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Emotion regulation and psychopathology in children and adolescents ( PDFDrive )

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Description: Emotion regulation and psychopathology in children and adolescents ( PDFDrive )

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721 Conclusions 127 Plessen, K. J., Bansal, R., & Peterson, B. S. (2009). Imaging evidence for anatomical disturbances and neuroplastic compensation in persons with Tourette syndrome. Journal of Psychosomatic Research, 67(6), 559–5 73. Plichta, M. M., Vasic, N., Wolf, R. C., Lesch, K. P., Brummer, D., Jacob, C., … & Grön, G. (2009). Neural hyporesponsiveness and hyperresponsiveness during immediate and delayed reward processing in adult attention-d eficit/h yperactivity disorder. Biological Psychiatry, 65(1), 7–1 4. Posner, J., Maia, T. V., Fair, D., Peterson, B. S., Sonuga-B arke, E. J., & Nagel, B. J. (2011). The attenuation of dysfunctional emotional processing with stimulant medication: an fMRI study of adolescents with ADHD. Psychiatry Research: Neuroimaging, 193(3), 151–1 60. Posner, M. I., & Rothbart, M. K. (1998). Attention, self–regulation and consciousness. Philosophical Transactions of the Royal Society of London B: Biological Sciences, 353(1377), 1915–1927. Polanczyk, G., de Lima, M. S., Horta, B. L., Biederman, J., & Rohde, L. A. (2007). The worldwide prevalence of ADHD: a systematic review and metaregression analysis. The American Journal of Psychiatry, 164(6), 942–9 48. Polanczyk, G. V., Willcutt, E. G., Salum, G. A., Kieling, C., & Rohde, L. A. (2014). ADHD prevalence estimates across three decades: an updated systematic review and meta-regression analysis. International Journal of Epidemiology, 43(2), 434–442. Rich, B. A., Grimley, M. E., Schmajuk, M., Blair, K. S., Blair, R. J. R., & Leibenluft, E. (2008). Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology, 20(02), 529–546. Saunders, B., & Chambers, S. M. (1996). A review of the literature on Attention‐Deficit Hyperactivity Disorder children: Peer interactions and collaborative learning. Psychology in the Schools, 33(4), 333–340. Saarni, C. (1999). The development of emotional competence. New York, NY, US: Guilford Press. Sanson, A., Smart, D., Prior, M., & Oberklaid, F. (1993). Precursors of hyperactivity and aggression. Journal of the American Academy of Child & Adolescent Psychiatry, 32(6), 1207–1 216. Sergeant, J. A., Oosterlaan, J., & van der Meere, J. (1999). Information processing and energetic factors in attention-deficit/h yperactivity disorder. In H. C. Quay & A. E. Hogan (Eds.), Handbook of disruptive behavior disorders (pp. 75–104). New York: Kluwer Academic/P lenum Publishers. Seymour, K. E., Chronis-Tuscano, A., Halldorsdottir, T., Stupica, B., Owens, K., & Sacks, T. (2012). Emotion regulation mediates the relationship between ADHD and depressive symptoms in youth. Journal of Abnormal Child Psychology, 40(4), 595–6 06. Seymour, K. E., Chronis-Tuscano, A., Iwamoto, D. K., Kurdziel, G., & MacPherson, L. (2014). Emotion Regulation Mediates the Association Between ADHD and Depressive Symptoms in a Community Sample of Youth. Journal of Abnormal Child Psychology, 42(4), 611–621. Shaw, P., Stringaris, A., Nigg, J., & Leibenluft, E. (2014). Emotion dysregulation in attention deficit hyperactivity disorder. American Journal of Psychiatry, 171, 276–2 93. Skirrow, C., McLoughlin, G., Kuntsi, J., & Asherson, P. (2009). Behavioral, neurocognitive and treatment overlap between attention-deficit/h yperactivity disorder and mood instability. Expert review of neurotherapeutics, 9(4), 489–503. Skounti, M., Philalithis, A., & Galanakis, E. (2007). Variations in prevalence of attention deficit hyperactivity disorder worldwide. European Journal of Pediatrics, 166(2), 117–123. Spencer, T. J., Biederman, J., & Mick, E. (2007). Attention-deficit/h yperactivity disorder: diagnosis, lifespan, comorbidities, and neurobiology. Journal of Pediatric Psychology, 32(6), 631–642. Stringaris, A., & Goodman, R. (2009). Longitudinal outcome of youth oppositionality: irritable, headstrong, and hurtful behaviors have distinctive predictions. Journal of the American Academy of Child & Adolescent Psychiatry, 48(4), 404–4 12. Stringaris, A., Maughan, B., & Goodman, R. (2010). What’s in a disruptive disorder? Temperamental antecedents of oppositional defiant disorder: findings from the Avon longitudinal study. Journal of the American Academy of Child & Adolescent Psychiatry, 49(5), 474–483.

821 128 Emotion Regulation and Attention Deficit Hyperactivity Disorder Timimi, S., & Taylor, E. (2003). ADHD is best understood as a cultural construct. The British Journal of Psychiatry, 184(1), 8–9. Travell, C., & Visser, J. (2006). “ADHD does bad stuff to you”: young people’s and parents’ experiences and perceptions of Attention Deficit Hyperactivity Disorder (ADHD). Emotional and Behavioural Difficulties, 11(3), 205–2 16. Thompson, M. J., Brooke, X. M., West, C. A., Johnson, H. R., Bumby, E. J., Brodrick, P., … & Scott, N. (2004). Profiles, co-morbidity and their relationship to treatment of 191 children with AD/HD and their families. European Child & Adolescent Psychiatry, 13(4), 234–2 42. Walcott, C. M., & Landau, S. (2004). The relation between disinhibition and emotion regulation in boys with attention deficit hyperactivity disorder. Journal of Clinical Child and Adolescent Psychology, 33(4), 772–782. Waschbusch, D. A. (2002). A meta-a nalytic examination of comorbid hyperactive-impulsive-attention problems and conduct problems. Psychological Bulletin, 128(1), 118. Wheeler Maedgen, J., & Carlson, C. L. (2000). Social functioning and emotional regulation in the attention deficit hyperactivity disorder subtypes. Journal of Clinical Psychology, 29(1), 30–4 2. Wilens, T. E., Gignac, M., Swezey, A., Monuteaux, M. C., & Biederman, J. (2006). Characteristics of adolescents and young adults with ADHD who divert or misuse their prescribed medications. Journal of the American Academy of Child & Adolescent Psychiatry, 45(4), 408–414. Willcutt, E. G., Doyle, A. E., Nigg, J. T., Faraone, S. V., & Pennington, B. F. (2005). Validity of the executive function theory of attention-deficit/hyperactivity disorder: a meta-a nalytic review. Biological Psychiatry, 57(11), 1336–1 346. Willcutt, E. G. (2012). The Prevalence of DSM-IV Attention-Deficit/H yperactivity Disorder: A Meta- Analytic Review. Neurotherapeutics, 9(3), 490–4 99. Wolraich, M. L., Wibbelsman, C. J., Brown, T. E., Evans, S. W., Gotlieb, E. M., Knight, J. R., … & Wilens, T. (2005). Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics, 115(6), 1734–1 746. Zelazo, P. D., & Cunningham, W. A. (2007). Executive Function: Mechanisms Underlying Emotion Regulation. In James J. Gross (Ed.), Handbook of emotion regulation (pp. 135−158). New York, NY, US: Guilford Press.

921 Chapter 7 Emotion Regulation and Conduct Disorder: The Role of Callous-U‰•â nemotional Traits Nicholas D. Thomson, Luna C. M. Centifanti, & Elizabeth A. Lemerise Conduct disorder Although all children disobey adults at times, children with conduct disorder (CD) persistently break the rules, engage in norm-âb•‰ reaking behavior, defy adults and authority figures across situa- tions, and repeatedly and seriously violate the rights of others (American Psychological Association [APA], 2013). CD was first introduced as a psychiatric diagnosis in the second edition of the American Psychiatric Association’s Diagnostic & Statistical Manual of Mental Disorders (DSM). Since this time the diagnosis of CD has become more refined (Kimonis, Frick, & McMahon, 2014). There are four types of symptoms that define CD: 1) aggression towards people and animals (e.g., fighting, bullying); 2) destruction of property (e.g., fire setting, vandalism); 3) deceitfulness, or theft (e.g., conning, shoplifting); and 4) serious violations of rules (e.g., truancy, running away from home [APA, 2013]). CD is one of the most prevalent mental health concerns for children and adolescents and is considered one of the most challenging childhood disorders to treat (Dadds & Fraser, 2003). To further complicate matters, children with CD are often viewed as “bad” rather than having a mental illness because their symptoms result in the violation of the rights of oth- ers (e.g., hostility, aggression, cruelty). Further, conduct problems represent a large cost to society (Welsh et al., 2008). Although CD is considered a behavioral disorder, differences in emotion (dys) regulation might identify subgroups of youth with CD. Some children with CD may exhibit irrita- bility and mood swings resulting in aggressive responding; whereas, other children with CD may be emotionally disconnected from others so they callously hurt others. This emotional heterogeneity may explain why some children with CD fail to be bothered by the effects of their behavior on other people, whereas others experience anxiety over their negative behavior (Pardini & Frick, 2013). In this chapter, we will discuss the evidence for considering how children with CD manage their emotions because subgroups of children with CD may show different developmental trajectories based on having strong or poor emotion regulation abilities. We will also discuss the implications for clinical practice in managing CD based on this heterogeneity. Based on the severity and number of symptoms displayed, CD can be classified from “mild,” such that the youth displays few symptoms and/oâ•‰ r causes minor harm (e.g., lying, truancy), to “severe,” such that the youth displays many more symptoms than required for a diagnosis and considerable harm to others is caused (e.g., forced sex, use of a weapon). Severity of CD has been found to affect the persistence of the disorder, with youths in the moderate to severe scale of CD more likely to retain CD symptoms into their adolescence (Cohen, Cohen, & Brook, 1993) and suffers from educational problems (Kim-âC•‰ ohen et al., 2005). Although the number of

031 130 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits children who display early and pervasive antisocial behavior is small in number (5% [Hinshaw & Lee, 2003]), they account for almost half the crime in the United States (Loeber, Burke, Lahey, Winters, & Zera, 2000). In the DSM-5â•‰ (APA, 2013), heterogeneity in CD diagnosis is recognized, such that persis- tence of antisocial behavior beyond childhood is characteristic of a subgroup of those with CD. Currently, the diagnosis takes into account the age at which the symptoms onset, because early onset of behavioral problems typically relates to lifetime-pâ•‰ ersistence of these behaviors (Moffitt, 1993). Childhood-oâ•‰ nset, which is defined as onset before the age of ten years, has been associated with greater cognitive impairment, mental health concerns, and more harmful, violent behavior than adolescent-âo•‰ nset CD (onset after the age of ten years) (Johnson, Kemp, Heard, Lennings, & Hickie, 2015). Heterogeneity in CD is in line with the dual taxonomy of offending posited by Moffitt (1993). Moffitt theorized that those who have an onset of offending during adolescence (adolescent-lâ•‰imited offenders) tend to cease their delinquency by early adulthood, whereas those with childhood-oâ•‰nset (lifecourse-âp•‰ ersistent offenders) continue their antisocial behavior into adulthood (Moffitt, 1993). A test of Moffitt’s (1993) taxonomic predictions revealed four antisocial behavior trajectories roughly in line with Moffitt: 1) lifecourse-pâ•‰ ersistent, 2) adolescence-âl•‰imited, 3) childhood-âl•‰imited, 4) and low (Odgers et al., 2008). There was empirical evidence for the developmental trajectories of antisocial behavior which coincided most with the designations of CD: lifecourse-pâ•‰ ersistent and adolescent-âo•‰nset antisocial trajectories coincided with childhood-â•‰and adolescent-âo•‰nset CD. However, the outcomes related to the trajectories differed for the adolescent-âo•‰ nset group (Odgers et al., 2008). Some individuals in the adolescent-oâ•‰ nset trajectory continued to show anti- social behavior into adulthood. Also, a trajectory not originally posited by Moffitt was identi- fied: A childhood-lâ•‰imited trajectory. People on this trajectory of antisocial behavior desisted past childhood. However, of importance to psychopathology, they only showed minor problems with smoking, managing finances, and internalizing behavior problems (e.g., anxiety and depression). Thus, there are some who present with early conduct problems but who grow out of them, only seeming to be left with the remains of their poor behavior management choices. Thus, it could be that other factors like emotion or behavior management could be useful in delineating heteroge- neity within CD. Yet, in line with childhood-oâ•‰ nset CD diagnoses, research finds that children with early-oâ•‰ nset of CD typically have a prior diagnosis of Oppositional Defiant Disorder (ODD). ODD is considered a precursor to and milder variant of CD (Loney & Lima, 2003). Longitudinal samples have shown that 80% (Loeber, Green, Keenan, & Lahey, 1995) of children with CD had a former diagnosis of ODD, and about 90% of clinically referred children with CD diagnosis meet the criteria for ODD (Faraone, Biederman, Keenan, & Tsuang, 1991). CD and ODD can co-oâ•‰ ccur, and a comorbid diagnosis of CD with ODD can be given (APA, 2013). In research, the term “conduct problems” (CP) is often used to jointly describe children with severe behavioral problems, or a diagnosis of CD or ODD (Kimonis, Frick et al., 2014). Prevalence and course Conduct disorder is one of the most prevalent disorders for children and adolescents (Kessler et al., 2012; Lindhiem, Bennett, Hipwell, & Pardini, 2015), but the negative impact is not limited to these early years and is associated with lifelong adjustment, mental health, legal, social, occupational, and physical health problems (Jones, 2013; Odgers et al., 2008). Based on study samples, the prevalence of CD is estimated to be between 2% and 15% (APA, 2013; Egger & Angold; Kim-Câ•‰ ohen et al., 2005) with more cases evident of adolescent-oâ•‰ nset than

