ emotional development (Yap et al., 2008). This research determined that parental style of emotion regulation (i.e., suppressive, hostile, controlling vs. caring and warm) (Jaffe et  al. 2010) and parental expression of emotions as well as their reactions to their children’s displays of emotion (Morris et  al. 2007)  are all important factors influencing regulatory development. Eisenberg and colleagues (1998) posit that socialization of emotion regulation occurs in three primary ways, namely, 1) the socializers’ expression of their own emotions 2) the socializers’ reac- tion to the children’s display of emotions and the 3) the socializers’ amenability towards discussing emotion (see Chapter 2 by Eisenberg and her colleagues on the developmental aspects of emotion regulation). Emotion regulation and psychopathology in children and adolescents In children aged two to five years, general rates of psychopathology are 16.2 overall, 10.5% for internalizing/​emotional disorders (see Chapters 8 and 9) and 9% for externalizing/​behavioral dis- orders (see Chapters 6 and 7), rates which are comparable to those found among older children (Egger & Angold, 2006). Alarmingly, in children, levels of anxiety and depression have increased continually at a dramatic rate since the 1950s (Gray, 2011). Research has shown two broad types of contributing factors: Environmental context/e​ vents and child temperament. In relation to envi- ronmental factors, this category includes both specific and global elements; in general, parental supervision, peer problems and sexual abuse have been shown to predict externalizing disorders, neglect has been linked to oppositional defiant disorder (ODD), lack of social support and expo- sure to violence have been associated with the internalizing disorders, while childrearing factors such as a controlling family environment have been linked to the anxiety and depressive disorders (Dierker & Szatmari, 1998; Jaffee, et al., 2002; Merikangas, et al., 2010; Rapee, 1997). However, it is important to note that risk factors are highly complex and it is likely that disorders do not have a single cause but rather a causal chain or multiple causal chains that are influenced by the interac- tion between various environmental, social, genetic, and biological risk factors (Kraemer, Stice, Kazdin, Offord, & Kupfer, 2014). Adolescence is a period characterized by marked changes occurring on a hormonal, neu- rological, and developmental level. These changes directly impact emotionality, affecting both the valence and intensity of negative and positive emotions, providing an opportune time for regulatory skills to be cultivated and honed (Silk et  al., 2003). In general, research has shown more extreme mood states (both positive and negative) are typical in adolescent daily life when compared with the adult demographic (Larson, Moneta, Richards, & Wilson, 2002; Larson & Richards, 1994). Roughly 20% of adolescents have a psychiatric disorder (McLeod, Uemura, & Rohrman, 2012). An epidemiological study by Costello, Copeland, and Angold (2011) determined the

01 10 Emotion Regulation: An Introduction prevalence rate for an anxiety disorder was 10.2%, with average onset occurring at eight years of age and 50% of cases falling between six to twelve years of age. Similarly, an epi- demiological study investigating general rates of psychopathology in high school students found 10% of students currently had a clinical disorder and 33% had experienced one in their life-t​ imes. Additionally, within this sample, high relapse rates were found for both substance abuse (15%) and depression (18%) (Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993). Relatedly, a large scale, longitudinal study by Essau, Lewinsohn, Olaya, and Seeley (2014) determined that adolescent anxiety predicted poor adjustment across a variety of domains (work, family etc.); reduced life satisfaction, substance, alcohol abuse/d​ ependency, and anxi- ety in adulthood in a large, community sample of 800 participants. In the developmental literature, the primary area of interest has focused on children’s malad- justed emotion regulation (Eisenberg, Spinrad, & Eggum, 2010). This research has investigated when normal emotional development is compromised and identified the risk factors associated with atypical development (Cicchetti & Cohen 2006). Factors influencing the development of emotion regulation skills include inherent disposition in addition to social and environmental resources available to the child. Additionally, genetic pre-​disposition and parental influences have been shown to influence the development of psychopathology in adolescents (Rosenstein & Horowitz, 1996). From a genetic stand-​point, a twin study by Eaves (2006) measuring symptoms of psycho- pathology, demonstrated that monozygotic twins were more strongly correlated than dizygotic twins with most measures showing small to moderate genetic effects. Concordantly, in relation to depression, the majority of twin studies suggest a moderate genetic influence, with heritability rates ranging between 30–​80% (Eley & Plomin, 1997; Murray & Sines, 1996; Thapar & McGuffin, 1997). In general, these studies support genetic susceptibility to psychopathology across a broad range of disorders in adolescent populations. In relation to parental influences on emotion regulation propensities, research supports a para- digm of adolescent psychopathology that is influenced by interpersonal interactions with parents (Rosenstein & Horowitz, 1996). This is supported by the work of Grant (2006), who found con- siderable evidence supporting the mediating role that family relationships play in the relation- ship between stressors and psychological symptoms in both children and adolescents. A study by Rosenstein and Horowitz (1996) determined, in a clinical sample of 60 adolescents psychiatri- cally hospitalized, both child and maternal attachment style were highly concordant, manifesting insecure attachments styles in both the adolescent and the parent. In general, when researching parental influence on adolescent psychopathology, fathers have been highly underrepresented. However, research shows there is substantial paternal influence; with particularly strong effects found with relation to externalizing problems manifested in adolescents. In most cases these effects were comparable to those associated with maternal psychopathology (Phares & Compas, 1992). A study by Achenbach (1991) determined that in four-​to eight-y​ ear-o​ lds, externalizing problems were associated with difficulties in emotion regulation including increased levels of anger and impulsivity. Similarly, internalizing problems were associated with enhanced levels of sadness, impulsivity, and reduced attentional control (Eisenberg et al., 2001). These relationships were investigated via a longitudinal design and similar findings were obtained two years later (Eisenberg et al., 2005). In children, certain components of emotion regulation have been associ- ated with particular behavioral difficulties. For example, inhibiting anger or expressing anger in a maladaptive way has been linked to internalizing problems (Zeman, Shipman, & Suveg, 2002). Similarly, in a sample of eight-​to twelve-y​ ear olds with various anxiety disorders, a significant relationship was demonstrated between psychiatric disorder and maladaptive emotion regulation as assessed via both self and parent report measures (Suveg & Zeman, 2004). More specifically,

1 Conclusion 11 children with anxiety disorders were more likely to be inflexible, demonstrating heightened worry, anger and negative affect when compared with children in the control conditions. Likewise, a recent study by Tortella-âF•‰ eliu, Balle, and Sesé (2010), determined that adolescents scoring high in negative affect were prone to implement dysfunctional emotion regulation coping styles. Conclusion Emotion dysregulation is strongly associated with psychiatric illness in youth. As mentioned pre- viously, in both children (Hughes, Gullone, & Watson, 2011) and adolescents, the use of emotional suppression has been linked to depressive and anxious symptomology (Betts, 2009; Hannesdottir & Ollendick, 2007; Larsen et  al., 2013). Furthermore, in adolescents, deficits in emotion regu- lation have been linked with aggressive behavior (Herts, McLaughlin, & Hatzenbuehler, 2012), substance abuse (Wilens et al., 2013), and pathological gambling (Potenza, et al., 2011). Due to the strong association between emotion dysregulation and psychopathology and related problems in living, many studies have been conducted on this topic in the past 15–â2•‰ 0 years. This book includes a collection of these studies, touching on numerous contemporary topics, such as developmen- tal psychology, developmental psychopathology, transdiagonostic issues, and cultural aspects of emotion regulation with exciting incites from leading researchers in the field. References Achenbach, T. M. (1991). Child behavior checklist/4‰•â –•â1‰ 8. Burlington: University of Vermont. Ainsworth, M. D. S., & Wittig, B. A. (1969). Determinants of infant behavior. Attachment and exploratory behavior of one-âo•‰ lds in a strange situation, 4. Ahmed, W., Van der Werf, G., Kuyper, H., & Minnaert, A. (2013). Emotions, self-r╉ egulated learning, and achievement in mathematics: A growth curve analysis. Journal of Educational Psychology, 105(1), 150–1•â‰ 61. Betts, J., Gullone, E., & Allen, J. S. (2009). An examination of emotion regulation, temperament, and parenting style as potential predictors of adolescent depression risk status: A correlational study. British Journal of Developmental Psychology, 27(2), 473–â4‰• 85. Blair, C., Zelazo, P. D., & Greenberg, M. T. (2005). The measurement of executive function in early childhood. Developmental Neuropsychology, 28(2), 561–≕571. Butler, E. A., Lee, T. L., & Gross, J. J. (2007). Emotion regulation and culture: are the social consequences of emotion suppression culture-s╉ pecific? Emotion, 7(1), 30. Cahill, L., Prins, B., Weber, M., & McGaugh, J. L. (1994). β-A╉ drenergic activation and memory for emotional events. Nature, 371(6499), 702–7•‰â 04. Carthy, T., Horesh, N., Apter, A., Edge, M. D., & Gross, J. J. (2010). Emotional reactivity and cognitive regulation in anxious children. Behaviour Research and Therapy, 48(5), 384–â3‰• 93. Campbell-S•‰â ills, L., & Barlow, D. H. (2007). Incorporating emotion regulation into conceptualizations and treatments of anxiety and mood disorders. In Gross (Ed.), Handbook of Emotion Regulation (pp. 542–╉ 559). New York: Guilford Press. Campos, J. J., Walle, E., Dahl, A., & Main, A. (2011). Reconceptualizing emotion regulation. Emotion Review, 3(1), 26–â3‰• 5. Canli, T., Ferri, J., & Duman, E.A. (2009). Genetics of emotion regulation. Special Issue: Neurogenetics as applied to systems and cognitive neuroscience. Neuroscience, 164, 43–â•5‰ 4. Casey, B. J., Somerville, L. H., Gotlib, I. H., Ayduk, O., Franklin, N. T., Askren, M. K., … & Shoda, Y. (2011). Behavioral and neural correlates of delay of gratification 40 years later. Proceedings of the National Academy of Sciences, 108(36), 14998–‰1â• 5003. Cassotti, M., Habib, M., Poirel, N., Aïte, A., Houdé, O., & Moutier, S. (2012). Positive emotional context eliminates the framing effect in decision-m╉ aking. Emotion, 12(5), 926–╉931.

