Emotion regulation and psychopathology in children and adolescents ( PDFDrive )

71 Emotion regulation difficulties 177 depressed children and young people (Hipwell, Sapotichne, Klostermann, Battista, & Keenan, 2011; Rawal & Rice, 2012a). This pattern of response distinguishes children with depression, not only from healthy controls, but also from children with other psychiatric disorders (Rawal & Rice, 2012a). Interestingly, there is evidence that over-âg•‰ eneral memory for negative cue words specifi- cally predicts later depression (Rawal & Rice, 2012a) and distinguishes high-r╉isk from low-âr•‰isk children (Woody, Burkhouse, & Gibb, 2015). It is important to note that the valence (i.e,. happy or sad) effect is observed for the type of word used as a cue to prompt the recall of a memory rather that the valence of the autobiographical memory itself. One longitudinal study reported that currently depressed adolescents were more over-g╉ eneral than healthy and psychiatric control groups for both positive and negative cue words, but that the predictive influence of OGM on later depressive symptoms and disorder was only observed for negative cue words (Rawal & Rice, 2012a). This provides indirect evidence that, OGM may be a process that begins initially with negative material (i.e., prior to a depressive episode) but becomes generalized to other material with time (i.e., once a depressive episode has begun) (Williams, 1996). Thus, OGM may indi- rectly measure a type of emotion regulation strategy where specific details of the personal past are avoided in order to reduce distress (Crane et al., 2014; Williams, 1996). Such a strategy is unlikely to be adaptive in the long-ât•‰erm. Over-âg•‰ eneral autobiographical memory may also interfere with using memory for other, more effective, forms of emotion regulation. Recalling positive autobiographical memories has been shown to be an effective strategy to repair low mood. This phenomenon has also been shown in experimental research, where acti- vating the neural substrate of a positive memory reduces depressive symptoms (Ramirez et al., 2015). It seems likely that the inability to recall specific details of the personal past will affect a person’s ability to use positive memories as a form of emotion regulation (Dalgleish & Werner-╉ Seidler, 2014). There is an indication that depressed individuals are less effective in using the recall of positive events as a strategy to repair sad mood (Joormann, Siemer, & Gotlib, 2007). It is not exactly clear why this might be; however, it is possible that recalling memories that lack detail and vividness may fail to have the desired mood-âr•‰epair effect. Indeed, one study showed that adults with remitted MDD recalled less vivid positive memories than healthy controls (Werner-âS•‰ eidler & Moulds, 2011). An intervention study found that training in positive imagery improved symp- toms of anhedonia in currently depressed adults (Blackwell et al., 2015). A preventive, universal intervention that reduced depressive symptoms in healthy adolescents also included a session based on recalling positive autobiographical memories (Rice et al., 2015). In summary, evidence suggests that recalling low levels of positive information is associ- ated with the onset of depressive symptoms over time. There is reason to believe that recalling positive autobiographical memories is an effective emotion regulation strategy. Studies of adults suggest this effective mood repair strategy goes awry in depression. Further research is required to test if this finding also applies to children and adolescents with depression. Another feature of autobiographical memory that is important in depression occurring in young people is the level of specificity that is recalled. Difficulties in recalling specific details of the personal past is likely to interfere with the ability to use happy memories as an effective mood repair strategy. Collectively, results illustrate the importance of positive memories in regulating and repairing low mood. Decision making and emotion regulation A body of research suggests that depressed young people have difficulty in making decisions involving the opportunity for reward. In particular, depressed young people fail to show a norma- tive bias towards stimuli associated with a more likely chance of obtaining reward. This type of

871 178 Emotion Regulation and Depression research most often uses behavioral tasks involving rewards, such as winning points or money; although, tasks involving other sorts of reward, including social reward are beginning to be devel- oped and used. Lowered reward responsiveness may be involved in the maintenance of depressive symptoms, as it may lead to diminished engagement in pleasurable activities and reduced motiva- tion to pursue outcomes that are usually enjoyable, such as social events, interpersonal relation- ships and activities like exercise (Depue & Iacono, 1989; Forbes & Dahl, 2005; Lewinsohn, 1975). Consistent with this idea, lowered reward-r​esponsiveness, as measured by fMRI, and behavioral tasks are correlated with affect in every-d​ ay life (Forbes et al., 2009) and engagement in positive daily activities, such as exercise and extra-​curricular activities (Rawal et al., 2013b). Several stud- ies have shown that depressed young people “play it safe” and bet less of their points compared to healthy individuals