13 Prevalence and course 131 childhood-onset (Nock, Kazdin, Hiripi, & Kessler, 2006; Perou et al., 2013). Overall, boys are twice as likely as girls to receive a CD diagnosis (4.6% versus 2.2% with current CD diagno- sis [Perou et al., 2013]). However, gender differences are greater early in childhood. At the age of five years, boys are three to five times more likely to be diagnosed with CD than girls (Kim-C ohen et al., 2005). Emerging into mid-adolescence, gender differences tend to reduce significantly with female CD prevalence peaking at the age of 16 years (Esser, Schmidt, & Woerner, 1990; McGee et al., 1990). For adolescent girls, CD is the second most common psychiatric diagnosis with a prevalence rate of about 10% in community samples (Dalwani et al., 2015; Pajer et al., 2008) and 36% in detention center samples (Washburn et al., 2007). Although research on CD tends to focus on male samples, there is evidence supporting simi- larities between males and females in biological (Fairchild et al., 2014) and psychosocial vul- nerabilities (Bardone et al., 1998; Pajer, 1998). Moffit’s (1993, 2006) dual taxonomy of conduct problems identifies two groups of youth based on the timing of onset of behavioral problems. The developmental typology suggests that con- duct problems developing in early childhood lead to “life-c ourse-p ersistent” antisocial behavior, whereas antisocial behavior that begins in adolescence is limited to the teenage years (Moffitt & Caspi, 2001). Prior research suggests that children who develop CD during childhood differ in the underlying mechanisms compared to youths who develop CD during adolescence. Evidence suggests that children with childhood-onset are exposed to family, social, and inherited neurode- velopmental risk factors more than youths with adolescent-onset of CD (Moffitt & Caspi, 2001; Odgers et al., 2008). By the age of 32, adults with a history of childhood-onset of CD show greater perpetration of violence, and more mental and physical health problems (Odgers et al., 2008). The different trajectories based on age of onset are attributed to causal mechanisms in the child’s envi- ronment as well as biological factors that seem to distinguish the two groups. Childhood-o nset has been associated with poorer neurological functioning (e.g., self-c ontrol, memory and verbal abilities), which in turn, negatively impacts the successful navigation of social relationships, man- agement of emotions, and the ability to control behaviors (Johnson et al., 2015; Moffitt, 2006; Pardini & Frick, 2013). The child is more likely to experience childhood maltreatment (Johnson et al., 2015), poorer parenting strategies (i.e., harsh and inconsistent discipline), and greater family-level conflict, poverty, mental health problems (Odgers et al., 2008) and parental history of antisocial behavior (McCabe, Hough, Wood, & Yeh, 2001). Whereas, youths with adolescent- onset CD are less likely to have a childhood history of ADHD or ODD, have neurological deficits, and have less severe family dysfunction and aggression and a greater remission rate of antisocial behavior into adulthood (Moffitt, Caspi, Dickson, Silva, & Stanton, 1996). Prior research supports the dual taxonomic trajectory of antisocial behavior; thus, the DSM-5 categorization of age of onset is an important factor. However, there is considerable evidence showing etiological hetero- geneity within the childhood-onset group based on emotionality (Frick & Viding, 2009; Pardini & Frick, 2013). Further heterogeneity in CD has recently been identified based on callous-unemotional (CU) traits. Research has identified a subgroup of youth with CD and callous unemotional (CU) traits, although the term used in the DSM is Limited Prosocial Emotions (LPE; APA, 2013). To meet diagnostic criteria for LPE, the youth must display two of the following four character- istics: a lack of remorse or guilt, a callous lack of empathy, shallow or deficient affect, or lack of concern about performance (Blair, Leibenluft, & Pine, 2014). Thus, children with LPE are emotionally cold and experience little concern over the effects that their problem behaviors may cause (see Munoz & Frick, 2012). Children with CU traits have a lack of concern for the welfare of others; they often act cruelly to others with the intention to cause physical or emo- tional harm in order to achieve a goal (e.g., exerting dominance [Pardini & Byrd, 2012]). This

231 132 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits group of children has a lack of emotionality (Essau, Sasagawa, & Frick, 2006) making them fearless perpetrators of antisocial behavior without consideration of the consequences of their actions (Fanti, Panayiotou, Lazarou, Michael, & Georgiou, 2015). Emotional deficits such as low empathy and guilt are suggested to play an integral role in the atypical development of moral values for children with CU traits (Frick, Ray, Thornton, & Kahn, 2014). Although children with conduct problems continue to show behavioral problems throughout childhood, children with conduct problems (CP) and CU traits continue to show the greatest levels of conduct prob- lems, delinquency, and police contacts (Frick, Stickle, Dandreaux, Farrell, & Kimonis, 2005). Compared to children with CD-oâ•‰ nly, children with CD + CU have been described as having different etiological mechanisms (i.e., social, genetic, behavioral, and cognitive vulnerabilities [Kimonis, Centifanti, Allen, & Frick, 2014; Sebastian et al., 2015]), and are hypoactive in their emotional responses (Frick & Viding, 2009; Sebastian et al., 2015). Evidence from twin stud- ies suggests that children with CU traits and conduct problems are more likely to have inher- ited contributing factors, whereas conduct problems in children with low levels of CU traits are explained mostly by environmental vulnerabilities (Viding, Blair, Moffitt, & Plomin, 2005; Viding, Jones, Frick, Moffitt, & Plomin, 2008). Therefore, prior research with community samples and clinic-âr•‰eferred samples has found that children and adolescents with CD and LPE (CD + LPE) are characteristically different from youth with only CD (CD-oâ•‰ nly) in terms of long-ât•‰erm outcomes. When compared to youth with CD-â•‰ only, youth with CD + LPE are more likely to display severe and persistent psychopathology (Rowe et al., 2010), get involved in criminal activities at a younger age (Pechorro, Jiménez, Hidalgo, & Nunes, 2015), have greater levels of externalizing behaviors (e.g., aggression, delinquency, psy- chopathic traits [Colins & Andershed, 2015]), and are more likely to develop antisocial personal- ity disorder symptoms in adulthood (McMahon, Witkiewitz, & Kotler, 2010). Development of emotion regulation Emotion is a complex and subjective phenomenon, which is composed of physiological arousal and expressive behavior (Calkins, 1994; Thompson & Calkins, 1996). Functionalists believe the purpose of emotions in infants is to serve as effective communication to caregivers (see Lemerise & Arsenio, 2000). Emotions regulate behavior and communicate the infant’s immediate needs and internal states to caregivers (Marshall, Fox, & Henderson, 2000). The caregiver’s consistent and sensitive responses to their infant’s emotions greatly influences the development of attach- ment security and contributes to the infant’s developing ability to regulate emotion (Lemerise & Dodge, 2008; Lemerise & Harper, 2014). Emotional competence is multifaceted and includes emotion awareness, identification, and understanding in self and others, as well as regulation of emotion/aâ•‰ rousal in service of adaptive coping during an emotionally arousing event (Bohnert, Crnic, & Lim, 2003; Halberstadt, Denham, & Dunsmore, 2001; Lemerise & Harper, 2010, 2014; Saarni, 1999). Although biologically based temperament plays a role in conduct problems, emotional com- petence is important and develops in a relational context, first with parents and later with peers. From the earliest days of infancy, mothers respond differentially to infants’ emotions, with the net result that children’s positive and neutral expressions increase, whereas negative expres- sions decrease (e.g., Malatesta, Culver, Tesman, & Shepard, 1989). Mothers continue to social- ize emotions indirectly, and as children develop language, more direct socialization methods are employed (Lemerise & Dodge, 2008; Lemerise & Harper, 2014). Socialization practices that act to modulate children’s emotional arousal scaffold children’s learning about emotions and how to regulate them. In particular, parents who employ the

31 Temperament and emotionality 133 practice of correctly labeling children’s emotions and coach their children on coping strategies and problem-sâ•‰olving have children who display better emotional competence (emotion aware- ness/âu•‰ nderstanding and emotion regulation [Gottman, Katz, & Hooven, 1997; Laible & Panfile, 2009; Thompson, 2006]). For example, mothers who remark appropriately about their child’s mental states appear to “scaffold” a richness in children’s understanding of emotions (Centifanti, Meins, & Fernyhough, 2015). Further, mothers’ appropriate verbal comments about their infant’s mental states and desires led to lower levels of CU traits at age ten years through a greater emotion understanding at age four years (Centifanti, et al., 2016). However, caregivers’ hostile responses to their children’s emotions, including anger, tend to increase children’s arousal, interfering with learning about emotions and with the regulation of emotions, raising risks for children’s aggres- sive and other problem behaviors (Lemerise & Dodge, 2008). Moreover, the stresses associated with poverty (a well-âk•‰ nown risk factor for aggressive behavior and CD) interfere with children’s regulatory development as well as with the supportive parenting that might buffer children from these stressors (Blair & Raver, 2015). With language development, children soon learn that they can communicate their needs more effectively using their words. However, Thompson (1994) theorized that emotions continue to serve in social signaling, defensive motivations, and in communication of one’s needs, but also serve to maintain affiliational ties. Indeed, nonhuman primates rely on expressions of threat to inhibit agonistic behavior from other primates (see Izard, 1991). Thus, emotions can communi- cate in addition to other forms of communication. Human infants respond to pain with crying, seemingly to summon their caregiver’s attention, as infants lack the ability to defend themselves. By 19 months, however, children respond to pain with anger (after a short period of crying), which might serve to inhibit any perpetrator. This developmental change in their emotional expression may, arguably, be due to many other factors related to the regulation of emotion and the emerging theory of mind (which both depend on cognitive processes [Lemerise & Dodge, 1993; Meltzoff, 2002]). Temperament and emotionality Emotional reactivity or emotionality, which has been variously defined as reflecting onset, dura- tion, and intensity of emotion, is thought to be central to theories of temperament (Eisenberg et al., 1997; Rothbart & Bates, 1998) and figure prominently in emotion regulation, such that greater intensities of emotion are harder to regulate. Rothbart and Bates (1998) include attention, activity, variability in arousability, and distress to overstimulation in theories of temperament, and temperamental characteristics are theorized to be consistent and stable across situations, and result due to biological dispositions. Compatible with the notion of multifinality, temperamental characteristics are modifiable with maturation and experience (Marshall et al., 2000; Rothbart & Bates, 1998). Thus, different developmental trajectories are possible given similar biological diatheses. Of importance, different temperamental dispositions may underlie heterogeneity in childhood disorders. Optimal development of emotion regulation depends on flexible control of attention and the ability to shift attention (Rothbart, Posner, & Hershey, 1995). A high degree of self-râ•‰egulation is essential when emotions, particularly negative emotions, are frequently experienced intensely (Eisenberg et al., 1997). That is, negative emotions that are very intensely experienced are more difficult to manage. Although emotionality and regulation may have additive effects on social competence (Blair et al., 2015; Dollar & Stifter, 2012; Rothbart & Bates, 1998), negative emo- tionality, alone, seems to distinguish those children with behavior problems from those without (Eisenberg et al., 1997; Nozadi, Spinrad, Eisenberg, & Eggum-âW•‰ ilkens, 2015).

431 134 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits Conduct disorder with callous unemotional traits Children in the CP + CU group have been characterized as temperamentally fearless with diminished emotionality, which is suggested to explain their propensity toward lifelong antiso- cial behavior (Fanti, Panayiotou, Lazarou, et al., 2015; Viding et al., 2012). The lack of emotional response is thought to explain why children with CU traits do not learn from others’ distress or, indeed, by cues for punishment (Frick & Viding, 2009; Pardini & Frick, 2013). Physiological studies have found that children with CU traits have reduced sympathetic reactivity (Muñoz, Frick, Kimonis, & Aucoin, 2008) and are less responsive to others’ emotional and physical distress (Fanti, Panayiotou, Kyranides, et al., 2015; Wolf & Centifanti, 2014). Specifically, children with CP + CU show lower startle potentiation to fearful mental imagery compared to children in the CP-oâ•‰ nly group (Fanti, Panayiotou, Lazarou, et al., 2015). Neuroimaging studies have supported this lack of emotionality to others’ distress, finding that children with higher levels of CU traits have less activation in the amygdala in response to fearful faces (Viding et al., 2012). Additionally, children with CP + CU have been found to have reduced grey matter volume in the left orbital frontal cortex and the right anterior cingulate cortex, which are key brain regions for decision-â•‰ making and empathy (Sebastian et al., 2015). Emerging evidence suggests a neurological continu- ity from childhood CU to adult psychopathy, with a reduction in white matter in regions of the limbic system notably occurring from childhood. Atypical neurological development may explain the hypoactivity to others’ distress, which impairs important brain regions for social and affective functioning (Breeden, Cardinale, Lozier, VanMeter, & Marsh, 2015; Hoppenbrouwers et al., 2013; Wolf et al., 2015). These biological influences suggest that a lack of emotional and physiological reactivity to fearful events could explain why children with CU traits are less receptive to learning as a result of punitive measures, hindering normative social development, which subsequently predisposes these children as life-câ•‰ ourse-pâ•‰ ersistent offenders. Conduct disorder with severe anger dysregulation Recent evidence has emerged which suggests that the combination of CD with severe anger dys- regulation (e.g., oppositional and defiant behaviors) has meaningful implications for the diagno- sis of childhood-oâ•‰ nset of CD, the pathway into adulthood outcomes, and treatment (Pardini & Frick, 2013). Although ODD is a common precursor to CD (Stringaris, 2011), and both disorders share theoretical and empirical overlap, the two are symptomatically distinct (Krieger et al., 2013; Whelan, Stringaris, Maughan, & Barker, 2013). The core feature of CD is the purposeful viola- tion of the rights of others and/âo•‰ r breaking of major social norms, whereas the nucleus of ODD is negative emotionality, such as irritability and anger (Lindhiem et al., 2015). It is common for these two disorders and symptoms to co-oâ•‰ ccur (Copeland, Angold, Costello, & Egger, 2013); how- ever, note that although most children with ODD receive a diagnosis of CD, the reverse is not so (Lindhiem et al., 2015). Of importance, children with ODD tend to develop anxiety and depres- sion later in life (Boylan, Vaillancourt, Boyle, & Szatmari, 2007; Pardini & Fite, 2010), whereas children with CD who had not received an ODD diagnosis tend to face a trajectory toward antiso- cial behavior, criminality, and the development of psychopathic personality traits (Burke, Loeber, & Lahey; Byrd, Loeber, & Pardini, 2012). Unlike the CD + CU group, children with CD and severe anger dysregulation tend to be hypersensitive to threat and hyper-râ•‰ eactive to fear (Pardini & Frick, 2013), which may result in reactive and explosive forms of aggression (Okado & Bierman, 2015). Although research shows that biological factors contribute to conduct problems for children with severe emotional dysregulation, evidence suggests that these biological factors are influenced by exposure to a negative childhood environment (Pardini & Frick, 2013).