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81 Chapter 2 The Relation of Self-R╉ egulation to Children’s Externalizing and Internalizing Problems Nancy Eisenberg, Maciel M. Hernández, & Tracy L. Spinrad Self-regulation in children The lack of emotional or behavioral regulation is often viewed as a component of psychopathology; indeed, some types of problems are defined in part by the lack of self-r╉ egulation (e.g., some exter- nalizing problems and depression/a╉nxiety; American Psychiatric Association, 2013). However, empirically, agreement has not been reached regarding what capacities are included in the con- struct of “regulation” or “self-âr•‰egulation” (e.g., see Eisenberg, Hofer, Sulik, & Spinrad, 2014). In this chapter, we consider some useful conceptual distinctions in the domain of control, briefly present heuristic hypotheses regarding the relations between regulation-âr•‰elevant constructs and externalizing and internalizing behaviors, and review representative empirical findings. Conceptual issues Eisenberg, Hofer, Sulik, and Spinrad (2014) defined emotion-âr•‰elated self-r╉egulation as a process used to “manage and change whether, when and how (e.g., how intensely) one experiences emo- tions and emotional-âr•‰elated motivational and physiological states, as well as how emotions are expressed behaviorally. Thus, it includes processes used to change one’s own emotional state, to prevent or initiate emotion responding (e.g., by selecting or changing situations), to modify the significance of an event for the self, and to modulate the behavioral expression of emotion (e.g., through verbal or nonverbal cues)” (p. 157). The term “emotion-âr•‰elated” self-âr•‰egulation is used because many of the processes/a╉ bilities that are part of emotion-âr•‰ elated regulation can be involved in regulating multiple aspects of functioning, which include not only the expression and experi- ence of emotion, but also aspects of cognition, attention, and behavior that do not involve (or secondarily or minimally involve) modulating the expression and experience of emotion. Thus, emotion regulation, defined by Gross (2014) as “shaping which emotions one has, when one has them, and how one experiences or expresses these emotions” (p. 6), can be viewed as occurring when emotion-r╉ elated self-âr•‰ egulatory skills are applied directly to the experience or expression of emotion. Of course, external influences such as parents or providers of social support can contrib- ute to the modulation of emotion and its expression, but for clarity, we have argued it is clearer to differentiate such external controlling factors from self-r╉ egulation (Eisenberg & Spinrad, 2004). Regardless of the specific terminology, we have suggested it is useful to distinguish between self-âr•‰egulatory processes that can readily become volitional when required to adapt or achieve

91 Conceptual issues 19 a goal and those “regulating” or controlling processes that affect emotion and behavior but are harder to control volitionally. As has been discussed by researchers from multiple subdisciplines of psychology (see Carver, 2005), many non-v╉olitional processes have important modulating (in a sense, regulating) effects on attention, behavior, cognition, and physiological responding. Eisenberg et  al. (2014) used the term “self-âr•‰egulation” to refer to “potentially volitional, self-╉ regulatory processes.” The interconnectedness of these constructs makes it difficult to differentiate emotion from its self-r╉egulation; someone who expresses little emotion in a potentially evocative context may be regulating his or her emotion or simply may not be responding emotionally. Thus, it is beneficial to focus on the processes used to manage emotion, cognition, and associated behavior, rather than to measure the amount of emotion experienced or expressed. Consequently, when studying the regulation of emotion, rather than look for possible self-âr•‰egulation of emotional displays, there are advantages to focusing on and measuring aspects of executive functioning that contribute to self-âr•‰egulation (e.g., executive attention) and dispositional differences in self-r╉egulation that employ the skills used for the regulation of emotion and related cognitive, physiological, and behavioral responses. Effortful self-âr•‰egulatory processes The temperamental underpinnings of self-r╉egulation are known as effortful control, defined by Rothbart and Bates (2006, p. 129) as “the efficiency of executive attention, including the ability to inhibit a dominant response and/âo•‰ r to activate a subdominant response, to plan, and to detect errors.” Effortful control includes the capacities to effortfully (i.e., willfully) deploy attention (e.g., to focus and shift attention as needed) and to willfully inhibit or activate behavior, especially when doing so is a non-p╉ referred (subdominant) response (i.e., inhibitory control and activational con- trol, respectively). Effortful control is often measured with parents’ and teachers’ ratings and with a variety of behavioral measures, including those assessing the ability to delay gratification (e.g., wait until a bell rings to pick up a snack), inhibiting and activating similar behaviors based on different commands (games like Simon says), and executive-âf•‰ unctioning skills involving the man- agement of attention and inhibiting behavior. Although effortful control is believed to be the temperamental core of self-âr•‰egulation, emerg- ing self-r╉ egulation can be conceptualized broadly, including more than the basic executive func- tioning-âr•‰elated skills involved in effortful control (e.g., the abilities to effortfully shift and focus attention and to effortfully activate and inhibit behavior as needed for adaptation). For instance, complex cognitive strategies (e.g., cognitive restructuring), seeking social support, persistence, and motivational components, such as the desire to act in ways consistent with norms or expecta- tions, may also be viewed as aspects of self-r╉ egulation. Eisenberg and colleagues (Eisenberg et al., 2014) have argued that although effortful control is defined as effortful or willful, individuals may not always be aware that they are modulating emotion, attention, or behavior. Some aspects of effortful control undoubtedly become automatic and executed without substantial conscious awareness in contexts with relevant triggering cues (Mischel & Ayduk, 2011); however, an effortful control-r╉ elated process can shift into a volitional and more conscious mode of functioning when it is adaptive to move from an automatic to effort- ful status (analogous to automobile driving becoming much more effortful and less automatic when on ice). Self-âr•‰ egulatory abilities are not necessarily inherently good or bad in terms of their outcomes. People can use self-âr•‰egulation to achieve goals that are maladaptive or adaptive, and whether a consequence is positive or negative (socially, morally, or in normative terms) can differ in the short-ât•‰erm versus long-ât•‰erm. Nonetheless, effortful self-r╉egulatory processes are probably more