and psychiatric controls when the chances of winning are very high (Forbes, Shaw, & Dahl, 2007; Guyer et al., 2006; Rawal et al., 2013b). This pattern of reward decision mak- ing has also been shown to predict depressive symptoms and new onset depressive disorder over time when controlling for prior symptom severity (Rawal et al., 2013b). Similarly, lowered activa- tion in the ventral striatum, a brain area involved in reward processing, has been found to predict the symptom of anhedonia/l​oss of interest over time (Stringaris et al., 2015). Thus, MDD in children and adolescents appears to be characterized by a reduced expectation of future reward, a diminished ability to change behavior according to the likelihood of a reward and alterations in the functioning of the brain’s reward circuit (Pizzagalli, 2014; Stringaris et al., 2015). Reduced sensitivity to reward is thought to be a factor underlying the symptoms of depres- sion that index low positive affect, such as anhedonia/l​oss of interest and social withdrawal. These sorts of symptoms may be particularly important markers of severity and prognosis. For instance, anhedonia has been reported to predict severity and relapse in treatment resistant adolescent depression (McMakin et al., 2012). Family studies have suggested that reductions in the capacity for positive affect may distinguish children at low and high familial risk for depression (Olino et al., 2011). Kovacs & Lopez-​Duran (2010) posit that an attenuated capacity for positive affect (which may stem in part from blunted reward sensitivity) is likely to interfere with the ability of young people to engage in effective mood repair strategies such as doing something fun, doing an enjoyable, distracting activity or focusing on happy memories. An intervention involving training in reward decision making and strategies to enhance positive affect reduced adolescent depressive symptoms; the change in reward decision making appeared to explain the reduction in symptoms (Rice et al., 2015). Thus, the lack of a normative positive bias, as indicated by reduced sensitivity to reward, may also impair effective emotion regulation strategies. In line with the idea that depressed young people fail to show a normative positive bias are studies of probability judgements. It is widely established that healthy individuals show an opti- mism bias where they judge negative events as more likely to happen to others than to themselves (Sharot, 2011). Depressed children and adolescents made more balanced judgements and (cor- rectly) judged these events as equally likely to occur to themselves as to another person (Dalgleish et al., 1997). This effect appeared to be mood-d​ ependent as it was not observed in a recovered depressed group (Dalgleish et al., 1998). In summary, there is good evidence that decision making, when there is the potential for reward, is impaired in individuals with depression and those at increased risk of developing depression. There is also good evidence that the neural correlates of reward processing are affected in depression and recent evidence also shows that this predicts depression over time (Stringaris et al., 2015) consistent with previous longitudinal behavioral studies (Forbes et al., 2007; Rawal et al., 2013b). Depressed and vulnerable young people appear not to expect future reward and are inflexible in modifying their behavior according to the likelihood of obtaining a reward (Rawal et  al., 2014). It is possible that low expectations of future reward, as well as lower capacity for

971 Emotion regulation difficulties 179 positive affect, may interfere with young people’s ability to engage in effective emotion regulation strategies, particularly those that involve up-âr•‰ egulating positive affect. Attitudes and emotion regulation Depressed young people show a range of explicitly negative patterns of thinking, including beliefs about themselves and interpretations about the world around them (Hankin & Abramson, 2001). Dysfunctional attitudes about the self are common in depression as are negative interpretations about the causes, consequences or self-i╉mplications of stressful events (Beck et al., 1979; Teasdale et al., 2002). Thus, depressed young people tend to interpret the meaning of a negative event in a negatively biased way as indexed by their attributional style (Schepman, Fombonne, Collishaw, & Taylor, 2014; Seligman et al., 1984) and under-e╉ stimate their own abilities relative to their peers and teachers (Cole, Martin, Peeke, Seroczynski, & Fier, 1999). Nonetheless, while negative styles of thinking are elevated during an episode of depression, they are not usually elevated in those whose depression has remitted (Teasdale, 1988), despite the fact that individuals with previous depression are at heightened risk of experiencing future episodes (Solomon et al., 2000). It has been suggested that negative thinking remains latent in remitted individuals until activated by depressive mood or stress and is not accessible in non-d╉ epressed mood (Miranda & Persons, 1988; Wenzlaff & Bates, 1998). Indeed, vulnerability-âp•‰ rovoking procedures, such as sad mood inductions, appear to “activate” or elicit negative thinking in young people at risk of depression (the offspring of depressed parents or those with a previous episode of depression) (Dearing & Gotlib, 2009; Ingram & Ritter, 