531 Childhood aggression 135 An example of the biological and environmental interplay can be seen in longitudinal studies. The parasympathetic nervous system facilitates a reduction in heart rate and increases respira- tory sinus arrhythmia (RSA). When operating effectively, this helps facilitate emotion regula- tion (Beauchaine, 2015; Hinnant, Erath, & El-âS•‰ heikh, 2015). Lower resting RSA and less RSA withdrawal (during a threatening or challenging event) has been associated with poor emotion regulation, executive control, adjustment problems, and greater levels of parent-âc•‰ hild aggression (Beauchaine, 2015; Whitson & El-âS•‰ heikh, 2003). In a recent study, children whose parents used harsher parenting strategies had reductions over time in their RSA withdrawal to stress, suggest- ing that children in a hostile home environment are more likely to suffer from long-ât•‰erm physi- ological alterations which affect their ability to regulate their emotions (Hinnant et al., 2015). In support of the emotion dysregulation subgroup, CD-oâ•‰ nly children have demonstrated a hyper- sensitivity to fear, and poor behavioral inhibition (Fanti, Panayiotou, Kyranides, & Avraamides, 2015). Children with poor emotion regulation tend to have elevated levels of hyper-vâ•‰ igilance to threat cues and attributions of hostile intent. Children with higher levels of hostile attributional bias misinterpret ambiguous social cues as hostile intent which results in the child responding reactively (Dodge et al., 2015). To further exacerbate matters, engaging in aggressive behavior inevitably places the child in hostile social situations, which will likely increase the child’s ten- dency to attribute hostile intent from peers (Dodge et al., 2015). Children with CD-oâ•‰ nly indeed show increased heightened emotional reactivity. Because of the emotional instability, a tendency to misinterpret benign intents as hostile intents, and hypersensitivity to fear, this subgroup of chil- dren uses reactive (i.e., in response to provocation) aggression as a result of poor emotion regula- tion (de Wied, van Boxtel, Matthys, & Meeus, 2012; Frick, Cornell, Barry, Bodin, & Dane, 2003). There are some factors that might distinguish CD-âo•‰ nly groups from CD + CU groups, making the former more amenable to intervention. Children with CD-oâ•‰ nly are more receptive to pun- ishment (Fanti, Panayiotou, Lazarou, et al., 2015) and affectively empathetic and sympathetic to others (de Wied et al., 2012; Frick et al., 2003; Frick & Morris, 2004). In contrast, CD + CU chil- dren are punishment insensitive, lack emotionality, and consider deviant strategies (e.g., revenge, blaming others, aggression [Pardini, 2011; Stickle, Kirkpatrick, & Brush, 2009]) as acceptable methods to achieve a goal (Frick et al., 2014). The juxtaposition of CD + CU and CD-oâ•‰ nly in childhood-âo•‰ nset illustrates distinguishing features that could affect treatment outcome, hence the importance of distinguishing childhood-oâ•‰ nset subgroups. Recent research supports the principle of equifinality, whereby different developmental mecha- nisms (e.g., hyper and hyposensitivity to fear) may lead to the same outcome of antisocial behav- ior (Fanti, Panayiotou, Kyranides, et al., 2015). However, the way in which a child perpetrates antisocial behavior may be indicative of the developmental pathway he\\she has taken. As with the two subtypes of childhood-oâ•‰ nset of CD, emotionality and emotion dysregulation play integral roles in how aggressive behavior in children is understood. Childhood aggression CU traits have been suggested to moderate antisocial behavior for youth with conduct problems (Helseth, Waschbusch, King, & Willoughby, 2015), including aggression subtypes that differ in emotionality and emotion regulation. Proactive aggression occurs without provocation and is typically motivated by intentional purpose (e.g., social dominance, physical goal). By comparison, reactive aggression occurs in response to a perceived provocation or threat (Dodge & Coie, 1987). Proactive aggression is characterized as cold-bâ•‰ looded, whereas reactive aggression is fueled by anger or frustration (Dodge, 1991; Teten Tharp et al., 2011). Theoretically, children with CU traits are more likely to be proactively aggressive, yet, empirically, children with CU traits tend to show

631 136 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits high levels of both reactive and proactive aggression (Centifanti, Fanti, Thomson, Demetriou, & Anastassiou-Hâ•‰ adjicharalambous, 2015; Muñoz et al., 2008). For instance, detained adolescents (13–â1•‰ 8 years) who reported being high on both reactive and proactive aggression (forming a “mixed” aggressor group) had higher levels of CU traits, and lower levels of physiological reactivity when provoked (Muñoz et al., 2008). The mixed group were also more aggressive in a behavioral task when they experienced no provocation from an opponent (Muñoz et al., 2008). Therefore, youth with CU traits may respond aggressively in all provocation situations (without provocation, or in response to low or high provocation), but they seem to have less of an emotional response. Development of reactive aggression Reactive aggression is characterized by “hot blooded” anger, driven by hostile responses to minor or perceived provocation, and intense physiological reactivity (Dodge & Coie, 1987; Dodge, Lochman, Harnish, Bates, & Pettit, 1997; Hubbard et al., 2002; Zhang & Gao, 2015). One of the hallmark differences between reactive and proactive aggression (Pardini, Raine, Erickson, & Loeber, 2014) is a differential association with a deficiency in processing information related to social threat (Crick & Dodge, 1996). In fact, reactive aggression, as opposed to proactive aggres- sion, has been related to social information-âp•‰ rocessing deficits and biases at many, if not all, levels of decision-mâ•‰ aking, but especially during early stage processing (encoding of social cues and interpretation of social cues [Arsenio, Adams, & Gold, 2009; Dodge et al., 1997; Dodge & Pettit, 2003; Lemerise & Arsenio, 2000]). Children who engage in mainly reactive aggression have been shown to attribute greater hostile intent to peer behavior (Dodge & Coie, 1987), which may cause them to respond aggressively. Indeed, studies have supported this assertion: higher levels of reactive aggression were associated with greater hostile attributional biases (Hubbard, Dodge, Cillessen, Coie, & Schwartz, 2001) and with being aggressive in response to low levels of provoca- tion (Muñoz et al., 2008). Although Dodge’s theory focuses mainly on social information-âp•‰rocessing, emotion and emotion regulation processes also are important to both the development and the expression of reactive aggression (Lemerise & Arsenio, 2000). For example, de Castro et al. (2005) found that reactive aggressive children often reported that they did not know a strategy to regulate their strong emotions or that another person(s) would have to regulate the emotions for them. In addition, there is evidence that strong emotions overwhelm reactively aggressive children’s social information-pâ•‰ rocessing, leading to impulsive reactions to threat (Crick & Dodge, 1994; de Castro, Verhulp, & Runions, 2012; Lemerise & Arsenio, 2000). Vitaro, Brendgen, and Tremblay (2002) found that only reactive aggression was related to high reactivity, inattention, anxiety, and depression. A child who is high in negative emotionality and lacks the ability to regulate his or her emotions would be highly susceptible to evoking negative responses from his or her environment (Schwartz et al., 1998). Deficits in emotion regulation may stem from an inability to focus or shift attention (Rothbart et al., 1995) or equally, may stem from a lack of inhibition and careful plan- ning due to executive functioning deficits (Bridgett, Oddi, Laake, Murdock, & Bachmann, 2013). Indeed, reactive aggression has been repeatedly related to peer social rejection (Dodge et al., 1997; Evans, Fite, Hendrickson, Rubens, & Mages, 2015; Schwartz et al., 1998). Moreover, having high negative emotionality or being easily angered might predispose a child to “cue up” (internally) past negative situations that resulted in hostility, but which may not necessarily be related to the child’s current situation (Lemerise & Arsenio, 2000). An aggressive response would thus become more likely. Children who show high levels of reactive aggression also show selective attention to social threat words or cues (e.g., “teased,” “rejected,” “failure,” and “unpopular” [Schippell, Vasey,

731 Development of proactive aggression 137 Cravens-Bâ•‰ rown, & Bretveld, 2003]). Aspinwall (1998) reviewed evidence that people in a nega- tive mood orient more quickly to negative information, but their resources are tied up in regu- lating their negative emotions; thus, they are unable to fully process the negative information. Alternatively, attentional systems may become dysregulated by intense emotional arousal, pre- cluding an adequate processing of relevant cues (Thompson & Calkins, 1996). Aspinwall’s (1998) conclusion may explain why Schippell et al. (2003) found that reactive aggressors showed selective attention and suppression of social threat words. A large stress reaction results in an internal-â•‰ focus (Thompson & Calkins, 1996), diverting attention away from the stimulus and precluding adequate processing. In the reactive-âa•‰ ggressive child, this diversion of attention may serve to pre- vent further emotional negativity that typically threatens their self-âi•‰mage (Schippell et al., 2003). In fact, aggressive children have been shown to overestimate their likeability with their peers (Rudolph & Clark, 2001). Hypervigilance to threat cues may serve to aid in their suppression and in the protection of esteem or may simply reflect the selection of mood-âc•‰ ongruent information (Lemerise & Arsenio, 2000; Schippell et al., 2003). Cognitive competence is essential for successful development of behavioral regulation (Olson, Bates, Sandy, & Schilling, 2002) or inhibitory control. A lower verbal intelligence quotient may lead to a generation of fewer alternatives when generating responses to a situation and a rapid accessing of aggressive responses, which could lead to aggressive behavior (Dodge & Pettit, 2003; Lemerise & Arsenio, 2000). Children who are more impulsively aggressive evidence intellec- tual deficits, particularly verbal deficits (Arsenio et al., 2009; Babcock, Tharp, Sharp, Heppner, & Stanford, 2014; Loney, Frick, Ellis, & McCoy, 1998). One study found that children classified as rejected-âr•‰eactive aggressive were better able to choose a constructive response, when given response options rather than free choice (Wood & Gross, 2002). The generation and subsequent selection of an aggressive response may result from deficits in inhibitory control and/âo•‰ r planning. Emotional competence involves being able to control one’s expressivity as well as to express emotions flexibly and appropriately within the situation (see Lemerise & Arsenio, 2000). In addi- tion, competence is shown by being able to sensitively respond to others’ emotional cues and behavioral cues, which are important in providing feedback for the child’s behavior. Of impor- tance, emotional cues are displayed by the child and by others as the encounter proceeds, which allow the child to adjust his or her response in-âl•‰ine with the current environmental demands (Lemerise & Arsenio, 2000). During situations of high arousal, this delicate interchange may dis- integrate. Emotional cues may be missed or misinterpreted, whereby a peer’s positive affective desire to share a toy may be misconstrued as an angry demand. The result is possibly an angry reaction or resistance on the part of the reactive-âa•‰ ggressive child. The outcome of these perceptual and interpretive processes is an emotional and behavioral response. Differences in the expression of emotion have been found to distinguish the two sub- types of aggression (Hubbard et al., 2002). During a competitive game, a dysregulation of angry or hostile emotions seemed to characterize reactive but not proactive aggression (Hubbard et al., 2002). Strong emotional reactions to stressful situations can impede attempts to regulate behav- ior as well as cognitive attempts to regulate emotion (Lemerise & Arsenio, 2000; Thompson & Calkins, 1996). All of the deficits discussed thus far increase the likelihood of aggressive behavior (Crick & Dodge, 1994). Development of proactive aggression Proactive aggression, unlike reactive aggression, is not typically associated with verbal defi- cits or early stage social information-âp•‰rocessing deficits or biases (cue encoding or attribu- tions). Proactive aggression, instead, is motivated by rewards or perceived gains, thus the term

831 138 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits “instrumental” is used in describing this type of aggression (Dodge et al., 1997; Raine, Fung, Portnoy, Choy, & Spring, 2014). Proactive aggressors have been shown to prefer instrumental and dominance goals over relational goals (de Castro et al., 2005; e.g., Salmivalli, Ojanen, Haanpää, & Peets, 2005), and to evaluate aggressive responses more positively in terms of their effective- ness and one’s emotional reactions and self-eâ•‰fficacy (Arsenio et al.; Dodge et al., 1997). Their preference for instrumental goals over relational goals biases response selection toward aggressive responses (see Harper, Lemerise, & Caverly, 2010). Those who use proactive aggression tend to show higher levels of aggression and blunted emo- tion or emotion that is inconsistent with their behavioral displays (Bobadilla, Wampler, & Taylor, 2012; Hubbard et al., 2002). This is similar to the low emotionality related to CU traits. As sug- gested above, those who experience distress, such as anxiety and fear, may be more easily social- ized (Eisenberg et al., 1997; Izard, 1991). Children who were emotionally reactive and more prone to negative emotion were also high in conscience development (Kochanska, 1991). High reactivity to transgressions may facilitate the affective and affiliative component of conscience development, but it also may hinder the enactment of guilt-râ•‰elated behavior (such as reparation attempts and confession [Kochanska et al., 1994]). Nonetheless, this pattern of responding was found to be more characteristic of girls than of boys (Kochanska et al., 1994). Eisenberg et al. (1997) found that, although both boys’ and girls’ negative emotionality positively relates to behavior problems, only boys’ anxiety (expressed in the laboratory) was negatively related to behavior problems. Thus, boys’ low anxiety might be more germane to the development of a cold, unfeeling type of aggression. In sum, reactive aggressive children appear to suffer more from information-âp•‰ rocessing errors, which result in hostile-âa•‰ ttributional bias, making their behavior amenable to interventions that focus on regulating their emotional arousal. For example, the Coping Power Program (Lochman, 1992; Lochman & Wells, 2004) specifically focuses on helping the aggressive child to deal with his/âh•‰ er intense anger arising from provocation. It also targets biases that often result in reactive aggression, such as viewing others’ actions as originating from hostile intentions. Using cognitive-â•‰ behavioral techniques, these programs target faulty information processing deficits that can lead to reactive aggression (Boxer & Frick, 2008). The verbal deficits, emotional reactivity, and impul- sivity that accompany reactive aggression may underlie information processing errors, as well as also underlying their unsuccessful attempts to regulate their behavior. Admittedly, proactive aggressive children also have social-câ•‰ ognitive biases in prejudicially perceiving positive outcomes for behaving badly. However, their emotional deficits predispose them to fail to develop complex cognitive and emotional processes, such as understanding and identifying emotions in others (specifically, negative emotions) and responding sensitively to them. Complex emotions such as guilt may fail to develop as a result. Thus, they require different types of treatments, such as inter- ventions that target the multiple contexts in which children function. Treatment Youths who engage in serious antisocial behavior are more likely to experience psychosocial, aca- demic, and occupational challenges (Frick & Dickens, 2006). The negative influence is not exclu- sive to the youths’ wellbeing but extends to the community, with extensive economic and social burden as well as the physical and emotional cost to victims. Therefore, the impact that interven- tions have is not isolated to the individual or the family involved, but they positively affect the greater community and society. However, high-âr•‰isk individuals and families (with severe exter- nalizing behaviors) are considered extremely difficult to treat due to the strength and stability of personality characteristics (Moffitt, 1993) and exacerbation by the (cross)generational reach of

931 MULTISYSTEMIC THERAPY AND CONDUCT DISORDER 139 antisocial behavior (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999). Although there are a variety of interventions that have demonstrated effectiveness in children and adolescents with severe antisocial behavior, the remainder of this chapter will focus on three empirically efficacious interventions designed for youth with conduct problems: Multisystemic Therapy, Functional Family Therapy, and The Incredible Years. Multisystemic therapy Multisystemic Therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009) is a family-âf•‰ocused home-â•‰and agency-bâ•‰ ased intervention designed to treat adolescents with severe antisocial behavioral problems. As shown in Figure 7.1, MST considers that antisocial behavior is attributed from multiple social domains including, peers, family, school, and the com- munity. As the name implies, MST is truly integrative of therapeutic practices, drawing on the use of cognitive–âb•‰ ehavioral approaches, behavior therapies, parent training, and family therapies. In order to address the multiple social domains that affect the child, MST functions as an intensive therapy tailored to the unique needs of the family and child, and builds on the assistance and involvement from multiple sources (e.g., teachers, parents, extended family). Based on the func- tion of social ecology, the MST practitioner delivers the intervention and assessments within the child’s day-ât•‰o-âd•‰ ay environment where the maladaptive behavior occurs naturally (e.g., at home, school), which adds to the ecological validity of MST. Multisystemic therapy and conduct disorder The strength of MST comes from the wealth of empirical support for it. After 18 months of MST, youth with serious antisocial behavior had decreased antisocial symptoms, improved social func- tioning, and had less out-âo•‰ f-âh•‰ ome placements (Faw, Stambaugh et al., 2007). Compared to com- munity services, for juvenile offenders who were at imminent risk of placement, MST significantly decreased substance use and rearrests, and improved school functioning (Timmons-Mâ•‰ itchell, Bender, Kishna, & Mitchell, 2006). Recipients of MST have been shown to be less likely to recidi- vate (Henggeler et al., 2009) and have improved family relations (Borduin et al., 1995). Further, Peers MST Improved family School Reduced antisocial functioning behavior and improved functioning Community Figure 7.1â•‡ Multisystemic (MST) Therapy Theory of Change Reproduced from Scott W. Henggeler, Sonja K. Schoenwald, Charles M. Borduin, Melisa D. Rowland, and Phillippe B. Cunningham, Multisystemic Therapy for Antisocial Behavior in Children and Adolescents, 2e, © Guilford Press, 2009, with permission.