02 20 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems likely than some less volitional aspects of control (see below) to result in adaptive outcomes, or at least in desired goals (regardless of whether or not they are actually socially or functionally adaptive) because they can be flexibly applied when needed to accommodate contextual demands rather than being applied in a rigid manner. Reactive control processes As previously noted, there are many processes that are controlling or regulating in the sense that they modulate another system but which are also relatively non-v╉ olitional, nearly always auto- matic, and less flexible than effortful control. Because both the volitional nature and the flexibility of “regulatory” processes likely affect their effectiveness and outcomes, it can be argued that it is useful to differentiate volitional self-âr•‰egulation from less volitional processes involved in control of emotion, physiological responding, and behavior. Rothbart and Bates (2006) differentiated between temperamental regulation and reactivity. They defined reactivity as “responsiveness to change in the external and internal environment” (p. 100), including emotional reactivity and action tendencies. We use the term “reactive control” to refer to the action tendencies, rather than the emotion, that are part of reactivity. Rothbart and Bates (2006) defined self-r╉ egulation as “processes such as effortful control and orienting that function to modulate reactivity” (p. 100). Although Rothbart and colleagues (e.g., Derryberry & Rothbart, 1997) view emotional reactivity and behavioral reactivity as strongly linked processes, it seems likely that reactive behaviors sometimes occur without being evoked by emotion because they are part of a child’s characteristic way of responding in particular contexts. In our view, overcontrolled and undercontrolled behaviors reflect two types of reactive control at the extremes of a heuristic continuum. In regard to overcontrol, children’s inhibited behavior in cer- tain contexts often is relatively involuntary and difficult to modulate willfully (Eisenberg & Morris, 2002). For example, children labeled as “behaviorally inhibited” by Kagan (1998) tend to be wary and overly constrained in novel and/o╉ r stressful situations and appear to have difficulty willfully modulating their inhibition. On the other extreme, undercontrol—ât•‰he impulse to approach people or inanimate objects in the environment (often quickly) without much thought—âo•‰ ften appears to be relatively involuntary. Such behavior is clearly reflected in at least some types of impulsive behavior. Undercontrol and overcontrol map onto Gray’s (Pickering & Gray, 1999) behavioral activation (BAS; which involves sensitivity to cues of reward or cessation of punishment) and behavioral inhibition (BIS; activated in situations involving novelty and stimuli signaling punishment or frustrative non- reward) systems. Both these systems are believed to be centered in subcortical regions of the brain. In contrast, effortful control appears to be centered primarily in cortical regions of the brain such as the anterior cingulate gyrus and prefrontal areas for the “cool” executive functioning components (Cohen & Lieberman, 2010; Rothbart & Bates, 2006) and perhaps the ventromedial prefrontal cor- tex and orbitofrontal cortex for “hot” tasks involving rewards/d╉ elays (Happaney, Zelazo, & Stuss, 2004). However, there undoubtedly are many connections between these cortical areas and the sub- cortical systems involved in reactive control and emotion (Goldsmith, Pollak, & Davidson, 2008). The distinction between volitional and non-âv•‰olitional regulatory or controlling processes has been discussed in diverse literatures, including work on coping (Compas, Connor-âS•‰ mith, Saltzman, Thomsen, & Wadsworth, 2001), and in the personality, clinical, social psychological, and cognitive literatures (see Carver, 2005, for a review of similar perspectives, including dual processing models). Supporting this distinction, Eisenberg and her colleagues (Eisenberg et al., 2004, 2013; Valiente et al., 2003), with modeling procedures, found that they could differentiate empirically between effortful and reactive control when assessed with a variety of adult-r╉eport and/âo•‰ r behavioral measures of effortful and reactive control from 30 months to pre/âe•‰ arly adoles- cence. Thus, prediction of maladjustment is likely to be enhanced by considering both effortful and reactive processes used in regulation/c╉ ontrol.

12 RELATIONS OF REGULATORY PROCESSES TO MALADJUSTMENT: A FRAMEWORK 21 Relations of regulatory processes to maladjustment: A framework In 1992, Eisenberg and Fabes developed a heuristic model to guide predictions regarding the relations of regulation (and emotional intensity) to an array of developmental outcomes, includ- ing some problem behaviors. The regulation aspect of this model was updated by Eisenberg and Morris (2002). Briefly, they hypothesized that externalizing problems tend to be related to low levels of effortful control/​self-​regulation, including attentional, activational, and inhibitory con- trol, and high levels of reactive undercontrol (impulsivity). In contrast, internalizing problems were predicted to be associated with high reactive overcontrol, low attentional control (used to modulate emotions associated with internalizing problems), and low activational control in some contexts (e.g., when used to counter tendencies to withdraw socially); internalizing problems were not expected to be associated with sizable deficits in effortful inhibitory control. Optimally regu- lated children—​those without internalizing or externalizing problems—w​ ere hypothesized to be high in all types of effortful control (attentional, activational, inhibitory) and to be neither overly controlled nor highly undercontrolled. Nigg (2006) argued that there are at least two temperamental pathways to conduct disorders. One is based on a low fear response and low affiliation (resulting in low empathy and sympa- thy), often accompanied by high impulsivity (low reactive control), and sometimes involving psy- chopathy. Low physiological arousal to potential punishment in these individuals makes efforts to socialize the child difficult and often unsuccessful. Nigg’s second pathway leading to impulsive conduct problems involves extreme levels of approach (e.g., to incentives), especially if combined with average to high negative emotionality (also see Eisenberg & Fabes, 1992), and average or low levels of reactive overcontrol and effortful control. Similarly, Nigg (2006) further suggested that attention deficit hyperactivity disorder has at least two temperamental pathways, one involv- ing very low effortful control (often co-o​ ccurring with high emotionality) and another involving strong approach tendencies. It is important to note that investigators vary somewhat in what they conceptualize as impul- sivity and this might affect theoretical predictions. For example, Johnson, Carver, and Joormann (2013) measured impulsive responses to emotions versus non-e​motion-​relevant impulsivity. They argued that people with sensitive incentive-​approach temperament (what many others call impulsivity) and high reactivity to emotions may be overwhelmed by strong desires and hence prone to sensation seeking or antisocial impulses. They further suggested that those with low approach temperament along with high reactivity to emotions might be overly affected by sadness and fatigue, resulting in lethargy and inaction that generally characterizes depression. In contrast, those with sensitive threat-​avoidance temperament and high reactivity to emotions may be especially prone to anxiety. This focus on control over emotion reactions differs from that of Eisenberg and colleagues (e.g., 2002), who focused more on the approach/​incentive behavioral component of impulsivity, which led to different predictions. We would argue that Johnson et al.’s (2013) measure of emotion-​relevant impulsivity reflects both a lack of effortful control of emotions and impulsivity when emotionally aroused. Frick and Morris (2004) proposed that although deficits in self-r​egulation contribute to reactive, emotionally driven conduct problems (e.g., reactive aggression), they are unlikely to be involved in covert externalizing problems (e.g., stealing) and proactive externalizing problems (e.g., unprovoked, unemotional aggression that is used for personal gain or to influ- ence and coerce others). They also suggested that children with reactive, emotionally driven externalizing problems are prone to negative emotion and have difficulties regulating emotion and inhibiting behavior when emotionally aroused. They further argued that these children’s emotion dysregulation can impair the development and use of sociocognitive skills involved