2000; Kelvin, Goodyer, Teasdale, & Brechin, 1999; Taylor & Ingram, 1999; Timbremont & Braet, 2004b). For instance, one study showed that children of depressed mothers exhibited negative interpretations of their performance on a task only during a mildly stressful situation and not in the absence of stress (Murray, Woolgar, Cooper, & Hipwell, 2001). Using a different approach, one study used reaction time as a more implicit measure of negative thinking, where speed to endorse a dysfunctional attitude was taken as a measure of the “strength” of the attitude (Rawal, Collishaw, Thapar, & Rice, 2013a). In that study, being relatively quicker to endorse dysfunctional attitudes differentiated remitted and control individuals and predicted depressive symptoms over time. Individuals who are depressed may also respond and relate to low mood differently than non-╉ depressed individuals. Depressed children and adolescents can become captured by and elabo- rate on negative information, consistently responding to low mood in ways that encourage its persistence. Rumination, a response to sad mood which involves analysing and questioning the reasons for low mood (Nolen-âH•‰ oeksema, 1991; Watkins, 2008), has been associated with depres- sive symptoms both cross-s╉ ectionally and longitudinally, suggesting that it is involved in the onset of depression as well as the current depressive state (Rood, Roelofs, Bogels, Nolen-H╉ oeksema, & Schouten, 2009). Nonetheless, it should be noted that there are relatively few longitudinal studies that control for prior depression and those that do, report a substantial reduction compared to the uncorrected correlation between depression and rumination (Rood et al., 2009). Thus, depressed individuals certainly ruminate, but whether this predicts the onset of depression over time, inde- pendently of depressive symptoms, is not completely clear due to a lack of studies using designs that allow this this question to be addressed. In summary, depressed individuals show pessimistic interpretations about themselves and the world. This negative style of thinking may remain latent when mood is normal but may increase vulnerability to depressed mood following exposure to a stressor. Rumination as a response to low mood is also increased in depressed young people and may increase vulnerability for future episodes.

081 180 Emotion Regulation and Depression Executive functioning and emotion regulation Thus far, we have presented evidence showing that individuals with depression show patterns in cognitive operations such as attention, memory, decision making and attitudes that can affect the balance of the accessibility of negative and positive emotional information. In this section, we discuss how executive functioning processes are involved in processing and exerting control over emotional material. Executive functions (EF) are a set of mental processes that enable goal directed behavior, planning and adaptive response to novel or challenging situations (Diamond, 2013; Hughes, Graham, & Grayson, 2004). Core executive functions include inhibitory control, working memory and mental flexibility. In this section, we discuss how executive functions that involve control and flexibility over emotional material may be important in emotion regulation (Schmeichel & Tang, 2014) and may be compromised in depression. The development of execu- tive functions starts in the first years of life and continues throughout childhood and adolescence, reaching maturity only in early adulthood (Best & Miller, 2010). A large body of research has shown that depression in adults is associated with impairments in execution functions, especially in tasks or situations that involve processing emotional informa- tion (Gotlib & Joormann, 2010; Wagner, Doering, Helmreich, Lieb, & Tadić, 2012). Although there are fewer studies examining executive functioning in depression in children and adoles- cents, a recent meta-âa•‰nalysis (Wagner, Müller, Helmreich, Huss, & Tadić, 2014)  showed that children and adolescents with MDD performed significantly worse on measures of a range of executive functioning tasks. Initial findings also suggest that executive functioning difficulties, in the context of emotional material, may be a cognitive risk factor for developing depression (Davidovich et al., 2015; Joormann, Talbot, & Gotlib, 2007a; Kilford et al., 2015). Kilford and col- leagues (2015) report findings suggesting that sad stimuli interfere with cognitive or behavioral control in currently depressed young people and in those who later go on to develop depres- sion. Davidovich and colleagues (2015) report that better executive functioning in the offspring of depressed parents protects against depressive symptoms in the children themselves. There are several pathways through which executive functioning may be associated with emo- tion regulation and risk for depression. One possibility is that the negative affective biases and mood regulation difficulties that characterize depressed individuals may be underpinned by impairments in executive functions (Harmer, Goodwin, & Cowen, 2009; Roiser et  al., 2012). Depressed individuals, as well as those at risk for depression, show impaired inhibition of emo- tional information (Gotlib & Joormann, 2010; Kilford et  al., 2015; Kujawa et  al., 2011). Such impairments may contribute to a tendency to get “captured” by negative