041 140 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits four years post-âM•‰ ST, adolescents had a reduction in violent crime and drug use (Henggeler, Clingempeel, Brondino, & Pickrel, 2002). Positive longitudinal results have been found with ado- lescent sexual offenders who have received MST. When compared to youth receiving commu- nity services, adolescents who received MST had decreased behavioral problems and symptoms, decreased sexual and other criminal offending, and improved social relations and academic per- formance nine years after treatment (Borduin, Schaeffer, & Heiblum, 2009). Based on the high intensity design of MST, there is strong empirical support for its use in adolescents with conduct disorder and for treating severe behavioral problems (Brestan & Eyberg, 2010; Curtis, Ronan, & Borduin, 2004; Henggeler & Sheidow, 2012). Functional family therapy Functional family therapy (FFT; Alexander & Parsons, 1973; Sexton & Alexander, 2004) is one of the oldest and widely applied evidence-bâ•‰ ased therapies for youth displaying severe antisocial behavior (Henggeler & Sheidow, 2012). FFT is a family-bâ•‰ ased intervention that targets the ado- lescent’s and family’s maladaptive behaviors. The relational dynamics of the family are central to FFT, however, FFT employs both cognitive and behavioral strategies. FFT has a focus on how the behavior of each family member contributes to the environment, which supports the youth’s behavior. Because all family members are important to the social-bâ•‰ ehavioral model of FFT, all family members are involved in the intervention. FFT is designed to move through three phases of change, each of which is designed to support the next phase and increase reciprocity and posi- tive reinforcement among family members: 1) engagement and motivation, 2) behavioral change, and 3) generalization. The goals of engagement and motivation are to develop an alliance, improve communication, engagement, and optimism within the family with the therapist. The aim of the behavior change is to implement individualized change plans, improve negative behaviors, and develop relational skills. The final stage, generalization, focuses on relapse prevention and making use of community support to ensure maintenance of positive gains. Functional family therapy and conduct disorder FFT has been recognized as an effective treatment for adolescents with disruptive behavior by the Centers for Disease Control (CDC) and the Surgeon General. Since the early development of FFT, it has yielded encouraging results. Compared to three treatment programs, FFT was more effective at decreasing recidivism and improving family interactions (Alexander & Parsons, 1973). FFT has been shown to reduce criminal activity for serious juvenile offenders (Barton, Alexander, Waldron, Turner, & Warburton, 1985). For adolescents who received treatment during their teens, a reduction in criminality carried over into early adulthood (Gordon, Graves, & Arbuthnot, 1995). A large scale study, including 400 families, showed that compared to a treatment-aâ•‰ s-uâ•‰ sual group, FFT clients had a 38% lower recidivism rate 18-âm•‰ onths post-tâ•‰ reatment (Barnowski, 2004). Further, FFT is considered an effective intervention for the most difficult to treat youths. Although adolescents with CU traits have been shown to be the most challenging subgroup of adolescents to treat for behavioral problems (Spain, Douglas, Poythress, & Epstein, 2004), encouraging evi- dence suggests that FFT is an effective form of treatment (White, Frick, Lawing, & Bauer, 2013). While youth with CU traits showed higher risk of violence when entering into treatment, FFT still resulted in improvements over the 20 month treatment period, with decreased risk for vio- lent offending at six and 12 month post treatment follow-âu•‰ ps (White et al., 2013). Because of the inclusive dynamic of FFT, positive influences on siblings of the target child have been found. FFT siblings were less likely to have court involvement (20%), compared to the no treatment group

14 INCREDIBLE YEARS AND CONDUCT DISORDER 141 (40%), client-âc•‰ entered treatment group (59%), and the eclectic-âd•‰ ynamic family program group (63% [Klein, Alexander, & Parsons, 1977]). Overall, there is a wealth of empirical support for the use of FFT in youth with severe behavioral and offending problems. Incredible Years Although research has shown the positive effect that interventions have for teens with CD, com- pared to early interventions (during childhood) the effectiveness is less reliable (Pardini & Frick, 2013). Therefore, early intervention and prevention during childhood is considered the opti- mum period for preventing the trajectory to severe antisocial behavior. The Incredible Years (IY; Webster-Sâ•‰ tratton, 1984, 2011) is a well-âv•‰ alidated set of three programs designed for children, parents, and teachers (Webster-âS•‰ tratton, Reid, & Hammond, 2004; Webster-Sâ•‰ tratton, 2016). The aim of the interlocking series of programs is to prevent, reduce, and treat behavioral problems and promote social and emotional stability through instruction. The parent training is designed to target high-râ•‰isk families as well as those families with children with behavior problems. The parent training programs are age adjusted (toddlers [one to three years], preschoolers [three to five years], and school-aâ•‰ge [six to 12 years]) to deliver developmentally appropriate strategies for increasing child prosocial attitudes and emotional wellbeing, while reducing and preventing behavior problems (Webster-âS•‰ tratton, 2016). The teacher training program is a six-âd•‰ ay workshop designed for educators and school counselors of pupils ages three to ten years. Teachers are taught classroom management strategies, and how to encourage children’s prosocial behavior and reduce problematic classroom behavior (e.g., aggression, hostile interpersonal relations). The child pro- gram promotes friendship, emotion regulation and literacy, and perspective taking for children ages three to eight years. Children are assessed on one of three “levels” for the most developmen- tally appropriate class. IY is based on well-eâ•‰stablished behavioral principles, which in applica- tion are simple and comprehensive to the user, making it a reliable and replicable intervention (Webster-Sâ•‰ tratton, Jamila Reid, & Stoolmiller, 2008). IY applies these teaching principles concur- rently across a variety of environments, supporting prosocial behaviors in “real-wâ•‰ orld” settings, which essentially covers all areas in which the child socializes (Boxer & Frick, 2008). Programs such as IY, that apply positive modifications to the child’s environment (e.g., parenting behaviors), are reliably shown to be effective methods of improving childhood behavioral outcomes (Gridley, Hutchings, & Baker-âH•‰ enningham, 2015). Incredible Years and conduct disorder Thirty years of development and validation with multiple randomized controlled trials supports IY as one of the most widely used, cost-eâ•‰ ffective, and validated programs for early intervention and prevention programs for children with conduct problems (McIntyre, 2008; Menting, Orobio de Castro, & Matthys, 2013). For teachers participating in the IY program, benefits have included more proactive teaching strategies, more emotional support for pupils, and the use of fewer critical and coercive tactics (Webster-âS•‰ tratton, Gaspar, & Seabra-âS•‰ antos, 2012). Parents respond positively to the IY program, which has led to a high attendance rate (Homem, Gaspar, Santos, Azevedo, & Canavarro, 2015). Parents of children with high levels of externalizing and conduct problems have sustained improvement in mother-âc•‰ hild interactions and decreases in children’s oppositional behaviors 12 months post intervention (Homem et al., 2015). Two years post treat- ment, parents of children (age four) who were at risk of developing chronic conduct problems were assessed by observational and self-âr•‰eport measures, and compared to a control group who received “care as usual” (Posthumus, Raaijmakers, Maassen, van Engeland, & Matthys, 2012).

241 142 Emotion Regulation and Conduct Disorder: The Role of Callous-Unemotional Traits The parents who participated in the program showed significant improvements compared to the control group. Parents reported using less harsh and inconsistent discipline and more positive parenting strategies (e.g., praise, appropriate discipline), and were observed using fewer critical statements to their child (Posthumus et al., 2012). IY has been shown to aid mothers who were recently released from prison, with parent-â•‰and teacher-râ•‰ eport of improvements in child behavior (Menting, de Castro, Wijngaards-âd•‰ e Meij, & Matthys, 2014). A meta-âa•‰ nalysis including 50 studies (see Menting et al., 2013) found that children who entered the program with more severe behav- ior problems reported the greatest improvements such that prosocial behavior had increased and oppositional behavior decreased immediately after the intervention, for observations, teacher and parent ratings. Children who come from homes with a family history of externalizing behaviors have been suggested to have a genetic risk as well as an environmental risk for showing antisocial behav- ior cross-gâ•‰ enerationally (Silberg, Maes, & Eaves, 2012). These children are more likely to have chronic behavior problems in childhood and develop antisocial personality disorder in adulthood (Lahey et al., 1988). A recent study (see Presnall, Webster-âS•‰ tratton, & Constantino, 2014) assessed the effectiveness of the IY program for children (three to eight years) with CD, with and without a family history of externalizing behaviors (e.g., Antisocial Personality Disorder). Although chil- dren from families with histories of externalizing behaviors had more severe conduct disorder symptoms upon entry into the program, both groups benefitted from the intervention showing a reduction in externalizing behavior (Presnall et al., 2014). Overall, IY has been shown to have excellent utility in diverse samples, including those who come from homes which pose the great- est risk for developing severe behavioral problems, which is why IY is considered by the National Institute of Justice as an effective form of prevention and treatment for children with conduct problems. Conclusion The cost of conduct problems is extensive, causing emotional and physical damage to victims, and causing financial and community resource burdens. To add to the challenge, these children are viewed by society as “bad” children rather than children suffering from a mental illness. Further, treatment is notoriously difficult in this population, especially due to the etiological and devel- opmental heterogeneity within the disorder. Despite all these setbacks, effective intervention programs have begun to accumulate evidenced in support of improving behavior for children with conduct disorder, even in the most challenging subgroups. These interventions offer sig- nificant life improvement for children and families, and substantial cost-sâ•‰ avings to society when compared to children not receiving adequate interventions (Bonin, Stevens, Beecham, Byford, & Parsonage, 2011). Although intervention programs tend to focus on outcome measures (e.g., aggression), further improvement in treatment outcomes can be accomplished by understanding that conduct disorder is multifaceted and subgroups can be differentiated based on etiological and developmental differences. Thus, we should aim to tailor treatment and family interventions to specific subgroups of children with conduct disorder. References Alexander, J. F., & Parsons, B. V. (1973). Short-ât•‰erm behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 81(3), 219–•‰2â 25. doi:10.1037/•‰âh0034537 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.

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351 Conclusion 153 Wolf, S., & Centifanti, L. C. M. (2014). Recognition of Pain as Another Deficit in Young Males with High Callous-Unemotional Traits. Child Psychiatry & Human Development, 45(4), 422–432. doi:10.1007/ s10578-013-0 412-8 Wood, C. N., & Gross, A. M. (2002). Behavioral Response Generation and Selection of Rejected-R eactive Aggressive, Rejected-Nonaggressive, and Average Status Children. Child & Family Behavior Therapy, 24(3), 1–1 9. Retrieved from http://eric.ed.gov/? id=EJ657151 Zhang, W., & Gao, Y. (2015). Interactive effects of social adversity and respiratory sinus arrhythmia activity on reactive and proactive aggression. Psychophysiology, 52(10), 1343–1 350. doi:10.1111/p syp.12473

451 Chapter 8 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment Dagmar Kr. Hannesdóttir & Thomas H. Ollendick Anxiety Some years ago, Barlow (1991) put forth the notion that anxiety was a disorder of emotion and was characterized by problems in regulating those emotions. In doing so, he noted that emotions themselves were not maladaptive or problematic in and of themselves but rather that the tim- ing and intensity of these emotions could be problematic. Furthermore, it has long been known that individuals differ in the ways in which they appraise their emotions (Gross & John, 1995; 1998). Subsequently, these appraisals contribute to whether emotions are perceived as aversive or nonaversive and whether the person attempts to avoid, escape or embrace them. If the emotion is perceived as aversive and undesirable, the individual is more likely to attempt to regulate the emo- tion than if the emotion is viewed as pleasant and desirable. Unfortunately, all attempts to regulate aversive emotions are not effective—âs•‰ ome attempts, in fact, lead to undesirable effects and their exacerbation. Given these relations, it is no surprise that emotion regulation and its associated deficiencies are intimately associated with the anxiety disorders and have been examined exten- sively over the years (e.g., Amstadter, 2008; Davidson, 1998; Kring & Werner, 2004). In this chapter, we will first briefly review the anxiety disorders of childhood and adolescence, examining the role of emotion regulation in the onset, maintenance and expression of these dis- orders, and then highlighting evidence-âb•‰ ased interventions for these disorders that incorporate emotion and its regulation. In doing so, we hope to illustrate the complexity of these disorders and to illustrate the promise of emotion-âb•‰ ased interventions. Anxiety disorders of childhood and adolescence Anxiety Disorders are among the most commonly experienced and diagnosed conditions of childhood (see below, and Grills-âT•‰ aquechel & Ollendick, 2012). Since the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5â•‰ ) has recently been published (APA, 2013), much of the work examining the anxiety disorders has used categorizations from DSM-âI•‰V-âT•‰ R (APA, 2000). Importantly, by and large, the core anxiety disorder descriptors have remained relatively unchanged across these editions. Anxiety Disorders, however, now include two disor- ders that were previously listed under “Disorders usually first diagnosed in infancy, childhood, or adolescence” (i.e., Separation Anxiety Disorder, Selective Mutism), separates Panic Disorder and Agoraphobia into separate diagnoses, and maintains inclusion of Specific Phobia, Social Anxiety Disorder, and Generalized Anxiety Disorder. In addition, criteria for separate Substance/â•‰ Medication Induced Disorders and diagnoses “Due to Another Medical Condition” (e.g., Anxiety

51 Anxiety disorders of childhood and adolescence 155 Disorder Due to Another Medical Condition) are included. Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder, previously included in the Anxiety Disorders, are now placed in separate diagnostic categories, Obsessive-C ompulsive and Related Disorders and Trauma-and Stressor-R elated Disorders, respectively. Based on the DSM-IV-TR (2000) criteria (as well as those put forth in DSM-5) the anxiety disorders diagnosable in childhood and adolescence have several features in common, includ- ing: 1) Persistent and excessive anxious arousal, and 2) symptoms that cause clinically significant distress or impairment in social, academic, and other important areas of functioning. The dif- ferent disorders vary primarily according to the stimuli eliciting anxiety in these disorders. In addition, although anxiety disorders are among the most commonly diagnosed disorders of child- hood, prevalence rates vary by disorder. Each of the disorders is briefly described. Significant anxiety regarding separation from home or individuals to whom the child is attached is the hallmark of Separation Anxiety Disorder (SAD). Children must show at least three of eight symptoms, with onset of these symptoms usually before age 18 years, and they must have the symptoms for at least four weeks to receive a diagnosis of SAD. Associated features include: per- sistent reluctance to attend school, remain alone, or go to sleep without a major attachment figure nearby, as well as nightmares involving the theme of separation and the presence of a number of physical complaints when separation occurs or is anticipated. The prevalence of SAD is reported to be between 1–4 %, with rates decreasing as children get older (Brückl et al., 2007; Canino et al., 2004; Egger & Angold, 2006; Merikangas, He, Burstein, et al., 2010). Social Anxiety Disorder (SOC), previously referred to as Social Phobia, is characterized by excessive and persistent (typically lasting for six months or more) fear and avoidance of social situations or situations where scrutiny could lead to embarrassment. Children with SOC may not be aware that their fears are unreasonable and/o r excessive and may express their distress through crying, tantrums, freezing, clinging, or shrinking from social situations with unfamiliar people. The feared stimuli (i.e., social situations) with SOC are typically avoided or endured with intense distress that may take the form of a panic attack in some cases. To be diagnosed with SOC, a child needs to demonstrate age-appropriate social relationships with familiar people and to display avoidance in interactions involving peers as well as adults. Prevalence rates for SOC are typically reported between 1–3% but also vary by age with increasing rates seen in adolescents (Canino et al., 2004; Egger & Angold, 2006; Essau, Conradt, & Petermann, 2000; Roberts, Roberts, & Xing, 2007; Wittchen, Nelson, & Lachner, 1998). Often considered similar to SOC in its focus on socialization and interpersonal relationships (Muris & Ollendick, 2015), Selective Mutism (SM) is diagnosed when a child refuses to speak in specific social situations (e.g., school, community, clinic) despite the ability to do so. Such refusal to speak must occur for at least one month with interference occurring in educational/occupa- tional, achievement or social communication domains. However, SM is not diagnosed when symptoms occur only within the first month of school or because of language/communication issues. Associated features include social concerns, shyness, or other anxiety symptoms and the prevalence of SM is thought to be quite small (i.e., <1%; Egger & Angold, 2006). Once referred to as Overanxious Disorder, Generalized Anxiety Disorder (GAD) is character- ized by excessive anxiety and worry about several different domains in the child’s life. The worry experienced by a child with GAD is often reported to be uncontrollable and occurs more days than not, typically for the past six months. Children must also exhibit at least one of the following six physical/somatic symptoms: 1) Restlessness or feeling keyed up or on edge; 2) easily fatigued; 3) difficulty concentrating or mind going blank; 4) irritability; 5) muscle tension; and 6) sleep disturbance. The worries reported by children with GAD are similar to the worries of children without GAD and vary primarily in terms of their frequency, intensity and duration. Some of the more common worries reported by children concern evaluation by others, perfectionism, health