2 22 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems in information processing and undermine the quality of socializing interactions. Similar to Nigg (2006), Frick and Morris (2004) hypothesized that children prone to proactive aggres- sion, including those with psychopathic (callous-âu•‰ nemotional) traits, are low in inhibition due to fear, which undermines the development of the conscience, but are not consistently low in self-‰•âregulation. The role of self-r╉ egulation in internalizing problem behaviors also likely varies with the type of problem. For example, social withdrawal is often a component of internalizing symptoms; how- ever, socially withdrawn behavior can stem from social anxiety and/âo•‰ r fearfulness, social rejec- tion (perhaps due to lack of self-r╉ egulation), and the mere preference of being alone (Coplan & Armer, 2007). Attentional control may be particularly important for modulating the experience of social anxiety and fearfulness, and effortful activational control may help fearful/a╉ nxious chil- dren overcome their withdrawn behavior. Lack of effortful inhibitory control may be especially related to social withdrawal due to peer rejection for inappropriate behavior (because of its role in externalizing behaviors that elicit peer rejection). In contrast, various components of effortful control may be irrelevant for social withdrawal due to the preference to be alone (which may not reflect an internalizing problem). Moreover, the attentional component of effortful control may be more highly related to depressive and anxious symptoms than is inhibitory or activa- tional control. Unfortunately, there are few studies in which various aspects of effortful con- trol/âs•‰ elf-r╉ egulation have been examined as separate predictors of psychological symptoms, both broadband (externalizing or internalizing more generally) or specific types of internalizing or externalizing problems. Externalizing problems Externalizing behaviors—“╉ behaviors that violate the rights of others (e.g., aggression, destruc- tion of property) and/o╉r that bring the individual into significant conflict with societal norms or authority figures” (American Psychiatric Association, 2013)—a╉re associated with adjustment problems in the academic, social, and emotional domains across the lifespan. Externalizing problem behaviors, unified by a common theme of outward behaviors, con- stitute a variety of behaviors:  Aggression, delinquency, hyperactivity, defiance (American Psychiatric Association, 2013), and subtypes of reactive aggression (e.g., emotionally-âd•‰ riven aggression), covert externalizing (e.g., stealing, lying), proactive externalizing (e.g., aggression for self-âg•‰ ain), and callous-âu•‰ nemotional trait conduct problems (e.g., unprovoked and unemo- tional aggression; Frick, Ray, Thornton, & Kahn, 2014). Growing empirical evidence supports the premise that emotion regulation is negatively associated—a╉nd impulsivity is positively associated—w╉ ith externalizing problem behaviors across development (Eisenberg, Spinrad, & Eggum, 2010). Self-regulation and externalizing problems Diverse measures of effortful emotion-r╉ elated self-r╉ egulation have been negatively associated with externalizing behaviors, especially emotionally-âd•‰ riven reactive externalizing (Eisenberg, Spinrad, & Eggum, 2010; e.g., Valiente et al., 2006). For example, attention refocusing (i.e., shifting atten- tion from an emotion-e╉ liciting stimulus) during a disappointment task was negatively associated with externalizing two years later, particularly for children who expressed higher anger than other children (assessed in preschool/âk•‰ indergarten; Morris, Silk, Steinberg, Terranova, & Kithakye, 2010). Also, performance on executive control (i.e., inhibition and attention) and delay tasks at 36 to 40 months has predicted lower hyperactivity and externalizing problems at 63 to 67 months (Lengua et  al., 2015). Similarly, from ages four to seven, emotion regulation (assessed with a

32 EXTERNALIZING PROBLEMS 23 combined measure of emotionality and regulation) was consistently negatively associated with externalizing across time, but not vice versa (Blandon, Calkins, Grimm, Keane, & O’Brien, 2010). Associations between effortful control and externalizing behaviors have also held across longer spans of time and/o​ r for older children (e.g., Eisenberg, Zhou, et al., 2005; Lengua, 2008). Effortful control (i.e., attention control, inhibitory control, low activity levels) at four-​and-a​ -​half years old was associated with lower externalizing and risk-t​aking behaviors at 15 years old (Honomichl & Donnellan, 2011). Similarly, Belsky, Pasco Fearon, and Bell (2007) found that at 54 months, first grade, and fifth grade, attention problems (measured with a continuous performance test) were positively associated with externalizing behaviors even when controlling for their prior levels. Wang, Brinkworth, and Eccles (2013) observed that misconduct behaviors decreased substan- tially from 13 to 18 years of age for adolescents with higher effortful control (i.e., attention shift- ing, activation control) at age 13. Relatedly, among nine-​and-​a-h​ alf-y​ ear-o​ lds, individual growth in effortful control (but not growth in impulsivity) predicted lower externalizing problems three years later (King, Lengua, & Monahan, 2013). In a recent study, among 36-​month-​olds assessed four times until 90 months of age in a cross-​ lagged panel design, executive functioning (assessed with a set of behavioral tasks closely related to effortful control) consistently predicted lower externalizing behaviors (Sulik et al., 2015). In one instance, however, externalizing behaviors also predicted lower executive functioning from 48 to 60 months of age. In contrast, Eisenberg, Spinrad, Eggum, et al. (2010) found that external- izing (and internalizing) at 30 months old significantly and negatively predicted effortful control at 42 months old (measured with a delay task and parent/​caregiver reports). However, effortful control (although correlated with) did not significantly predict externalizing across time while controlling for the stability of all measures (also see Eisenberg, Taylor, Widaman, & Spinrad, 2015, with the same sample at 30 to 54 months). Thus, although executive functioning/​effortful control frequently predicts low levels of later externalizing problems, there may be age-​or context-d​ epen- dent periods (e.g., in the transition to formal schooling) when externalizing behaviors and execu- tive functioning abilities form a reciprocal process or, perhaps, when externalizing problems have a stronger effect on self-​regulation. Indeed, although effortful control frequently has been associated with subsequent externalizing problems, the relation of self-r​egulatory abilities to concurrent and later externalizing problems varies across studies and samples, especially when controlling for initial levels (e.g., Eisenberg, Spinrad, Eggum et al., 2010; Spinrad et al., 2012). Among children of Chinese immigrant parents in the United States, effortful control (i.e., parent-​and teacher-​reported inhibitory control, atten- tion focusing) measured among first and second graders was positively associated with social competence but not with externalizing behaviors in fifth and sixth grade (Zhou, Main, & Wang, 2010). Also, among Dutch children, effortful control (i.e., parent-r​ eported inhibitory control and attention focusing) and delayed gratification among preschoolers (36-m​ onth-​olds) were nega- tively associated with concurrent hyperactivity and conduct problems but did not significantly predict later measures of maladjustment in kindergarten when controlling for initial levels at 36 months old (Gusdorf, Karreman, van Aken, Dekovic, & van Tuijl, 2011). Similarly, Lengua (2003) found that difficulty in delay of gratification was positively associated with externalizing symp- toms concurrently, but not one year later, among third through fifth graders; however, inhibitory control did predict lower levels of later externalizing symptoms (Lengua, 2003). These results echo findings from a meta-a​ nalysis showing that inhibitory control, compared to executive function- ing, was more strongly associated with externalizing behaviors among preschoolers (Schoemaker, Mulder, Deković, & Matthys, 2013). In examining effortful control, some researchers have also distinguished “hot” and “cool” aspects based on the emotional and cognitive demands of the different tasks used to assess

42 24 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems effortful control (“cool” tasks often are executive functioning tasks). Di Norcia, Pecora, Bombi, Baumgartner, and Laghi (2014) found that hot (i.e., delayed gratification), but not cool (e.g., slow down, reverse categorization) effortful control, was negatively associated with concurrent aggres- sion and anger among Italian preschoolers. Similarly, Kim, Nordling, Yoon, Boldt, and Kochanska (2013) found that only “hot” effortful control (i.e., delayed gratification) was negatively associ- ated with behavioral problems at 67–â1•‰ 00 months of age. Effortful control measured with “cool” tasks (e.g., day/ân•‰ ight, motor inhibition) did not significantly predict behavioral problems unless estimated together with delayed gratification (Kim et  al., 2013). Thus, although most research has examined effortful control as one construct given conceptual concordance and measurement properties (Eisenberg et  al., 2013), continued examination of the aspects of different effortful control measures is warranted given that in some studies not all components of effortful self-╉ regulation have significantly predicted maladjustment (Di Norcia et al., 2014; Kim et al., 2013). Callous-unemotional, covert, and proactive externalizing Most of the studies cited thus far have evaluated models predicting reactive externalizing (aggres- sive emotional responses to blocked goal/âp•‰rovocation; Frick et  al., 2014)  or undifferentiated externalizing problems. Less is known about the extent to which regulatory processes are associ- ated with covert (i.e., secretive externalizing such as lying, cheating, stealing) and proactive (i.e., aggression for self-g╉ ain) externalizing across development. Verbal ability may differentially pre- dict reactive and proactive aggressive tendencies, suggesting a social-âc•‰ ognitive pathway; Arsenio, Adams, and Gold (2009) found that among adolescents, verbal ability was negatively associated with reactive aggression and positively associated with proactive aggression. Also, in that study, attention problems (an indicator of low effortful control) were more strongly and positively asso- ciated with reactive than with proactive aggressive tendencies. In another study, impulsivity and inattention measures were also positively associated with overt antisocial behaviors and positively associated with covert behaviors particularly for children with higher verbal ability (McEachern & Snyder, 2012). Relatedly, White, Jarrett, and Ollendick (2012) found that behavioral regulation was associated with reactive but not proactive aggression among children and adolescents. These studies suggest that proactive and reactive aggression have different correlates and that emotion regulation may be most associated with reactive externalizing difficulties. Furthermore, these studies imply that impulsivity and verbal ability are different risk factors for covert versus overt externalizing behaviors in childhood. However, some findings are inconsistent with those just reviewed. Evidence regarding the rela- tion of reactive and proactive aggression to self-r╉egulation is not very clear. Marsee and Frick (2007) reported that reactive aggression was uniquely associated with poor emotion regula- tion when controlling for proactive aggression but not in the zero-o╉ rder correlation. Moreover, other researchers (de Castro, Merk, Koops, Veerman, & Bosch, 2005; Xu, Farver, & Zhang, 2009) found that reactive and proactive aggression were both inversely associated with effortful con- trol. Perhaps different domains of self-r╉ egulation (e.g., regulation of emotional experience versus behavior) are associated with reactive and proactive aggression. Alternatively, deficits in “cool” executive functioning skills, which could undermine integration and decision making, may con- tribute to proactive aggression, whereas self-âr•‰ egulation of more emotionally tinged behavior may be particularly related to problem behaviors that are impulsive and appear to be emotionally driven. Consistent with that view, the tendency to experience negative emotions (e.g., anger) has been more consistently associated with reactive than proactive aggression (e.g., Hubbard et al., 2002). In any case, the research suggests that attention to the type of externalizing problem may be important when examining associations with self-r╉ egulation (and emotionality).