thoughts and mood, impede mood regulation and lead to sustained negative affect. In line with this notion, difficul- ties in inhibiting responses and shifting cognitive sets have been found to be associated with higher levels of rumination, a cognitive style which perpetuates low mood (De Lissnyder, Koster, Derakshan, & De Raedt, 2010; Joormann & Quinn, 2014). Effective mood regulation strategies, such as reappraisal, and examining an issue from different perspectives, may rely on elements of executive functioning. Employing such strategies requires inhibition in order to disengage from a particular interpretation or perspective, mental flexibility, in order to generate and shift to another interpretation or change perspectives and working mem- ory, in order keep the different options accessible in memory and manipulate them (Kross, Ayduk, & Mischel, 2005; McRae, Jacobs, Ray, John, & Gross, 2012; Ochsner & Gross, 2008). Preliminary findings indicated that the ability to use cognitive reappraisal as an emotion regulation strategy is associated with aspects of executive functioning such as working memory and set shifting in adults (McRae et al., 2012).

18 Evidence-based intervention approaches for depression 181 Reduced executive functioning capacities might interfere with retrieving specific autobiograph- ical memories, which may serve as an important resource when coping with negative or stressful events. Difficulties in retrieving specific autobiographical memories (i.e., overgeneral autobio- graphical memory; [OGM]) have been shown to characterize currently depressed children and adults (Kuyken, Howell, & Dalgleish, 2006; Park, Goodyer, & Teasdale, 2002; Vrielynck, Deplus, & Philippot, 2007; Williams et al., 2007). Longitudinal studies also demonstrate that overgeneral autobiographical memory increases the risk for developing depression (Hipwell et al., 2011; Rawal & Rice, 2012a). Several theorists suggest that impairment in retrieving specific autobiographical memories may be at least partially due to reduced executive functions (Conway & Pleydell-âP•‰ earce, 2000; Hertel & Hardin, 1990; Williams et  al., 2007; Zacks & Hasher, 1994). Studies conducted with adults and children give support to the role of executive functioning in the retrieval of spe- cific autobiographical memories (Picard, Reffuveille, Eustache, & Piolino, 2009; Raes, Verstraeten, Bijttebier, Vasey, & Dalgleish, 2010; Rawal & Rice, 2012b; Williams et al., 2007). This may inter- fere with the ability to use autobiographical memory as a form of emotion regulation strategy as described above. Finally, it is possible that executive functioning could affect how individuals respond to preven- tive or therapeutic interventions. It has been suggested that psychological interventions used for depression, including Cognitive Behavioral Therapy(CBT), encourage the patient to exercise cog- nitive control over thoughts and emotional responses. These strategies attempt to change how the person relates and responds to their thoughts by generating alternative interpretations, switch- ing between thoughts and interpretations or examining thoughts from a distanced perspective (Brewin, 2006; Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Siegle et al., 2007). While such inter- ventions may improve executive functioning by practicing these skills, it is also possible that those with executive functioning difficulties might find these tasks challenging. In summary, depressed children and adolescents show a range of difficulties in processing emo- tional material that may compromise their ability to use effective emotion regulation techniques. These difficulties include biases for negative information, an absence of bias for positive informa- tion and difficulties in exerting control over emotional material. The best evidence of emotion regulation difficulties predicting the onset of depressive disorder and symptoms comes from low levels of bias for positive information. Later we review the interventions that are used to amelio- rate depression in young people and relate these to the emotion regulation difficulties described previously. Evidence-based intervention approaches for depression Psychological therapies are the intervention of choice for depression in children and young people (National Institute for Health and Clinical Excellence, 2005). Until recently, CBT was considered the “gold-s╉tandard” in psychological therapy for depression. However, it is now believed that there is little good quality evidence to suggest that any one psychological treatment is better than another (National Institute for Health and Care Excellence, 2015). The results of a large trial comparing differ- ent types of psychological treatment support the view that no one psychological treatment is superior to another (Goodyer et al., 2017; National Institute for Health and Care Excellence, 2015). We focus on describing CBT as an evidence-âb•‰ ased intervention as there have been more studies of CBT than other sorts of psychological intervention, such as interpersonal therapy. We also describe modifica- tions of CBT that focus on the behavioral components of CBT, with the aim of targeting the low levels of positive affect seen in depression in young people. We also briefly consider practical issues and adaptations that may need to be made when working with depressed children and young people.