651 156 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment of significant others, and catastrophic events. Prevalence rates have been reported to vary widely 1–4% (Canino et al., 2004; Egger & Angold, 2006; Lavigne, LeBailly, Hopkins, Gouze, & Binns, 2009; Merikangas, He, Burstein, et al., 2010; Wittchen, Zhao, Kessler, & Eaton, 1994). Specific Phobias (SP) are excessive and persistent (typically lasting 6 months or longer) fears of explicit objects or situations, which are typically avoided or endured with intense anxiety or distress. Exposure or anticipation of exposure to the feared stimulus results in extreme anxiety including panic attacks in some cases. Children may not be cognizant of the unreasonable or excessive nature of their fears and may express their fear by crying, throwing a tantrum, freez- ing, or clinging. At a clinical level, phobias tend to be involuntary, inappropriate, and limiting to a child’s quality of life (Anderson, 1994; Essau et al., 2000). Specific phobias can be speci- fied as falling into one of the following subtypes: Animal (e.g., snakes, spiders, dogs), Natural Environment (e.g., storms, heights, water), Blood-Injection-Injury (e.g., seeing blood, getting an injection, receiving an injury), Situational (e.g., tunnels, flying, enclosed places), or Other (e.g., choking, loud sounds, costumed characters). Prevalence rates vary by child age and gender but are typically reported to range from 2–6 % (Burstein et al., 2012; Egger & Angold, 2006; Essau et al., 2000; Wittchen et al., 1998). Panic Disorder (PD) and Agoraphobia (AG) are each diagnosed separately in DSM-5. The hallmark symptom of panic disorder is the recurrence of panic attacks, which are acute and extreme feelings of anxiety that occur unexpectedly and are followed by one month or more of persistent concern about having another attack, worry about the consequences of the attack, or a change in behavior related to the attack. Agoraphobia is characterized by excessive anxiety resulting from situations in which escape or avoidance may be inhibited or in which help may not be available if panic symptoms were to occur. Panic Disorder and Agoraphobia are among the less commonly diagnosed anxiety disorders during childhood, with prevalence rates of about 1–3 % increasing into adolescence and adulthood (Canino et al., 2004; Doerfler, Connor, Volungis, & Toscano, 2007; Essau et al., 2000; Merikangas, He, Brody et al., 2010; Ollendick, Birmaher, & Mattis, 2004; Roberts et al., 2007; Wells et al., 2006; Wittchen et al., 1998). Although the stimuli that elicit anxiety and fear in these disorders differ, the disorders all share commonalities in the expression of anxiety. Fundamentally, anxiety is an emotional state asso- ciated with heightened physiological arousal and behavioral avoidance that is triggered by the perception of real or imagined threat. At times, these perceptions can be distorted and the threat is exaggerated well beyond the real threat imposed by the stimulus. As Barlow (1991) noted, how- ever, this emotion can be adaptive and can lead to constructive attempts to handle the threat and to prepare the organism for adaptive change and growth; however, at other times, the emotion is intense, frequent, and durable as in an anxiety or phobic disorder and it becomes less adaptive and leads to a host of problems, including academic, behavioral, and social difficulties (Grills- Taquechel & Ollendick, 2012). The etiology of the Anxiety Disorders is complex and not straightforward. Equifinality (i.e., multiple pathways to any one outcome; Cicchetti & Toth, 1991) is the most succinct way to describe the etiology of anxiety and its disorders in children. Indeed, fears and anxieties in chil- dren have been described as multiply determined if not over-determined (Marks, 1987; Ollendick, 1979; Weems & Stickle, 2005). Contemporary etiological models reflect this heterogeneity with consideration of various influences that cut across personal-social-ecological systems and typi- cally include biological, developmental, psychological, social, and environmental components (e.g., Grills-Taquechel & Ollendick, 2012; Hirshfeld-B ecker, Micco, Simoes, & Henin, 2008; Vasey & Dadds, 2001). Biological contributions have been well documented in familial, twin, and genetic research studies, as have various connections with early developmental behaviors

751 Avoidance, Cognitions and Physical Symptoms 157 (e.g., temperament, attachment) and child dispositional characteristics (e.g., anxiety sensitiv- ity, cognitive biases, and emotion regulation difficulties). Family influences, beyond genetics, have also received a great deal of research attention in the past several decades. Research in this domain has generally concentrated on anxious parenting behaviors and child-âr•‰earing practices. For example, several investigators have drawn upon Rachman’s (1977) influential work denoting three common pathways for fear acquisition and suggested parenting practices that may result in heightened child anxiety. Indeed, using a variety of paradigms (e.g., cross-sâ•‰ ectional, longitudinal, observational, experimental), researchers have demonstrated the influences of parental model- ing of anxious behaviors, conveying anxiety-âp•‰ rovoking information, and reinforcing anxious behaviors displayed by their children (cf, Beidel & Turner, 1998; Fisak & Grills-Tâ•‰ aquechel, 2007; Grills-âT•‰ aquechel & Ollendick, 2012; Muris, van Zwol, Huijding, & Mayer, 2010), as well as for parent-âr•‰ earing behaviors characterized by rejection, control, and overprotection (cf., DiBartolo & Helt, 2007; Ollendick & Benoit, 2012; Rapee, 1997). Importantly, however, there is no single or direct cause of anxiety disorders in children and ado- lescents. As noted by Thompson (2001, p. 160), “the action is in the interaction” among multiple internal and external influences that contribute to their onset and expression. For example, tem- peramental vulnerability as shown in behavioral inhibition may not determine alone the develop- ment of an anxiety disorder but in combination with other influences it may play an important role (Ollendick & Benoit, 2012). Temperamental inhibition may serve to sensitize young children to anxiety-âp•‰ roducing stimuli in a manner not seen in children who are not behaviorally inhibited. So, too, anxiety sensitivity, emotion regulation difficulties, and parenting practices may function in similar ways—tâ•‰hey can heighten the aversive response to the feared stimuli and contribute to an accumulation of risk over time (Thompson, 2001). Such a conceptualization of how children develop anxiety disorders sheds light on how children with a biological disposition to experience anxious feelings easily and who avoid situations that elicit intense emotions might develop anxiety disorders through a dynamic interplay between parental reactions, feedback from the environment and their own biased cognitions and expecta- tions of how the world works for them. However, as noted, the process is not a straightforward one; difficulties with emotion regulation, like other risk factors, can set the stage for the onset of anxiety disorders but do not directly cause them. In the next sections, research is reviewed on emotion regulation and the role it plays in the development and maintenance of anxiety disorders in children and adolescents and how emerg- ing knowledge on emotion regulation might improve and increase the effectiveness of cognitive-â•‰ behavioral treatment (CBT) for anxiety. Recent findings on emotion knowledge and emotion regulation strategies among children with anxiety are reviewed and discussed in light of new trends in treatment development, such as emotion-âf•‰ocused CBT (e.g., Suveg, Kendall, Comer, & Robin, 2006), so that current treatment programs can become more effective for a larger group of children. In addition, the role of parents in modeling emotion regulation skills for anxious youths are discussed in terms of developmental psychopathology and the implications for treatment pro- grams currently in use are evaluated. Avoidance, Cognitions and Physical Symptoms As noted, in the past ten to 15 years, an increased focus has been placed on examining the role of emotion knowledge, emotion understanding and emotion regulation skills in developing and maintaining anxiety disorders among children (Hannesdottir & Ollendick, 2007; Southam-â•‰ Gerow & Kendall, 2002; Suveg & Zeman, 2004; Thompson, 2001). Research has been aimed at examining negative emotions among children with internalizing problems (anxiety and/âo•‰ r

851 158 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment depression) in general and how they are perceived and handled, such as anxious feelings, sad- ness, and anger alike. Collective evidence suggests that children with internalizing disorders seem to have problems managing negative emotions in general (Trosper, Buzzella, Bennett, & Ehrenreich, 2009), not just emotions relating to their specific problems and the nature of their disorder. Cognitive aspects of emotion regulation and anxiety Initial studies on emotion understanding and regulation in developmental and developmental psychopathology research revealed that children’s use of planned and goal directed strategies to control their emotions increased as their ability for effortful control and executive function capac- ity was realized (Eisenberg & Morris, 2002). The normal course of emotion development suggests that children’s emotion regulation skills are dependent on knowledge of how emotions work and what is appropriate to express (Kail, 2007), what emotion regulation strategies are most effective in certain situations (Southam-Gâ•‰ erow & Kendall, 2002), and the modeling of emotion regulation competence by parents (Eisenberg, 1998). With regard to children with anxiety, various studies have shown that they tend to interpret ambiguous situations as more threatening than they actually are (Chorpita, Albano & Barlow, 1996) and that they are hypervigilant with regards to information relating to potential threats in their environment (Vasey & MacLeod, 2001). In addition, children with anxiety seem to have more limited knowledge compared to non-aâ•‰ nxious children in terms of when it is appropriate to “hide” their emotions and that it is possible to actually change and control their emotions (Southam-âG•‰ erow & Kendall, 2000). Children with anxiety also seem to experience negative emotions more intensely than non-â•‰ anxious children. For example, in one study children were asked to engage in reappraisal to decrease negative emotions after seeing mildly disturbing pictures. Children diagnosed with anxiety reported experiencing negative emotions in response to such scenarios more intensely than the non-âa•‰ nxious group and had a more difficult time reappraising the situation to improve their mood (Carthy, Horesh, Apter, Edge, & Gross, 2010). In another study conducted by the same research group (Carthy, Horesh, Apter, & Gross, 2010), it was shown that anxious youths not only had difficulties with reappraisal strategies but also engaged in more avoidant (e.g., I will ask to go to the bathroom in school as so to miss my turn to talk about my project; I will pretend my leg hurts so I cannot go outside where there might be bees or wasps) and inap- propriate support-sâ•‰ eeking strategies (e.g., I will ask my dad to do it for me; I will ask my mom to come and lie down with me to fall asleep). These authors also showed low levels of self-â•‰ efficacy relating to regulating emotions in these anxious youths. Similar findings have emerged in other studies where children with anxiety have been shown to have difficulty managing nega- tive emotions in general (worry, sadness and anger), experience such negative emotions more strongly, and have reduced self-âe•‰ fficacy in their ability to change their emotional state (Suveg & Zeman, 2004). Thus, with regard to emotion regulation, children with anxiety tend to engage in select strate- gies to calm themselves down when faced with emotionally difficult situations. As noted, they tend to use ineffective emotion regulation strategies for the given situation. They tend to rely too much on others to help them reduce negative feelings and are less likely to use problem-sâ•‰ olving methods in anxiety provoking situations. In many respects, they select emotion regulations strate- gies that work to reduce negative feelings in the short run but are detrimental in the long run (e.g., avoidance or escape; Carthy et al. 2010; Trosper et al., 2009). Thompson and Calkins (1996) refer to these strategies as “two-âe•‰ dged;” they reduce anxiety in the short term but lead to more anxiety and impairment in the long term.

951 Avoidance, Cognitions and Physical Symptoms 159 Behavioral factors and emotion regulation skills Not only do anxious children tend to view negative emotional experiences differently than non-â•‰ anxious children and have difficulty reappraising emotionally provoking situations, they also engage in various strategies that help them avoid experiencing these negative situations. As noted, such strategies can be efficient in terms of regulating negative emotions in the short run but serve to maintain the anxiety disorder, making it necessary for the child to escape the anxiety provok- ing situation each time it is encountered. Behavioral emotion regulation strategies (i.e., strategies intended to prevent or modify negative emotional experiences) are described by Gross (1998) as situation selection and situation modification strategies. An example of a situation selection emo- tion regulation strategy for a child with a specific phobia of heights would be that the child might feign illness on the day of a school trip to an amusement park to avoid riding on a roller coaster with her friends. Similarly, a child who is socially anxious might avoid social interactions with a group of peers by insisting that she wants to stay home and finish a book or work on her stamp collection. Anxious children also try to modify situations in an effort to regulate their emotions. Examples of such efforts might be the use of safety signals and maintaining routines and rituals. For example, a child with fears of being alone and separation anxiety might agree to stay in the car while her father runs into the house to get something only if her one-yâ•‰ ear old brother is also in the car or if she can stay on the phone with her father constantly while he goes inside. Children with anxiety usually have a wide range of avoidance and escape strategies that serve to shelter them from experiencing negative emotions (fear, worry, embarrassment, etc.). While such strategies are useful for short-tâ•‰erm goals such as making the child feel better in the situation, these strategies prevent the child from learning that they can handle this particular situation and that the feared consequences usually do not occur. Thus, providing anxious children with different behavioral strategies in treatment and having them practice them in session (e.g., through exposure) and at home can prove essential for changing the course of their anxiety and the impairment their disor- der causes on a daily basis due to avoidance. Physiological factors of emotion regulation and anxiety In various studies, children with anxiety have reported that they experience negative emotions, such as anxiety, more intensely than other children (e.g., Carthy et al., 2010; Suveg & Zeman, 2004). To complicate the picture of whether children with anxiety actually have a lower threshold in their sympathetic nervous system for experiencing anxiety and negative emotions, anxious children also report that they are hypersensitive to bodily cues that they believe signal negative emotions (Thompson, 2001). They also tend to have catastrophic beliefs and lower tolerance regarding experiencing physiological symptoms of anxiety, that is, high anxiety sensitivity (Reiss, Silverman, & Weems, 2001). The question that needs to be answered is therefore, whether it has been shown that children with anxious dispositions or temperament are likely to be more physi- ologically reactive in stressful situations and whether they have a harder time regulating their emotions and calming down. Indeed, various studies have shown that this pattern emerges both for very young and somewhat older children. For instance, infants and toddlers who show withdrawal behaviors, fearfulness and distress in new and unfamiliar situations and are considered to have a behaviorally inhib- ited temperament have been shown to demonstrate greater right frontal EEG symmetry patterns opposed to more outgoing children (e.g., Fox, Bell & Jones, 1992; Fox, Henderson, Rubin, Calkins, & Schmidt, 2001). Behaviorally inhibited temperament, especially when stable throughout early childhood, has been shown to increase the chances of children developing anxiety disorders later on in childhood (Hirshfeld et al., 1992; Ollendick & Hirshfeld-âB•‰ ecker, 2002).