52 Externalizing problems 25 A type of externalizing problem that is generally proactive is conduct problems with callous unemotional traits (i.e., unprovoked/u╉ nemotional aggression, lack of guilt and concern for oth- ers; Frick et al., 2014). Temperamental fearlessness (assessed with parent-r╉eport measures) has been positively associated with conduct problems or callous-u╉ nemotional traits among older children and adolescents (Barker, Oliver, Viding, Salekin, & Maughan, 2011; Lengua, 2003); how- ever, compared to children without conduct problems, first graders with conduct problems and callous-âu•‰ nemotional behaviors exhibited more intense fear reactions (during a mask task) and higher baseline cortisol levels at the age of two (Mills-K╉ oonce et al., 2015). Perhaps intense fear observed in toddlers, a sign of emotion dysregulation and heightened sensitivity, is a precursor to or marker of conduct problems with callous-âu•‰ nemotional traits, and fearlessness develops later. Alternatively, relations of fearfulness (and its regulation) may vary as a function of method of assessing fear (e.g., observations versus parents’ reports; Mills-K╉ oonce et al., 2015). Impulsivity and externalizing problems Impulsivity—âc•‰haracterized by unplanned and sudden reactions without concern for negative consequences—a╉ lso confers a risk for deviant behaviors, is related to temperamental surgency (Rothbart & Bates, 2006) and, as previously argued, has been viewed as a distinct element of emo- tion dysregulation separate from effortful control (Eisenberg et al., 2013; Spinrad et al., 2012). Marmorstein (2013) identified five types of impulsive behavior: Sensation seeking, lack of plan- ning, lack of perseverance, negative urgency, and positive urgency; however, it could be argued that some of the forementioned actually tap effortful control as much or more than impulsivity. Impulsivity is concurrently and prospectively associated with externalizing in childhood and adolescence. Youths who report more impulsive behaviors (e.g., act without thinking, need a lot of self-c╉ontrol to stay out of trouble) also report more risky behavior, including externalizing problems (e.g., Johnson et al., 2013; Romer et al., 2011). Among middle school students, negative urgency (i.e., impulsive behavior when distressed or in a negative mood) was positively associ- ated with attention deficit/âh•‰ yperactivity disorder and conduct disorder symptoms (Marmorstein, 2013). Also, impulsivity predicted rank-âo•‰ rder change in adolescents’ alcohol use, conduct prob- lems, and hyperactive/iâ•n‰ attention behaviors, and sensation seeking predicted higher alcohol problems one year later (Wang, Chassin, Geiser, & Lemery-C╉ halfant, 2016). However, Lengua (2003) found that mother-âr•‰ eported impulsivity was positively correlated with, but did not signifi- cantly predict, children’s externalizing symptoms among third through fifth graders one year later. Similarly, impulsivity may not be uniquely associated with externalizing problems in older chil- dren once the predictive effects of effortful control are taken into account (Eisenberg, Spinrad et al., 2004; Valiente et al., 2006; Wang, Chassin, Eisenberg, & Spinrad, 2015). Such findings suggest that impulsivity may not always be uniquely associated with externalizing and that prospective associations vary with age and/âo•‰ r context. Other work suggests that different aspects of impulsivity predict externalizing problems, although this work is difficult to interpret because some measures of impulsivity may actually tap effortful control. Based on a cross-âs•‰ ectional study, Settles et al. (2012) found that among fifth grade students, negative urgency (but not lack of planning) positively predicted alcohol use and smoking status (behaviors that often are considered to be externalizing problems). Furthermore, lack of perseverance (which might assess low effortful control) positively predicted smoking sta- tus among boys, but not among girls (Settles et al., 2012). Associations between components of impulsivity and types of externalizing may vary by age. For instance, lack of planning (which might reflect low effortful control or high impulsivity) and negative urgency both positively pre- dicted alcohol and drug use among college students, whereas lack of planning positively predicted

62 26 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems delinquent behavior, and negative urgency positively predicted aggression (Settles et al., 2012). Continued examination of the predictive validity of impulsivity subscales and combined mea- sures of emotion self-r╉ egulation will help inform various pathways to externalizing across devel- opment (e.g., Eisenberg, Spinrad et al., 2004). For example, Morales, Beekman, Blandon, Stifter, and Buss (2015) found that exuberance (i.e., combined measures of impulsivity and activity) was positively associated with later externalizing in kindergarten, particularly for children with high physiological dysregulation (e.g., low baseline respiratory sinus arrhythmia [RSA], higher RSA suppression during an emotion stimulus). The role of culture Researchers have found that effortful control is negatively associated with externalizing difficulties in children from Indonesia (Eisenberg, Liew, & Pidada, 2004), China (Zhou, Eisenberg, Wang, & Reiser, 2004; Zhou, Lengua, & Wang, 2009), Portugal (Conceição & Carvalho, 2013), and Latino and African American backgrounds in the United States (Loukas & Roalson, 2006). However, a limited number of studies have found concurrent but not longitudinal empirical support for the association between effortful control and externalizing difficulties across children of Chinese immigrant parents (Zhou et al., 2010) and Dutch children (Gusdorf et al., 2011). What cultural processes inform the association between self-r╉ egulation and externalizing problems across time are less clear. Research and praxis: Targeting regulation Given the empirical support that emotion self-r╉egulation predicts lower externalizing problems, interventions targeting self-r╉ egulation to prevent the development of externalizing behaviors have been designed and increasingly implemented (Eisenberg, Spinrad, & Eggum, 2010). Research of this sort can be a stringent test of causal relations between self-âr•‰ egulatory skills and externalizing problems, although often more than self-r╉ egulation is targeted by these interventions. Moreover, the results from school-âb•‰ ased interventions intended to improve children’s behavioral regulation and reduce subsequent problem behaviors are promising, although some show mixed results, sometimes as a function of participant background characteristics (Morris et al., 2014). Among preschoolers from low-i╉ncome backgrounds, children participating in The Incredible Years intervention (which includes curriculum on regulation and emotion knowledge) had higher emotion knowledge post-âi•‰ntervention, but they showed similar executive functioning and prob- lem behaviors compared to children in the control group (Morris et al., 2014). However, among children who had higher levels of behavioral problems at baseline, fewer problems were reported after the intervention compared to children in the control condition. Children participating in Tools of the Mind, a similar intervention, showed increased levels of executive functioning, par- ticularly for those from high-âp•‰ overty schools (Blair & Raver, 2014). Programs that integrate parent-╉and child-f╉ocused components in the implementation of interventions are also likely to increase the prospect of favorable outcomes. Parents likely help children develop self-r╉ egulation skills through their parenting strategies and modeling of self-╉ regulation (Belsky et  al., 2007). Moreover, some researchers have found that self-r╉egulation mediates the association between environmental factors (e.g., parenting, socioeconomic sta- tus) and externalizing behaviors (e.g., Lengua et al., 2015). Thus, targeting parenting may have downstream effects on problem behaviors. For example, the Parents and Children Making Connections—H╉ ighlighting Attention (PCMC-A╉ ) program includes parenting-âf•‰ocused (i.e., stress management, parent discipline, language use, and child attention exercises) and child-╉ specific (i.e., modifying attention regulation and emotion states curriculum for children)