281 182 Emotion Regulation and Depression Finally, we discuss psychological approaches to reducing and preventing symptoms in young people without depressive disorder. CBT focuses on altering dysfunctional styles of thinking and behavior through challenging negative thoughts and beliefs. CBT programs encourage and support young people in identifying and evaluating negative thoughts and cognitive distortions with the aim of encouraging more balanced, less negative, more reflective beliefs about the self, the world and the future. CBT is, therefore, aiming to target the negative feelings, thoughts and beliefs that are common in depres- sion. CBT also encourages individuals to exert greater executive control over automatic emotional reactions (Siegle et al., 2007). It is possible that young children, or those whose meta-c​ ognitive skills (i.e., the ability to think about thoughts) are not well developed and may struggle with this aspect of CBT. A number of CBT-​based programs have been used in preventive interventions. Preventive inter- ventions can be delivered to high-r​ isk groups, including those with known risk factors for a disor- der or those with high symptoms that fall below the traditional diagnostic (selective or indicated prevention). Preventive interventions can also be delivered to all members of a group, regardless of symptoms (universal prevention). CBT programs appear to be effective in preventing depres- sive symptoms and disorder in those at high-​risk (Garber et al., 2009; Horowitz & Garber, 2006; Merry, McDowell, Hetrick, Bir, & Muller, 2004; Stice et al., 2009). In particular, the Coping with Adolescent Stress program has been shown to be effective (Clarke et al., 1995; Garber et al., 2009). In contrast, CBT-b​ ased programs do not appear to be effective in universal prevention programs with a very large randomized controlled trial finding no benefit (Stallard et al., 2012). In our review of the emotion regulation difficulties seen in depression in children and ado- lescents, we have identified low levels of positive affect as important in predicting the onset of depression and in interfering with adaptive styles of emotion regulation. To that end, it is also worth considering behavioral activation and the more behavioral elements of CBT that are rec- ommended for interventions with depressed young people. Behavioral activation involves activ- ity monitoring and scheduling and aims to encourage individuals to engage in interesting and pleasurable activities (Dichter et  al., 2009). Meta-​analysis has indicated that behavioral activa- tion is effective in reducing symptoms in depressed adults and is as effective as CBT or antide- pressant treatment (Cuijpers, van Straten, & Warmerdam, 2007). Activity scheduling may be the “active” element of behavioral activation packages as this alone is effective in reducing depression in adults (Cuijpers et al., 2007; Jacobson et al., 1996). An appealing aspect of behavioral activation is that it may be simpler for individuals to understand and for therapists to deliver then cognitive behavioral therapy. A preliminary trial suggested that behavioral activation may be efficacious in depressed adolescents (McCauley et al., 2015). Behavioral activation has been shown to alter the responding of brain areas involved in reward processing (Dichter et al., 2009). We developed TRY (see later), which incorporated CBT and behavioral activation and focused on enhancing reward-​processing and tested it as a classroom-b​ ased universal prevention program (Rice et al., 2015). TRY aimed to enhance reward-​processing through activities such as illustrating the use of rewarding experiences to lift mood and evaluating potential risk and rewards involved in day-​to-d​ ay decision making. We also measured reward-​decision making with a behavioral task pre and post intervention and compared TRY to two other psychological therapies (cogni- tive behavioral therapy and mindfulness based cognitive therapy) as well as a comparison group. TRY was the only intervention associated with a reduction in depressive symptoms at follow-​ up. Reward-​seeking increased following TRY. In the TRY program, which focused on increas- ing sensitivity to rewarding activities, reward seeking increased; this increase was associated with decreased depressive symptoms. There is, therefore, preliminary evidence that behavioral