061 160 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment A few studies have also shown that this pattern of increased reactivity in infancy and early childhood is predictive of physiological reactivity and emotion regulation difficulties in later childhood. For instance, McManis and colleagues demonstrated a link between high reactiv- ity to stress in infancy and right frontal asymmetry activation patterns among these children at the age of ten to 12 years while performing a stressful speech task (McManis, Kagan, Snidman, & Woodward, 2002). Similar findings were obtained in another study where right frontal EEG activation patterns at approximately four years of age predicted increased heart rate and slower cardiovascular recovery after a stressful speech task at age nine in a small sample of non-aâ•‰ nxious children (Hannesdottir, Doxie, Bell, Ollendick, & Wolfe, 2010). Concurrent studies on anxious youths have also shown this pattern of cortical activation patterns emerging when anxious chil- dren are faced with stressful situations. Hum and colleagues found that children with anxiety showed heightened attention and arousal in response to a task with various emotion faces (both positive and negative) while the non-aâ•‰ nxious control group showed differential patterns of activa- tion dependent on whether the faces were angry, sad, or happy (Hum, Manassis, & Lewis, 2013). These results indicated that children with anxiety experienced heightened reactivity and were engaged in a process of emotion regulation simply by being shown faces of people; irrespective of what emotions those faces were showing. Overall, the studies that have examined physiological reactivity, cerebral activation patterns and emotion regulation among children with anxiety support the notion that these children experi- ence heightened arousal easily and have a lower sympathetic activation threshold compared to less anxious children (cf., Beauchaine, 2015). In addition, these children may need to put more effort into regulating such intense emotions and into recovering from them, while not being able to allocate their cognitive resources elsewhere at the same time. This may in turn limit their abil- ity to perform well in a particular situation (e.g., a socially anxious child speaking in front of the class) or to think rationally to reduce catastrophic beliefs in the situation (e.g., a separation anxious child convincing herself that her mother is simply running late and has not been in a car accident). Thus, strong physiological reactivity to anxiety provoking situations and considerable emotion regulation efforts in such situations may play a large role in maintaining anxiety disor- ders among children and reinforce avoidance and escape behaviors. Parental reactions and child anxiety Emotion regulation skills in children do not develop in a vacuum. From the day they are born infants seek out comfort from their caregiver when distressed and through the years learn how to become more and more independent in terms of understanding and managing positive and negative emotions in various situations through socialization by their caregivers, teachers and peers (Dunsmore & Halberstadt, 1997; Eisenberg, 1998; Halberstadt, Denham, Dunsmore, 2001; Thompson, 2001). It is also important to keep in mind that from early on caregivers often choose which situa- tions their children experience (e.g., situation selection, see Gross, 1998). Therefore, when parents know that their child fears certain situations and believe that their child would not be able to cope with experiencing fear, worry, sadness or some other negative emotions in particular situations, parents are likely to help their child avoid or escape such situations. Such situation selection or assisted avoidance will in turn increase the child’s anxiety regarding the feared object or situation and deprives the child of the opportunity to obtain new information on the feared object and to correct catastrophic beliefs. Another reason for encouraged avoidance might be that the parent, who might be anxious himself, believes he will not be able to cope with seeing his child experience distress and therefore helps the child avoid these situations all together. This works well for the

16 Parental reactions and child anxiety 161 parent while the child is still relatively young (about birth to five years of age) and the parent is able to control and select situations for the child. However, when children become more indepen- dent and enter the school system the parent has less and less control over which situations their children will find themselves in and then anxiety may become more debilitating for them and more distress will be evident in their daily lives. Numerous studies have shown that parents of anxious children tend to do exactly this. For example, parents of anxious children have been found to be more overinvolved and intrusive, allowing avoidance of uncomfortable situations and less encouraging of autonomy than parents of non-a nxious children (e.g., Barrett, Rapee, Dadds, & Ryan, 1996; Hudson, Comer, & Kendall, 2008; Hudson & Rapee, 2001; Hurrell, Hudson, & Schniering, 2015). Studies on emotion social- ization have also shown that parents of anxious children, especially mothers, tend to show greater intrusiveness even when simply discussing previously experienced emotionally arousing negative situations (anxiety or anger) in a structured interaction task as opposed to parents of non-a nxious children or when discussing happy events and positive emotions (Hudson et al., 2008). In addi- tion, the way children with anxiety interpret ambiguous situations as threatening may impact subsequent conversations and discussions with parents (Chorpita, Albano, & Barlow, 1996). Therefore, children who develop anxiety disorders may have had fewer opportunities to prac- tice discussing and experiencing negative emotions and figuring out ways to manage their emo- tions since their parents have often been too quick to assist them in avoiding or escaping negative emotion situations or taking over the situation themselves. When the parent takes over the situ- ation or removes the child from a mildly threatening or embarrassing situation (e.g., the child is asked their name at a family party but cannot utter a single word due to shyness), the child learns indirectly that 1) “this was in fact a dangerous situation since my parent felt the need to rescue me,” and 2) “I cannot take care of it myself and I need to be rescued from such situations.” In one recent study, Suveg, Morelen, Brewer, and Thomassin (2010) explored behavioral inhi- bition (a temperament characteristic associated with anxiety, as seen earlier in the chapter) and family emotional environment (restricted expressiveness, as seen earlier in the chapter) and their associations with anxiety in a sample of late adolescents. They also examined whether emotion regulation mediated these relationships. They argued, as above, that emotional reactivity as seen in behaviorally inhibited youths would lead these youths to be “keyed up” or “wired,” making emotional regulation more difficult and anxiety more probable. Similarly, they argued that the family emotional environment would influence emotion dysregulation through a failure to appro- priately socialize the emotion understanding and regulation skills necessary for adaptive func- tioning, also resulting in increased anxiety. Basically, consistent with their hypotheses, they found that a measure of emotion regulation fully mediated the relationship between behavioral inhibi- tion and anxiety and partially mediated the relationship between family emotional environment and anxiety. Thus, these risk factors, in tandem, were related to anxiety but mostly through their effects on emotion regulation. In sum, children with anxiety have less knowledge of emotion and emotion regulation strate- gies, have fewer ways of solving problems in emotionally arousing situations, show higher emo- tional reactivity, and have a more difficult time calming down. In addition, because the child’s anxious behavior often elicits overprotective behavior from the parent (Rapee, Lau, & Kennedy, 2010), parents of anxious children are more likely to accept their avoidance behavior, be overly intrusive, and encourage less autonomy and expression of emotions compared to parents of chil- dren without anxiety. Therefore, it is important when reviewing the role of emotion regulation in child anxiety and its implications for treatment that treatment components focusing on emotion and emotion regulation are included in programs for child anxiety reduction and that their par- ents are included to some extent in the treatment of their children.

261 162 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment Current CBT programs for child anxiety Various CBT programs have been developed to treat children with anxiety and to help them overcome their fears and modify their maladaptive behaviors. For instance, the Coping Cat pro- gram (Kendall, 1994; Kendall & Hedtke, 2006) and the Cool Kids program (Lyneham, Abbott, Wignall, & Rapee, 2003) were developed for treatment of school-aâ•‰ ged children with various anx- iety disorders. One-âs•‰ ession treatment (OST) was developed for treatment of children with a vari- ety of specific phobias (Ollendick et al., 2009, 2015; Öst, Svensson, Hellström, & Lindwall, 2001). Recently, less intensive programs have been developed for parents of children with anxiety, such as Cool Little Kids for preschool children (Rapee, Lau, & Kennedy, 2010) and From Timid to Tiger (Cartwright-Hâ•‰ atton, 2010) for somewhat older children. The focus of these various programs has been mostly on modifying maladaptive and catastrophic thoughts associated with anxiety and changing maladaptive, avoidance responses. Little or no attention has been paid to emotions or emotion regulation skills in these programs. For the most part, the children are not taught how to manage their emotions more skillfully or how their emotions are entwined with cogni- tions and behaviors. In order for children to learn how to overcome, manage, or at least endure anxiety and other negative emotions, some teaching and skill building in the emotion area seems necessary. As has been pointed out by several researchers (e.g., Hannesdottir & Ollendick, 2007; Trosper et al., 2009; Suveg et al., 2006), despite a fairly high success rate of these CBT programs in reducing clinical problems and anxiety (e.g., Kendall, Hudson, Choudhury, Webb, & Pimentel, 2005; Ollendick et al., 2009, 2015; Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005), it is possible that the children who remain symptomatic (up to one-tâ•‰ hird to a half) and are still meet- ing clinical diagnosis after CBT treatment, might benefit more if an emotion component were included in their treatment. Treatment gains might more likely be increased if emotions and emotion regulation skills were targeted more specifically in these well-eâ•‰ stablished and evidence-â•‰ based programs. Recently, treatment programs have been developed to focus more specifically on emotions and building emotion regulation skills for children and adolescents with anxiety. In one of the first efforts, Suveg and colleagues (Suveg et al., 2006) developed a modified version of the Coping Cat program called Emotion-Fâ•‰ ocused Cognitive-âB•‰ ehavioral Therapy (ECBT) where an emotion component was added to each of the 16 sessions of the CBT program. Components such as iden- tifying and discussing emotions associated with anxiety-pâ•‰ roducing situations, learning how to identify different kinds of emotions and not just anxiety (e.g., sadness, anger, guilt, jealousy, pride, and happiness), solving ambiguous emotion vignettes, and learning how to regulate both anxious feelings and other emotional feelings (e.g., guilt, sadness, etc.), completing exposure tasks that elicit not only anxiety but these other emotions as well (e.g., sadness, anger), and learning how to regulate these emotions have all been included (Suveg et al., 2006). Results from a multiple base- line study with six children on ECBT indicated that the children not only reduced their anxiety level but they also improved their emotion understanding of various emotions and emotional states and increased their knowledge of emotion regulation strategies. However, only four of the six children were diagnosis free—â6•‰ 7%, a rate almost identical to that observed in the standard CBT program (e.g., Kendall, 1994). Subsequently, these authors examined changes in emotion-â•‰ related functioning following the standard Coping Cat program for anxiety (Suveg, Sood, Comer & Kendall, 2009) and found that standard CBT did not improve children’s broad emotion regula- tion skills. Thus, although the ECBT program appears promising, it needs to be further evaluated with a larger sample and to be compared directly to standard CBT for children to evaluate what changes in emotion knowledge and emotion regulation occur and how critical these changes are for enhanced outcomes (Suveg et al., 2006).

361 Current CBT programs for child anxiety 163 Another program focusing specifically on improving emotion understanding and emotion regulation skills has been developed for adolescents with emotional problems, anxiety and/o r depression. A program called the Unified Protocol for the Treatment of Emotional Disorders in Youth (UP-Y ) was developed by Ehrenreich and colleagues to address the comorbid and not nec- essarily well defined emotional problems that adolescents often face and have overall difficulties in managing (Trosper et al., 2009). Emotion components in their program include, among several others, increased awareness of emotional states, learning how to manage crisis situations, emotion exposure, and motivational enhancement. Results of an open trial investigation of UP-Y revealed a reduction in clinical severity for both adolescents with anxiety or anxiety and depression, a reduction in overall emotion dysregulation, and improved coping with worry and anger (Trosper et al., 2009). Again, however, this program too resulted in about 67% of the youth being diagnosis free following the intervention. This program is now being modified and examined for seven to 12 year old children who have anxiety disorders and depressive symptoms. For this age group the program is called Emotion Detectives (Ehrenreich-May & Bilek, 2012). Two new developments have targeted parents and their emotion regulation difficulties to address anxiety in children. In the Cool Little Kids program (Rapee, Lau & Kennedy, 2010), a new anxiety prevention program intended for parents of preschool children who are showing the first signs of anxiety, parents learn various skills intended to change maladaptive responses they show with their children. Among various skills the parents learn is how to inhibit themselves from jumping in too quickly when the child is faced with a mild anxiety-provoking situations and therefore, allowing the child to develop tolerance for the negative emotion and practice their own emotion regulation skills. This particular program has shown beneficial effects in reducing early anxiety symptoms and the effects are maintained for at least one year following treatment (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2005). One of the goals of the Cool Little Kids program is therefore, to reverse a maladaptive response cycle between parent and child in which the parent allows the child to avoid or escape anxiety provoking situations and instead the child learns to face such situations through modeling, practice and simple graduated exposure exercises. Teaching parents of young anxious children these skills and modifying overprotective parenting tenden- cies early on seems important to inhibit the development of anxiety disorders since studies have shown that these parents are more likely to accept their children’s avoidance behavior and dis- courage autonomy. The SPACE program addresses similar parenting issues in older children and adolescents diag- nosed with anxiety disorders (Lebowitz & Omer, 2013). It is based on a family systemic model of anxiety and addresses the delicate interplay between child and parent interactions that serves to maintain anxiety in the child. In contrast to standard CBT, it aims to promote coping, minimize avoidance, facilitate exposure, and address catastrophic thinking in the child, SPACE addresses parental overprotective and accommodating behaviors. As noted by Lebowitz and Omer, parental overprotectiveness and accommodation of the anxious child may encourage the ongoing reli- ance of the child on the parent for regulating and helping them manage their emotional state. In effect, these parental behaviors serve to maintain the very behaviors they are intended to change. In this program, the intervention targets the problematic parental behaviors and the need for parents to model emotion regulation skills themselves. As such, the program focuses entirely on the parents’ behaviors and emotions. More specifically, parents are encouraged to model use of self-r egulation skills to better cope themselves with their child’s distress in the anxiety-p roducing situation. Parents are informed that by applying these self-regulation skills to themselves when they are feeling overwhelmed by the child’s distress (and likely to overprotect or accommodate), the cycle linking their behavior and the child’s anxiety can be broken. Initial findings in an open trial with ten anxious children and their families appear promising as significant improvements