72 Internalizing problems 27 training components for low-âi•‰ncome parents and their preschool children attending Head Start (Neville et al., 2013). Compared to no-p╉ reschool/H╉ ead Start-âo•‰ nly control participants, PCMC-╉ A children showed increased attention regulation (measured with event-r╉elated potentials [ERP] during attention tasks) and decreased problem behaviors after the eight week interven- tion. Parents in PCMC-A╉ also showed decreased parenting stress. Physiological measures, such as those assessed with ERP, provide additional support for the regulatory mechanisms modi- fied by intervention. Similarly, among homeless youth participating in an intervention with emotional self-r╉ egulation and parenting guidance components, intervention effects on reduced conduct problems were mediated by improvements in children’s executive functioning (Piehler et al., 2014). Some interventions have addressed specific needs of children. For example, Fast Track Promoting Alternative Thinking Strategies (PATHS) integrated the classroom-âb•‰ased socio-╉ emotional curriculum from Fast Track and additional intervention components (i.e., parent- ing support classes, home visits) for children identified by teachers at higher risk for aggression (Conduct Problems Prevention Research Group, 2010). Compared to controls, participants in Fast Track PATHS showed lower aggression and higher prosocial behavior from first to third grade, with some effects strongest for boys and children originally high in aggression (Conduct Problems Prevention Research Group, 2010). Thus, programs addressing socio-âe•‰ motional learn- ing through curriculum in the classroom and home (especially for children identified at higher risk for behavior problems) show promising results. Across development, children increase in their regulatory capabilities but also encounter dif- ferent sets of challenges that may require varied skills and support; for example, risk taking and problem behaviors often show increases in the transition to adolescence (Duckworth, Gendler, & Gross, 2014). Family-b╉ ased interventions intended to address system-âl•‰evel factors (e.g., fam- ily, peers, school) have found reduced problem behaviors among children and adolescents (e.g., Chang, Shaw, Dishion, Gardner, & Wilson, 2014; Prado et al., 2013). Together, empirical results suggest that interventions that target different levels of the child’s system (e.g., child-,╉ parent-â,•‰ peer-â,•‰ and/o╉ r school-âl•‰evel factors) modify emotion self-r╉ egulation and adjustment. Internalizing problems Effortful control (particularly attentional control) is expected to reduce the internalizing symp- toms of depression, anxiety, and social withdrawal. In contrast, children who are rigid, con- strained, and behaviorally inhibited (i.e., discomfort with novel stimuli, including people; Kagan & Fox, 2006) may be prone to internalizing problems. Thus, as discussed previously, it may be hypothesized that children with internalizing symptoms are somewhat low in effortful control (particularly attentional control) and reactive undercontrol (i.e., impulsivity), but high in reactive overcontrol (i.e., behavioral inhibition). Self-r╉egulation and internalizing problems In fact, the empirical findings regarding the relations of effortful control and reactive control to children’s internalizing problems are somewhat mixed. For the most part, investigators have found the predicted negative relation between effortful control and internalizing problems, anxiety, and/o╉ r depression (Buckner, Mezzacappa, & Beardslee, 2009; Eisenberg et  al., 2001; Eisenberg et al., 2007; Emerson, Mollet, & Harrison, 2005; Hopkins, Lavigne, Gouze, LeBailly, & Bryant, 2013; McCoy & Raver, 2011; Morris et  al., 2013; Muris, 2006; Muris, de Jong, & Engelen, 2004; Oldehinkel, Hartman, De Winter, Veenstra, & Ormel, 2004; Verstraeten, Vasey, Raes, & Bijttebier, 2009; Zalewski, Lengua, Wilson, Trancik, & Bazinet, 2011). Longitudinal

82 28 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems data also support the negative relation (Eisenberg et al., 2005; 2009; Kiff, Lengua & Bush, 2011; King, Lengua, & Monohan, 2013; Lengua, 2006; Oldehinkel, Hartman, Ferdinand, Verhulst, & Ormel, 2007; Valiente, Eisenberg, Spinrad et  al., 2006). Nonetheless, in a sample of tod- dlers, effortful control was negatively related to toddlers’ separation distress at both 18 and 30  months of age. However, the relations became nonsignificant once stability in separation distress was controlled (Spinrad et al., 2007; see Eisenberg, Spinrad et al., 2010, for similar find- ings at 42 months of age). Moreover, some investigators have found a positive relation between self-r​ egulation and inter- nalizing problems. For example, Murray and Kochanska (2002) reported that children with high effortful control exhibited higher internalizing symptoms than did those with moderate effort- ful control, although very few children in the study had severe internalizing problems. Other researchers have reported no relations (see Lengua, 2008). In most research, investigators have used continuous measures of internalizing and external- izing and have not dealt with the reality of frequent co-o​ ccurrence of the externalizing and internalizing symptoms. Thus, relations of low regulation to internalizing symptoms could be due to the co-o​ ccurrence of externalizing symptoms. In research that examined pure internal- izing problems, Eisenberg and colleagues (2001, 2005; Eisenberg, Valiente, et al., 2009; Wang, Eisenberg, Valiente, & Spinrad, 2016) found little evidence of relations of effortful control to pure (non-c​ o-o​ ccurring) internalizing problems except in the early school years. Oldehinkel et al. (2004) found that preadolescents with pure internalizing symptoms were lower in effortful control than nondisordered children, but that difference was not nearly as great as for youths with co-o​ ccurring problems. In a more at-r​isk adolescent sample, low effortful control pre- dicted higher pure (non-​co-​occurring) depression (Wang et al., 2015). Thus, co-o​ ccurrence and age may affect the strength of relations between indices of self-r​ egulation and internalizing symptoms. It is important to differentiate between aspects of effortful control in understanding the rela- tions. It is likely that some aspects of effortful control, such as attentional control, may be par- ticularly important for children with internalizing problems. Specifically, attentional control is thought to reduce bias toward negative emotions such as sadness and anxiety and may serve to move attention from negative to neutral or positive thoughts (Derryberry & Rothbart, 1997). On the other hand, other components of effortful control, such as inhibitory control, may be related to internalizing problems due only to its negative associations with externalizing problems; that is, relations of inhibitory control to internalizing problems may be inflated because of co-​occurring externalizing problems (see Eisenberg, Spinrad, & Eggum, 2010). Indeed, children with pure internalizing symptoms, compared to non-​disordered children, exhibited deficits in attentional control at 55 to 97 months (Eisenberg et al., 2001), although not two or four years later (Eisenberg, Sadovsky, et al., 2005; Eisenberg, Valiente, et al., 2009). Attentional control also has been negatively associated with anxiety disorder symptoms (Muris et al., 2004) and with boys’ anxiety and depression (Emerson et al., 2005). In longitudinal research, low attentional control has been associated with more internalizing problems from four-a​ nd-a​ -​half to eleven years (or consistently high internalizing problems; Kim & Deater-​ Deckard, 2011) and with withdrawal that was high and declined over six years (Eggum et al., 2009). Another aspect of effortful control, inhibitory control, has been examined in relation to inter- nalizing problems, although it is conceptually less related to internalizing than attentional con- trol. Findings have been somewhat mixed. Some researchers have reported a negative relation between the two constructs, but potential co-o​ ccurring externalizing problems were not con- trolled in these studies (Lengua, 2003; Rhoades, Greenberg, & Domitrovich, 2009; Riggs, Blair, &