461 164 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment in child anxiety were evidenced as were improvements in parents’ own self-râ•‰egulation skills and reductions in parental accommodation of the child’s anxiety (Lebowitz, Omer, Hermes, & Scahill, 2014). Again, however, only six of the ten children were designated as treatment responders—aâ•‰ rate remarkably similar to the other emotion-bâ•‰ ased interventions and the standard evidence-â•‰ based treatments. Future direction and conclusion Although significant progress has been made in the understanding of emotions and the role of emotion regulation in the onset, expression, and course of anxiety disorders in children and ado- lescents as well as the treatment of these disorders, much work remains to be accomplished. For example, how we define and measure emotion regulation and its dysregulation remains contro- versial (see chapters in this volume; also White, Mazefsky, Dichter, Chiu, Richey, & Ollendick, 2014). As noted by White and colleagues, at the basic science level, there are various social-â•‰ cognitive (e.g., emotion awareness, recognition, and accurate expression as well as attention, working memory, and cognitive control processes), physiological (e.g., cardiovascular activity, skin conductance responses, pupillometric indices), and neural mechanisms (e.g., neural connec- tivity among socio-âa•‰ ffective regions in the brain) that underlie emotion regulation deficits in chil- dren and adolescents. These mechanisms and others are poorly understood but are being actively explored in greater detail at this time (see Chapters 2–5â•‰ of this volume). Thus one may conclude we have much to learn about emotion regulation and how it “works” at the basic science level. So, too, we need to see advances in how we measure emotion regulation in youths. To date, we have relied largely upon self-âr•‰eport measures to assess emotion regulation difficulties as exem- plified by the Emotion Regulation Checklist (ERC; Shields & Cicchetti, 1997), the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004), and the Children’s Emotion Management Scales (CEMS; Zeman, Shipman, & Penza-Câ•‰ lyve, 2001). Although these scales have been shown to be reliable and related positively to one another, they have not been carefully vali- dated against behavioral, physiological, or neural measures of dysregulation. As a result, it is diffi- cult to compare and contrast the various studies. Thus, we need more consistent and standardized measures that entail multi-mâ•‰ ethod and multi-âi•‰nformant strategies (see McLeod, Jensen-âD•‰ oss, & Ollendick, 2013, for more detail). In the treatment realm, we need randomized control trials comparing any one of the four innovative and emotion-bâ•‰ ased programs described above to “treatment as usual” and, ideally, to standard CBT programs. To date, the evidence supporting these “newer” programs is sparse and consists largely of small pilot studies and single case studies. We really do not know whether they are more effective than the more standard clinic-âb•‰ ased or research-âb•‰ ased interventions. In fact, to date, these programs do not appear to be more effective than the standard ones. As these studies are undertaken, it will be important to explore the effective ingredients in these programs through dismantling strategies. We really do not know what it is about these newer emotion-bâ•‰ ased treat- ments that contribute to their effectiveness. As but one example, the first eight sessions of the 16-âs•‰ ession protocol for EBCT are focused primarily on education and the development of skills to identify and manage broad emotional experiences (Suveg et al., 2006). Are these initial sessions really necessary? Or, would the program be more effective if greater emphases were placed on the last half of the 16-âs•‰ ession treatment which is focused on exposure tasks that provide the child opportunities to gain mastery over various emotions in addition to anxiety during actual anxiety-â•‰ producing situations? Such may seem unexpected but this is exactly what has been found with the standard Coping Cat program in which the first eight sessions are not found to produce reliable changes in avoidance behaviors (Kendall, 1994).

561 Future direction and conclusion 165 Furthermore, following these studies, it will be important to compare the relative efficacy of parent-bâ•‰ ased interventions such as the Supportive Parenting for Anxious Childhood Emotions (SPACE) program (Lebowitz & Omer, 2013; Lebowitz et al., 2014) to the more child-âf•‰ocused interventions such as Emotion Focused CBT (ECBT; Suveg et al., 2006; Suveg, Davis, & Jones, 2015) and the UP-Yâ•‰ ; (Ehrenreich-Mâ•‰ ay & Bilek, 2012; Trosper et al., 2009). In doing so, it will be important to examine moderators of change in these distinctly different approaches (see Maric, Prins, & Ollendick, 2015). For which families does a more parent-fâ•‰ocused intervention work better? It certainly seems plausible that the SPACE program might be more appropriate and thus more effective in families in which the parents accommodate their child’s emotional dis- plays and show poor emotion regulation strategies themselves. After all, the program is specifi- cally designed to alter parent behavior, which is then hypothesized to result in changes in their child’s anxiety. So, too, of course might the UP-âY•‰ and EBCT programs work best for children and adolescents who themselves display emotion regulations difficulties. In one of our recent trials (Ollendick et al., 2015), for example, only about one third of the anxious children exhib- ited emotion regulation difficulties. For these children adding an emotion regulation compo- nent makes good sense; for the other two thirds it might not. We might also consider whether emotion regulation training would benefit some subgroups of children with anxiety disorders more so than others. For example, since there is considerable overlap in symptomatology for children with anxiety/âw•‰ orry and depression (Cummings, Caporino, & Kendall, 2014), emo- tion understanding and regulation training might benefit this group of children with comor- bid symptoms more in terms of learning how to manage and withstand negative emotions in daily life. In the final analysis and consistent with a developmental psychopathology framework (Cicchetti & Rogosch, 1996; Lease & Ollendick, 2000), multiple pathways to anxiety disorders exist and it will be important to tailor our interventions to the specific pathways involved for any one child with an anxiety disorder. Thus, although much has been accomplished, continued progress is needed before we fully understand the parameters and underlying causes of emotion dysregulation in anxious youths and to develop, evaluate, and eventually disseminate evidence-âb•‰ ased treatments for them. Thanks to the pioneering work of Barlow (1991) some 25 years ago, we are moving in the right direction and the next generation of research holds considerable promise for reaching our goal. References Amstadter, A. (2008). Emotion regulation and anxiety disorders. Journal of Anxiety Disorders, 22, 211–‰â•221. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Press. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: Text revision (4th ed.). Washington, DC: American Psychiatric Press. Anderson, J. C. (1994). Epidemiological issues. In T. H. Ollendick, N. J. King, & W. Yule (Eds.), International handbook of phobic and anxiety disorders in children and adolescents (pp. 43–6â•‰ 5). New York, NY: Plenum Press. Barlow, D. H. (1991). Disorders of emotion. Psychological Inquiry, 2, 58–•‰7â 1. Barrett, P. M., Rapee, R. M., Dadds, M. M., & Ryan, S. M. (1996). Family enhancement of cognitive style in anxious and aggressive children. Journal of Abnormal Child Psychology, 24, 187–â•‰203. Beauchaine, T. P. (2015). Future directions in emotion dysregulation and youth psychopathology. Journal of Clinical Child and Adolescent Psychology, 44, 875–‰8•â 96. Beidel, D. C., & Turner, S. M. (1998). Shy children, phobic adults: Nature and treatment of social phobia. Washington, DC: American Psychological Association.

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961 Future direction and conclusion 169 Rapee, R. M. (1997). Potential role of childrearing practices in the development of anxiety and depression. Clinical Psychology Review, 17, 47–6 7. Rapee, R. M., Kennedy, S., Ingram, M., Edwards, S., & Sweeney, L. (2005). Prevention and early intervention of anxiety disorders in inhibited preschool children. Journal of Consulting and Clinical Psychology, 73, 488–4 97. Rapee, R. M., Lau, E. X., & Kennedy, S. J. (2010). The Cool Little Kids Anxiety Prevention Program— Therapist Manual. Centre for Emotional Health, Macquarie University: Sydney. Reiss, S., Silverman, W. K., & Weems, C. F. (2001). Anxiety sensitivity. In M. W. Vasey & M. R. Dadds (Eds.), The Developmental Psychopathology of Anxiety (pp. 92–111). Oxford: Oxford University Press. Roberts, R. E., Roberts, C., & Xing, Y. (2007). Rates of DSM-IV psychiatric disorders among adolescents in a large metropolitan area. Journal of Psychiatric Research, 41, 959–967. Shields, A., & Cicchetti, D. (1997). Emotion regulation among school-aged children: The development and validation of a new criterion Q-s ort scale. Developmental Psychology, 33, 906–917. Southam-G erow, M. A., & Kendall, P. C. (2000). A preliminary study of the emotion understanding of youths referred for treatment of anxiety disorders. Journal of Clinical Child Psychology, 29, 319–327. Southam-G erow, M. A., & Kendall, P. C. (2002). Emotion regulation and understanding. Implications for child psychopathology and therapy. Clinical Psychology Review, 22, 189–222. Suveg, C., Davis, M., & Jones, A. (2015). Emotion regulation interventions for youth with anxiety disorders. In T. J. Cleary (Ed.), Self-r egulated learning intervention with at-risk populations: Academic, mental health, and contextual considerations (pp. 137–1 56). Washington DC: APA Press. Suveg, C., Kendall, P. C., Comer, J. S., & Robin, J. (2006). Emotion-focused cognitive-behavioral therapy for anxious youth: A multiple-b aseline evaluation. Journal of Contemporary Psychotherapy, 36, 77–85. Suveg, C., Morelen, D., Brewer, G. A., & Thomassin, K. (2010). The emotion dysregulation model of anxiety: A preliminary path analytic examination. Journal of Anxiety Disorders, 24, 924–930. Suveg, C., Sood, E., Comer, J. S., & Kendall, P. C. (2009). Changes in emotion regulation following cognitive-behavioral therapy for anxious youth. Journal of Clinical Child and Adolescent Psychology, 38, 390–4 01. Suveg, C. & Zeman, J. (2004). Emotion regulation in children with anxiety disorders. Journal of Clinical Child and Adolescent Psychology, 33, 750–759. Thompson, R. A. (2001). Childhood anxiety disorders from the perspective of emotion regulation and attachment. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (pp. 160–182). Oxford: Oxford University Press. Thompson, R. A., & Calkins, S. D. (1996). The double-edged sword: Emotional regulation for children at risk. Development and Psychopathology, 8, 163–1 82. Trosper, S. E., Buzzella, B. A., Bennett, S. M., & Ehrenreich, J. T. (2009). Emotion regulation in youth with emotional disorders: Implications for a unified treatment approach. Clinical Child and Family Psychology Review, 12, 234–2 54. Vasey, M. W. & Dadds, M. R. (2001). An introduction to the developmental psychopathology of anxiety. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (pp. 3–26). New York: Oxford University Press. Vasey, M. W. & MacLeod, C. (2001). Information-processing factors in childhood anxiety: A review and developmental perspective. In M. W. Vasey & M. R. Dadds (Eds.), The developmental psychopathology of anxiety (pp. 253–2 77). Oxford: Oxford University Press. Weems, C. F., & Stickle, T. R. (2005). Anxiety disorders in childhood: Casting a nomological net. Clinical Child and Family Psychology Review, 8, 107–1 34. Wells, J., Browne, M., Scott, K. M., McGee, M. A., Baxter, J., & Kokaua, J. (2006). Prevalence, interference with life and severity of 12 month DSM-I V disorders in Te Rau Hinengaro: The New Zealand Mental Health Survey. Australian and New Zealand Journal of Psychiatry, 40, 845–854.

071 170 Emotion Regulation and Anxiety: Developmental Psychopathology and Treatment White, S. W., Mazefsky, C. A., Dichter, G. S., Chiu, P. H., Richey, J. A., & Ollendick, T. H. (2014). Social-cognitive, physiological, and neural mechanisms underlying emotion regulation impairments: understanding anxiety in autism spectrum disorder. International Journal of Developmental Neuroscience, 39, 212–236. Wittchen, H., Zhao, S., Kessler, R. C., & Eaton, W. W. (1994). DSM-III—R generalized anxiety disorder in the National Comorbidity Survey. Archives of General Psychiatry, 51, 355–364. Wittchen, H., Nelson, C. B., & Lachner, G. G. (1998). Prevalence of mental disorders and psychosocial impairments in adolescents and young adults. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 28, 109–126. Zeman, J., Shipman, K., & Penza-C lyve, S. (2001). Development and validation of the Children’s Emotion Management Scales. Journal of Nonverbal Behavior, 25, 187–205.

17 Chapter 9 Emotion Regulation and Depression: Maintaining Equilibrium between Positive and Negative Affect Frances Rice, Shiri Davidovich, & Sandra Dunsmuir Depression In this chapter we describe the main features of depression in children and adolescents in terms of symptomatology, epidemiology and risk factors. One way of viewing depression is as an imbal- ance of positive and negative affect systems. We take a broad view of emotional regulation as comprising responses to, interpretations of and control of emotional material affecting the bal- ance between positive and negative affect and can, therefore, influence a person’s thoughts and beliefs about themselves and the world around them. We describe cognitive behavioral therapy and behavioral activation as psychological interventions primarily aimed to alter negative and positive affect systems respectively. Depression in children and adolescents What is depression? Depression is defined by a constellation of co-oâ•‰ ccurring symptoms that cause functional impair- ment in areas such as family and peer relationships, as well as school work and participation in activities. Depression can be defined as a disorder that is either present or absent or as a dimen- sion of symptoms ranging from low to high. We first describe the criteria used to define depressive disorder in children and adolescents and then discuss the evidence for viewing depression as a continuum of symptoms. Symptoms of depression include disruptions in mood, cognition and vegetative functions, which refer to disturbances in sleep and appetite. Both of the major clas- sification systems (DSM-â5•‰ and ICD-1â•‰ 0; American Psychiatric Association, 2013; World Health Organization, 2015) use the same criteria to diagnose major depressive disorder (MDD) in chil- dren, adolescents and adults, with the exception that DSM-5â•‰ allows irritable mood instead of depressed mood as a core diagnostic symptom in children and adolescents. The ICD-1â•‰0 diagnostic system specifies the core symptoms of depression as the following: depressed mood, loss of interest or pleasure in activities and decreased energy. Associated symp- toms include loss of confidence or self-âe•‰ steem, unreasonable feelings of self-râ•‰ eproach or excessive inappropriate guilt, recurrent thoughts of death or suicide or any suicidal behavior, diminished ability to think or concentrate, change in psychomotor activity (either agitation or retardation), sleep disturbance and change in appetite with corresponding change in weight. According to ICD-â1•‰ 0 criteria, at least four of these symptoms must be present for at least two weeks to diagnose a mild depressive episode, six to diagnose a moderate depressive episode, or eight for a severe depressive episode (these symptoms must include at least two of the core symptoms described

271 172 Emotion Regulation and Depression above). Depressive disorder is usually defined by clinical interview and there are fairly rigorous quantitative and qualitative criteria for operationalizing or defining each symptom. For instance, in order to meet the criteria for depressed mood, the low mood must be present most of the time and nearly every day for at least two weeks (i.e., the “quantity” is high) and the low mood should be qualitatively different from the ordinary ups and downs of mood; for instance, it should be present to a degree that is definitely abnormal for the particular individual and should be rela- tively unaffected by external factors. The symptoms must also cause significant distress or impair- ment in social, educational or other important areas of functioning. The diagnostic criteria for depression include symptoms of both increased negative affect as well as decreased positive affect. Symptoms like low mood and irritability index, high levels of negative affect and symptoms like loss of interest or pleasure index low levels of positive affect and both are indicative of a depres- sive mood state. One way of viewing depression is as an imbalance between negative and positive affect systems (Insel et al., 2010). There is good evidence to support the validity of viewing depression as a continuous dimension of symptoms. For instance, when depressive symptoms are present but fall short of meeting the diagnostic threshold, they are still impairing (Angold, Costello, Farmer, Burns, & Erkanli, 1999; Pickles et al., 2001), increase the risk of later depressive disorder (Pine, Cohen, Cohen, & Brook, 1999) and are associated with a range of poor outcomes similar in severity to that of the diagnosis of MDD (Wesselhoeft, Sorensen, Heiervang, & Bilenberg, 2013). Depressive disorder and depres- sive symptoms are associated with a range of adverse short-tâ•‰erm and long-ât•‰erm outcomes includ- ing deliberate self-âh•‰ arm, educational failure and future depressive episodes (Angold et al., 1999; Pickles et al., 2001; Riglin, Petrides, Frederickson, & Rice, 2014; Skegg, 2005). Thus, high sub-â•‰ threshold symptoms indicate an increased probability of developing MDD and are also associated with functional impairment. The usual approach to defining severity of depression is to sum the number of symptoms endorsed; however, it is also accepted that particular symptoms may only be present at higher levels of severity and that certain symptoms, such as suicidality, may be of particular concern (National Institute for Health and Clinical Excellence, 2005). It is worth noting that there are different methods used to define depressive symptoms including semi-sâ•‰tructured interviews, structured interviews and self or parent reported questionnaires. The threshold for endorsing symptoms differs according to the method used, with the most conservative estimates of the prevalence (i.e., lower estimates) provided by semi-âs•‰ tructured interview. How common is depression in children and adolescents? The method used to assess depression estimates the rate of depression in a population during a specified time frame (i.e., prevalence estimates). MDD during childhood is relatively uncommon and prevalence estimates in a 12-mâ•‰ onth period range from 0.5–â3•‰ % (Birmaher, Ryan, Williamson, Brent, & Kaufman, 1996; Harrington et al., 1993). During adolescence, the prevalence of MDD and depressive symptoms falling below the diagnostic threshold increase dramatically (Lewinsohn, Rohde, & Seeley, 1998; Rushton, Forcier, & Schectman, 2002), particularly in girls. Estimates of the 12-âm•‰ onth prevalence of depressive disorder in adolescence range from 2–â8•‰ %. During the whole period of adolescence, around 20% of individuals will experience an episode of MDD (Birmaher et al., 1996; Costello, Foley, & Angold, 2006). In childhood, either an equal proportion of boys and girls are affected, or a slight excess of boys is affected. However, in adolescence, the ratio of affected females to males is two to one; this reflects the pattern seen in adult life where females are twice as likely to be depressed as males (Costello et al., 2006). Symptoms of depression are much more common than MDD and also increase around adolescence (Angold et al., 2002; Rushton et al., 2002).