92 Internalizing problems 29 Greenberg, 2003). On the other hand, Eisenberg and colleagues (2001) found that internalizing children (without externalizing symptoms), compared to nondisordered children, had similar levels of inhibitory control. As previously noted, children’s age may moderate the relations between effortful control/âr•‰eac- tive control and internalizing problems. In a series of studies, Eisenberg and colleagues (Eisenberg et al., 2001; Eisenberg, Sadovsky, et al., 2005; Eisenberg, Valiente, et al., 2009) found that whereas the relation between effortful control and pure internalizing problems was evident in young children, it was not found in mid-╉to late-âe•‰lementary school. Effortful control may be linked to children’s internalizing in younger age groups because effortful control at younger ages may be particularly important when effortful control is rapidly developing. Further, effortful control may be particularly important in early development when internalizing problems may require the regulation of negative emotions of sadness and anxiety as opposed to more cognitive processes. As further evidence for moderation by age, Dennis, Brotman, Huang, and Gouley (2007) reported that children’s observed effortful control was negatively related to internalizing problems at age four but not at ages five and six. However, it is clear that internalizing problems are associated with deficits in executive functioning—i╉ncluding overlapping self-r╉ egulatory capacities—âi•‰n adulthood (see Snyder, 2013, for a meta-a╉ nalysis). Continued research on age-r╉ elated changes in the relations of effortful control to internalizing problems is needed. Other emotion regulation strategies, such as cognitive reappraisal or suppression of emotion, have been studied in association with internalizing symptoms. Lougheed and Hollenstein (2012) found that adolescents who had a range of emotion regulation strategies were lower in internal- izing problems than those with limited emotion regulation strategies. In addition, adolescents’ cognitive reappraisal has been found to predict lower levels of depression, whereas suppressing emotional expressions has been related to higher social anxiety (Eastabrook, Flynn, & Hollenstein, 2014). Similarly, rumination, defined as “the process of thinking perseveratively about one’s feel- ings and problems rather than in terms of the specific content of thoughts” (p. 400), often has been viewed as reflective of the lack of effective coping or self-r╉ egulation (Nolen-âH•‰ oeksema, Wisco, & Lyubomirsky, 2008), is thought to be related to maladaptive suppression, and has been related to a variety of internalizing problems (Nolen-âH•‰ oeksema, Stice, Wade, & Bohon, 2007; Nolen-╉ Hoeksema et al., 2008). Thus, it appears that internalizing problems are associated with specific maladaptive methods of regulating emotion. Reactive control and internalizing problems Researchers have less frequently examined the associations of impulsivity (i.e., reactive under- control) to internalizing problems. Eisenberg et  al. (2001) found that exclusively internalizing children (i.e., those without externalizing problems) were characterized by low levels of impulsiv- ity (also see Eisenberg et al., 2007; Eisenberg, Valiente, et al., 2009). However, Lengua et al. (1998) found a positive relation between impulsivity and depression after removing overlapping items among the constructs, but not before removing overlapping items (note, however, that they did not differentiate children with pure from co-o╉ ccurring internalizing symptoms). Similarly, Stifter and colleagues (2008) reported that exuberant children (i.e., those high on approach and posi- tive affect) were rated by their parents as higher in internalizing behaviors, as well as externaliz- ing problems, than were low-r╉ eactive children. Given that exuberant children were differentiated from inhibited children, it is likely that the exuberant children’s impulsivity was related to their high level of externalizing problems. On the other hand, reactive overcontrol (i.e., behavioral inhibition) tends to show consistent positive relations to internalizing symptoms (Caspi, Henry, McGee, Moffitt, & Silva, 1995; Degnan, Almas, & Fox, 2010; Kagan & Snidman, 1999; Schwartz, Snidman, & Kagan, 1999). Eggum and

03 30 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems colleagues (2012) reported that children’s shyness (a construct highly related to behavioral inhibi- tion) was positively related to internalizing problems, even after controlling for earlier levels of internalizing symptoms. Further, Spinrad et al. (2007) found that toddlers’ inhibition to novelty was positively correlated with separation distress at both 18 and 30 months, controlling for the effect of effortful control. Culture and the self-regulation of internalizing problems It is likely that cultural norms play a role in how temperamentally based self-r╉egulation capaci- ties impact children’s outcomes because certain traits may be more acceptable in certain cultures. For example, in collectivist cultures, such as China, where group harmony is emphasized and the expression of negative emotion is discouraged, children’s characteristics such as regulation and attention may be highly valued and reinforced. Further, it is possible that shyness and social withdrawal have been viewed as less problematic in Asian, compared to Western cultures (Chen, Cen, Li, & He, 2005). Although more cross-c╉ ultural work in the area needs to be conducted, it appears that the rela- tions between effortful control and internalizing problems in current day China are similar to findings in the US (Eisenberg et al., 2007; Muhtadie, Zhou, Eisenberg, & Wang, 2013; Zhou et al., 2004). In a within-âc•‰ ulture study of Chinese children, first and second graders with low effortful control were found to have relatively high levels of pure internalizing problems (Eisenberg et al., 2007); these children were also low in impulsivity. In another study, childhood delay ability at age two negatively predicted Chinese children’s loneliness and depression (Chen, Zhang, Chen, & Li, 2012). In a cross-c╉ ultural study, Zhou et al. (2009) found that country of origin (China versus US) did not moderate the findings when predicting children’s membership in an internalizing (versus nondisordered) group. Similar findings have been obtained in Western European countries. In a series of studies, Muris and colleagues found that in the Netherlands, children’s effortful control was negatively related to anxiety or more global internalizing symptoms (Muris et  al., 2004; Muris, Meesters, & Blijlevens, 2007; Muris, Meesters, & Rompelberg, 2007; Muris, van der Pennen, Sigmond, & Mayer, 2008; see Oldehinkel et  al., 2004, for similar findings). Further, as found in the US, behavioral inhibition was positively correlated with internalizing problems (Muris, Meesters, de Kanter, & Timmerman, 2005). Rydell and colleagues (2003) reported that poorly regulated fear was associated with internalizing problems in a sample of Swedish children. Finally, in a multi-╉ ethnic sample of adolescents from the Netherlands, de Boo and Kolk (2007) found that the inverse relations between effortful control and depressive mood were consistent across Dutch, Turkish, Moroccan, and mixed ethnic participants. Thus, findings for Western European samples appear quite consistent with US samples. Cross-âc•‰ultural differences between the US and Russia were found in one study examining the role of infant temperament to toddlers’ behavior problems. Gartstein and colleagues (2013) found that infants’ falling reactivity (i.e., the ability to calm following arousal) predicted lower internalizing problems in the US but not in Russia. It should be noted that there were also mean-╉ level differences in internalizing problems in the Russian sample, such that Russian toddlers were significantly lower than US toddlers on internalizing problems, regardless of regulatory skills in infancy. Thus, these findings may be attributed to the fact that internalizing symptoms were quite rare in the Russian sample. Of course, there may be cultural differences in relations within the United States. Because most studies have focused on White, non-âH•‰ ispanic children in the US, it is important to

13 Internalizing problems 31 understand whether relations of effortful and reactive control to internalizing problems dif- fer across ethnic groups. In one of the few studies to examine such relations, Loukas and Roalson (2006) reported that effortful control was negatively related to depression in both European American and Latino adolescents. Consistent with these findings, in a sample of Head Start preschoolers, the negative relation between regulation and internalizing problems was not moderated by ethnicity/âr•‰ace (Hispanic versus African American; McCoy & Raver, 2011). Thus, the evidence thus far suggests that the relations of effortful and reactive control to children’s internalizing problem behaviors are quite similar across countries and cultural groups. Moderating processes Perhaps some of the inconsistencies in the relations of effortful control and reactive control to internalizing problems are due to interactions between effortful control (or impulsivity) and other aspects of temperament (i.e., negative emotionality, shyness) when predicting internalizing prob- lems. Indeed, there is evidence that effortful control moderates the positive relations between negative affect and depression/iâ•n‰ ternalizing problems (Muris, 2006; Oldehinkel et  al., 2007; Verstraeten et al., 2009; Yap et al., 2011). Specifically, the positive relations between negative emo- tionality and internalizing problems appear to be stronger for children low in effortful control. In contrast, Eisenberg and colleagues (2004) found no evidence of an interaction between negative emotionality and effortful control when predicting internalizing problems. Relations between reactive control and children’s internalizing problems also may be mod- erated by effortful control. White, McDermott, Degnan, Henderson and Fox (2011) found that behavioral inhibition (reactive overcontrol) at 24 months predicted parent-r╉ eported anxiety dur- ing preschool, but only for children with poor attention shifting. Similarly, in a study conducted with adolescents in the Netherlands, behavioral inhibition predicted higher internalizing prob- lems, particularly for children with low attentional control (Sportel, Nauta, de Hullu, de Jong, & Hartman, 2011). Contrary to the findings for attentional control, the positive relations between behavioral inhibition and anxiety have been found for children high in inhibitory control but not for those with low inhibitory control, suggesting that children who are high in both inhibi- tory control and behavioral inhibition may be somewhat overcontrolled and anxious (White et al., 2011). Mediating processes The relation between effortful control and internalizing symptoms may also be mediated by dispositional factors such as ego-âr•‰ esiliency. That is, effortful control may allow for flexible and adaptive behavior in the face of challenge, and this flexibility may counter the development of internalizing problems. In a number of studies, ego-r╉esiliency mediated the relations of effortful control to low levels of internalizing (but usually not externalizing) problems (e.g., Eisenberg, Spinrad, et  al., 2004; Valiente et  al., 2006). This mediated relation also has been found in Chinese (Eisenberg, Chang, Ma, & Huang, 2009)  and French (Hofer, Eisenberg, & Reiser, 2010) samples. In sum, the relations of effortful control and reactive control to children’s internalizing problems are somewhat complex. Although most literature supports a negative relation between effortful control and internalizing problems, findings are somewhat mixed. A  more nuanced approach indicates that perhaps attentional components of effortful control are more strongly related to internalizing problems than are behavioral components (i.e., inhibitory control). Further attention