371 Depression in children and adolescents 173 Depression in young people is under-âr•‰ecognized; studies across the world show that only a small minority of children and adolescents meeting diagnostic criteria for depressive disorder receive any kind of intervention from a health professional (Paula et al., 2014; Sayal, Yates, Spears, & Stallard, 2014; Zhong et al., 2013). This low rate of access to services is also true of individuals with known risk factors for depression such as the offspring of depressed parents (Potter et al., 2012) and young people with previous depressive episodes (Brenner et al., 2015). Various features may contribute to difficulties in identifying depression in this age group, including the presen- tation of depression (where mood may be irritable rather than depressed or low mood may be fluctuating), as well as the presence of other difficulties such as academic impairment, which may mask the underlying problem. Risk factors It is generally accepted that depression has a complex, multi-âf•‰actorial aetiology. This means there are multiple causal risk factors involved acting in concert with protective factors in complex ways. These risk and protective factors are varied (e.g., cognitive, biological, contextual) and both genes and environment are likely to contribute. In this section, we discuss factors that may be useful for identifying groups at high risk of developing depression. We also include a brief discussion about what is known about genetic and environmental risk factors. As mentioned earlier, high levels of sub-ât•‰hreshold depressive symptoms increase risk for episodes of MDD. Other important risk factors for depression in young people are depressive disorder in a parent and exposure to stress- ful life events. Children of depressed parents are around three times more likely to be diagnosed with MDD compared to the children of healthy control groups (Rice, Harold, & Thapar, 2002). Nevertheless, familial risk is not depression-sâ•‰ pecific and there is familial clustering of other types of psychopathology, such as antisocial behavior (Harrington et al., 1997) and anxiety (Rende, Warner, Wickramarante, & Weissman, 1999; Warner, Weissman, Mufson, & Wickramaratne, 1999; Weissman, Warner, Wickramaratne, Moreau, & Olfson, 1997). Stressful life events are important in the onset of depressive disorder and 60% of adolescents with depression experience an acutely disappointing life event in the month prior to the onset of depression (National Institute for Health and Clinical Excellence, 2005). Stressful events involving the loss of a significant relationship due to death or separation and acutely disappointing events, such as failing an exam, appear to be especially important in precipitating depression. Stressful life events may be particularly important in the first onset of depression, as opposed to recurrences (Kendler, Thornton, & Gardner, 2000; Monroe, Rohde, Seeley, & Lewinsohn, 1999). Depressed young people may also “evoke” or “create” stress in their lives because of the way they behave, for instance, losing a friend following an argument (Hammen, 1991). There is evidence that exposure to social stress increases around adolescence (Rice, Harold, & Thapar, 2003). Girls appear particu- larly sensitive to depressive symptoms following social stress (Rudolph, 2002). Consistent with their important role in the development of depression, sub-tâ•‰ hreshold symptoms, family history of depression in a parent and exposure to stressful events have all been used as criteria for the selec- tion of individuals to receive therapeutic intervention, with the aim of reducing symptomatology (i.e., selective or indicated prevention programs; Horowitz & Garber, 2006; Stice, Shaw, Bohon, Marti, & Rohde, 2009). Twin studies show that depressive symptoms and disorder in adolescence are influenced by genetic factors to a moderate degree (Rice, 2010). It is unclear exactly what is inherited, but it seems likely that part of the heritable effect is indirect. For instance, genes may operate indirectly via influences on behavior or personality traits that affect exposure to stress. Interestingly, a num- ber of twin studies show that depressive symptoms in childhood are not influenced by genetic

471 174 Emotion Regulation and Depression factors but environmental influences predominate (Eaves et al., 1997; Rice et al., 2002; Scourfield et al., 2003; Thapar & McGuffin, 1994). Longitudinal studies also suggest that childhood and adolescent depression may differ in rates of continuity into adult life, with childhood depression showing low rates of continuity with depression in adulthood and adolescent depression showing higher rates of continuity with depression in adulthood (Harrington et al., 1991). There are dif- ferences in the prevalence, sex ratio of cases, rates of continuity and aetiology of childhood and adolescent onset depressive symptoms and disorder. Evidence, to date, suggests that adolescent depression can be viewed as an early onset form of the adult disorder (Thapar, Collishaw, Pine, & Thapar, 2012); whether this is the case for childhood onset depression is less clear and it may be that childhood onset depression is different. In summary, depression can be viewed both categorically and continuously. There are differ- ences between depression in childhood and adolescence. Depression in a parent, stressful life events and sub-tâ•‰hreshold symptoms are important risk factors for MDD. Depression involves symptoms that reflect an excess of negative affect, such as low mood and irritability and a dearth of positive affect, such as a loss of interest. Emotion regulation difficulties Psychological theories of depression Cognitive theories of depression suggest that negative biases, such as selectively attending to and elaborating on depression-râ•‰elated stimuli, are involved in the onset and maintenance of depres- sion (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979). Other cognitive theories highlight that indi- viduals who become depressed may have difficulty employing adaptive strategies to regulate mood and “recovering” from low mood; they therefore, respond to low mood in ways that encourage its persistence (Nolen-âH•‰ oeksema, Wisco, & Lyubomirsky, 2008; Teasdale, 1988). Recent cognitive theories of depression have also highlighted the importance of lower level cognitive processes in forming “higher level” negative beliefs about the self, the world and the future (Roiser, Elliott, & Sahakian, 2012). Such lower level cognitive processes underlie the bleak and pessimistic views that depressed individuals exhibit and include cognitive control processes. Indeed, it is increas- ingly recognized that the control of emotional material is compromized in depression (Gotlib & Joormann, 2010). To some extent, interventions for depression such as Cognitive Behavioral Therapy (CBT), encourage participants to employ cognitive or executive control over thoughts, feelings and behavior (Siegle, Ghinassi, & Thase, 2007). Cognitive theories of depression and its treatment have predominated research and practice in recent years. However, it is also important to note that behavioral theories of depression take a different stance and emphasize low levels of engagement in enjoyable activities as important in the onset and maintenance of depression (Lewinsohn, 1975; Lewinsohn & Graf, 1973). There has been a resurgence of interest in the impor- tance of positive information and rewarding activities in depression, given strong neuro-âs•‰ cientific evidence that this is compromized in depression (Pizzagalli, 2014). Emotion regulation in childhood and adolescent depression Depressed individuals exhibit a number of difficulties in effectively processing and regulating emotional responses. In this section, we describe the role of key emotional regulation difficul- ties present in children and adolescents that are depressed. Emotional regulation difficulties can be organized as relating to a preference or bias for negative information, or an absence of a preference or bias for positive information. Such emotion regulation difficulties can apply to

571 Emotion regulation difficulties 175 attention, to memory, to decision making, to attitudes and to the cognitive/âe•‰ xecutive control of emotional information. We discuss each of these in turn. We also discuss the role of emo- tion regulation problems in the onset and maintenance of depression in children and young people. Various methodologies and designs have been used to assess the role of emotion regulation dif- ficulties in the aetiology of depression. Tests of whether emotion regulation difficulties are present only during the actively depressed state or whether they persist following remission have involved comparing currently depressed and remitted groups. Studies investigating whether emotion regu- lation problems increase risk for depression have involved comparing high risk groups, such as the offspring of depressed parents, to low risk groups. Nevertheless, in the absence of longitudinal follow-âu•‰ p, such group based designs lack the important test of whether observed differences are related to the development of later psychopathology. Whilst there is a general lack of longitudinal studies, a handful of such studies have examined the role of emotion regulation difficulties in the onset and persistence of symptoms over time. In our review of emotion regulation, where possible, we focus on research that uses behavioral tasks to assess aspects of cognition involved in emotion regulation. We do this because performance-bâ•‰ ased measures allow for the measure- ment of cognitive biases that may not be open to introspection, whereas, self-râ•‰eport measures do not (Harmer, O’Sullivan, et al., 2009; Rawal, Collishaw, Thapar, & Rice, 2013b). A focus on performance-bâ•‰ ased indicators of cognitive bias and emotion regulation also lessens the likelihood that associations with depression are due to shared method variance, which is possible when the same informant rates a risk factor (e.g., cognitive bias) and an outcome (e.g., depressive symp- toms) (Rutter, Pickles, Murray, & Eaves, 2001). Attention and emotion regulation Cognitive theories of depression suggest that affective biases, whereby individuals pay attention to depression-âr•‰elated stimuli and have difficulty in disengaging from them, are involved in the onset and maintenance of depression (Beck, 1976). The deployment of attention is also posited as an important early mechanism of emotional regulation (John & Gross, 2007). For instance, shifting attention away from an emotionally distressing stimulus may help regulate emotion. An affective bias towards negative stimuli would involve being more accurate, quicker to respond to and slower to disengage from negative stimuli compared to positive or neutral stimuli. Such a bias is likely to affect an individual’s view of themself, the future and the world around them. There is evidence that such a bias exists in depressed adults. (Gotlib & Joormann, 2010; Mathews & MacLeod, 2005). However, the evidence for a negative attentional bias in depressed children and adolescents is inconsistent. Several studies report a negative affective bias (Gibb, Benas, Grassia, & McGeary, 2009; Joormann, Talbot, & Gotlib, 2007b; Kyte, Goodyer, & Sahakian, 2005) while others report a preference for positive material or reduced accuracy for negative material, which is inconsistent with a negative affective bias (Harrison & Gibb, 2014; Kilford et al., 2015). For instance, one study found that depressed young people avoided sad stimuli or preferred happy stimuli (Harrison & Gibb, 2014) and another found that depressed adolescents made more errors for sad compared to happy stimuli (Kilford et al., 2015). Findings are also fairly inconsistent for emotional recognition tasks (Joormann, Gilbert, & Gotlib, 2010; Lewinsohn, Zeiss, & Duncan, 1989; Lopez-âD•‰ uran, Kuhlman, George, & Kovacs, 2013). Thus, one study found evidence that depressed young people may be more sensitive to sad stimuli, in that they detected sad faces at lower levels of intensity exposure compared to healthy individuals (Schepman, Taylor, Collishaw, & Fombonne, 2012). Another study also reported a similar finding in high-râ•‰ isk, unaffected boys

671 176 Emotion Regulation and Depression (Lopez-Dâ•‰ uran et al., 2013) but a different pattern of results where shown in a study of high-râ•‰ isk girls, where they appeared less sensitive to sad stimuli (Joormann et al., 2010). Studies of remit- ted, depressed adolescents (Maalouf et al., 2011) and a longitudinal study examining the affective processing of depressed adolescents, prior to the onset of depression (Kilford et al., 2015), showed that any observed affective bias appeared to be state dependent and was not observed in remitted adolescents. Collectively, these results do not suggest a clear pattern of attentional bias for emo- tional information in depressed children and adolescents. Studies that have reported a preference for happy stimuli in depressed cases have suggested that some depressed young people may use this as a rudimentary form of emotion regulation (Cohn & Tronick, 1983). Thus, allocation of attention away from a negative stimulus (such as a sad face) and towards a happy one may serve to reduce emotional distress. There is evidence that this may occur in infants of depressed mothers and the use of this strategy is related to the infant’s own affect (Cohn & Tronick, 1983; Termine & Izard, 1988). In summary, there is inconsistent evidence for negative affective bias as measured by atten- tional tasks in depressed children and adolescents. This contrasts with the pattern of results for depressed adults and illustrates the importance of considering developmental differences. Results of one longitudinal study suggested that sad and happy material may differentially interrupt task performance in depressed and healthy individuals and that it may be important to consider the role of cognitive control of emotional material (Kilford et al., 2015). We deal with the control of emotional material later in this chapter. Memory and emotion regulation Classic studies of depressed adults show that they remember the past differently to non-â•‰ depressed individuals. Depressed adults show a skewed recollection of negative experiences, whereby autobiographical memories that are negative are recalled more often and more quickly (Gotlib & Joormann, 2010; Lloyd & Lishman, 1975). Studies have used the Self Referent Encoding Task (SRET) in children and adolescents. This task involves asking individuals to judge whether a set of positive and negative adjectives are self-dâ•‰ escriptive, followed by a sur- prise free recall task where participants are asked to recall as many of the words as possible. Depressed young people have been reported as recalling fewer positive and more negative self-â•‰ referent words (Prieto, Cole, & Tageson, 1992; Timbremont & Braet, 2004a; Zupan, Hammen, & Jaenicke, 1987), or fewer positive self-râ•‰ eferent words only (Gençöz, Voelz, Gençöz, Pettit, & Joiner, 2001; Hammen & Zupan, 1984). Interestingly, two independent studies report that fewer recalled positive words predict later increases in depressive symptoms over time (Connolly, Abramson, & Alloy, 2015; Goldstein et al., 2014), suggesting that a relative lack of memory for positive information may be involved in the onset of depression. Thus, memory bias for recall- ing less positive information is present in the depressed state and may also predict the develop- ment of depression over time. Another memory bias present in depressed children and adolescents is over-gâ•‰ eneral autobio- graphical memory (AM). AM refers to the recollection of experiences and is important because it relates to the sense of self and influences social problem solving and functioning (Goddard, Dritschel, & Burton, 1996; Raes et al., 2005; Williams et al., 2007). One quality of AM that has been closely linked with depression is the specificity of the recalled material, that is, recalling events that occurred at a (specific) particular time and place. There is good evidence that depres- sion in adults is associated with a tendency to recall autobiographical memories that are over-â•‰ general and refer to extended periods of time or repeated events (Williams et al., 2007). Thus, autobiographical memory in depressed adults lacks contextual detail. Similar evidence exists for

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Emotion regulation and psychopathology in children and adolescents ( PDFDrive )

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