23 32 The Relation of Self-Regulation to Children's Externalizing and Internalizing Problems to moderating and mediating processes might help to clarify the relation between self-r╉ egulation and internalizing problems. Self-regulation and co-occurring problems Internalizing and externalizing behaviors are positively associated (Bornstein, Hahn, & Haynes, 2010) and comorbidity can develop concurrently and/o╉ r sequentially (Boylan, Vaillancourt, Boyle, & Szatmari, 2007). However, we know less about the underlying regulatory mechanisms involved in the development and maintenance of their co-occurrence. Unfortunately, most researchers have used measures of internalizing and externalizing problems without differentiating children with pure problems of either type from those with co-o╉ ccurring problems. In early work in which children with co-âo•‰ ccurring symptoms (at a borderline clinical level or higher) were differentiated from those with pure externalizing or internalizing problems, findings for children with pure externalizing problems and co-o╉ccurring problems were combined when looking at relations with effortful control and impulsivity (Eisenberg et al., 2001, 2005). In one longitudinal study (Eisenberg et  al., 2001, 2005), children in the early and mid-e╉lementary school years with both pure externalizing and co-o╉ ccurring problems (teacher-╉and parent-âr•‰eported) were low in adult-âr•‰eported effortful control (inhibitory con- trol, attention focusing, and attention shifting) and high in impulsivity. When Eisenberg and colleagues followed up the children at, on average, mid-╉to late-e╉ lementary school (or middle school) age, they separated pure externalizing from co-âo•‰ ccurring externalizing and internal- izing (Eisenberg, Valiente, et al., 2009). Children with co-o╉ ccurring problems were still low in attentional and inhibitory control and high in impulsivity compared to nondisordered chil- dren (as were children with pure externalizing problems). These researchers did not directly compare youth with pure symptoms versus co-âo•‰ ccurring ones. However, Oldehinkel et  al. (2004) constructed similar groups and found that preadolescents with co-o╉ ccurring symptoms were lower in effortful control than children with pure internalizing or pure externalizing symptoms or non-âd•‰ isordered children. In the aforementioned studies, children were assigned to one maladjustment group or another and the relations of effortful control/âi•‰mpulsivity to maladjustment were examined in relation to a control group and, sometimes, another maladjustment group; the relations of effortful control/╉ impulsivity to the various maladjustment groups were not necessarily unique. In a recent study, Wang et  al. (2015) examined the unique prediction of levels of pure internalizing (depressive symptoms), pure externalizing (antisocial/a╉ ggressive behaviors), and co-âo•‰ ccurring internalizing and externalizing (depressive and antisocial/âa•‰ ggressive behaviors) in adolescence from effortful control and impulsivity (simultaneously) five to six years earlier. Using the bi-âf•‰actor modeling technique, they first computed factors for pure externalizing, pure internalizing, and co-o╉ ccurring symptoms that were orthogonal from each other (e.g., variance unique to pure externalizing after covarying out variance attributable to pure internalizing or co-âo•‰ ccurring symptoms). Then they predicted three symptom factors from both effortful control and impulsivity. Low effortful control uniquely predicted pure externalizing problems and both low effortful control and low impul- sivity uniquely predicted pure internalizing and co-âo•‰ ccurring problems. According to an inter- action among effortful control, impulsivity, and age, for older adolescents only, lower effortful control predicted more pure externalizing and co-o╉ ccurring symptoms at average and high levels of impulsivity. Controlling for the relation of effortful control to maladjustment likely eliminated the expected positive relation of impulsivity to co-âo•‰ ccurring problems; indeed, in zero-âo•‰ rder correlation, impulsivity was positively related to externalizing problems (but was not related to depression).

3 Summary 33 Other research suggests that children and adolescents with co-o╉ ccurring internalizing and externalizing symptoms, like those with pure externalizing problems, have difficulties with self-âr•‰egulation. For example, in research with a behavioral measure of inhibitory con- trol administered to aggressive children, eight-╉to 12-year-olds with pure externalizing prob- lems, had somewhat greater problems with slowing down and monitoring responding when needed than those with co-o╉ ccurring internalizing problems, although the latter group still exhibited marginally less response slowing than did nondisordered children (Stieben et al., 2007). In a study of adolescents, Garnefski, Kraaij, and van Etten (2005) found that those with co-âo•‰ ccurring symptoms or pure internalizing were higher on the maladaptive emotion regulation strategies of self-âb•‰ lame and rumination than those with pure externalizing or no symptoms. Moreover, Pang and Beauchaine (2013) found that eight-╉to 12-ây•‰ear-o╉ ld children with co-╉ occurring internalizing (diagnosed depression) and externalizing (conduct disorder) problems exhibited lower resting RSA and greater RSA withdrawal to emotion evocation beyond com- promised RSA responding for pure diagnoses. Baseline RSA is often viewed as reflecting physi- ological self-r╉ egulation and excessive RSA withdrawal is viewed as an index of emotional lability. However, results on RSA and co-o╉ ccurring internalizing and externalizing problems vary across studies (e.g., see Hinnant & El-âS•‰ heikh, 2013). In contrast, in research with eight-╉to 12-y╉ ear-âo•‰ ld aggressive children (Stieben et al., 2007), ERP responding to an emotional induction supported the conclusion that children with pure externalizing problems had greater regulatory difficul- ties. Results in regard to regulatory deficits may differ depending on whether the measure of regulation taps inhibition of behavior (which may be worse to pure externalizers) or modula- tion of emotion and related attention (which may be exacerbated by co-âo•‰ ccurring internalizing problems). Summary In summary, investigators have frequently found that children’s self-âr•‰egulation is related to their externalizing and internalizing symptoms. However, research on co-m╉ orbidity is limited, and relatively little is known about differential relations with self-r╉egulatory processes for various types of internalizing problems (e.g., anxiety, depression, and social withdrawal) and externaliz- ing problems (e.g., overt versus covert, behaviors that vary in destructiveness to others). Similarly, more research is needed to determine if some aspects of self-âr•‰egulation (e.g., delay skills versus “cooler” executive attention abilities) relate to externalizing and/o╉ r internalizing symptoms more than others (Kim et al., 2013). In addition, it would be useful to examine additional moderators (besides negative emotional- ity) of the association between self-r╉ egulation and children’s externalizing and internalizing symp- toms. For example, impulsivity may interact with self-âr•‰ egulatory skills to predict maladjustment, perhaps more at periods of development when individual differences in impulsivity are relatively marked (e.g., in the early years and in adolescence; see Wang et al., 2015). More attention to the mediators of the relation between self-âr•‰egulation and children’s symptoms would also be useful; coping efficacy or self-e╉ fficacy come to mind as potential mediators. Moreover, there is limited research examining potential causal relations between self-âr•‰ egulation and maladjustment, either in experimental designs or in longitudinal research that controls for prior levels of maladjustment. The research suggests that relations are bi-d╉ irectional and may vary in causal predominance at different ages (Sulik et al., 2015). The results from interventions suggest that children, especially those high in baseline levels of maladjustment or other risk factors, improve more in regulation/âl•‰ower externalizing than