381 Interventions for depression: CBT with children and adults 183 activation may be worth considering as an adjunct to therapeutic and preventive interventions in young people (McCauley et al., 2015; Rice et al., 2015). Interventions for depression: CBT with children and adults The National Institute of Clinical Excellence (NICE) has evaluated CBT as an effective interven- tion for depression in both children and young people (National Institute for Health and Clinical Excellence, 2005) and adults (National Institute for Health and Clinical Excellence, 2009). Beck (1976) proposed that cognition has a key role in the maintenance of depression, and distinguished between three levels of cognition: core beliefs (or schema), dysfunctional assumptions (or rules for living) and negative automatic thoughts (NATs; Beck et al., 1979). Specific psychotherapeutic techniques have been developed in practice with adults to facilitate cognitive change (Greenberger & Padesky, 1995). It is less certain whether the three levels of cognition, proposed by Beck, are distinguishable in children and young people, due to the paucity of studies into the developmental origins of core beliefs and a theoretical vacuum with regard to the relationship between core beliefs, schemas and early memories (James, Southam, & Blackburn, 2004). Beck et al. (1979) propose that cog- nitions are internalized from previous experiences and that an individual’s response to a current situation is embedded in behavioral and cognitive responses from the past. Therapy with adults involves seeking to modify these patterns of response, through changing conceptualisations; however, children are still in the midst of childhood, and therefore, lack responsibility and the autonomy to instigate changes within their relationships or environments. Mental health difficulties in children are more likely to be related to the current social context, not to past relationships where the dysfunctional cognitions developed. Furthermore, cognitive change is difficult to justify to a child living in a context where their negative beliefs fulfil an adaptive function. For example, a child that is constantly criticized by adults may develop beliefs related to feelings of anger, expressed as “it’s not me; it’s not my fault; you are wrong.” To some extent, such thoughts have a protective and adaptive function in relation to the child’s self-âc•‰ oncept, although it is likely to be maladaptive with regard to the development and maintenance of harmonious relationships. Social cognition, therefore, develops throughout childhood, with the child gradually internalising thoughts and beliefs during interaction with others (Sharp, Fonagy, & Goodyer, 2008). CBT interventions for depression have a number of common features. The aims are to enable participants to develop an understanding of the associations between cognitions, emotions, physiology and behavior, to identify “dysfunctional thoughts” or “thinking errors” and become motivated to develop more realistic, balanced cognitions (Padesky & Mooney, 1990). However, many of the strategies used in adult therapy require adaptation for children and young people. Interventions need to take into account a child’s age, cognitive capabilities and educational experi- ence (Doherr, Reynolds, Wetherly, & Evans, 2005) as all these factors influence their capacity to engage with cognitive techniques. Younger children tend to use cognitive strategies (e.g., mne- monic ones) with less frequency and effectiveness than older children (Bjorklund & Douglas, 1997). Similarly, there is a developmental progression in a child’s ability to generalize learned cog- nitive strategies to other settings or adapt them to different experiences (Crowley & Siegler, 1999; Siegler, 1996). It is also important to ensure that CBT related activities are scaffolded to support new understandings (Vygotsky, 1980; Wood, Bruner, & Ross 1976). The concept has been devel- oped to capture how adults, or more capable peers, provide temporary and adjustable support during adjustments to materials, presentation and linguistic support. These aspects all influence

481 184 Emotion Regulation and Depression the nature of the scaffold, which in CBT with children may be varied according to the child’s interests and needs. A central tenet of CBT for depression is psychoeducation and, therefore, there is a need for therapy to support children’s learning about internal processes linked with cognitive and emo- tional aspects of functioning. There has been substantial research that has looked at the teaching approaches most associated with effective learning (see Hattie, 2009). There are clear indications that, in order for children to grasp new ideas, information needs to link with pre-âe•‰ xisting under- standings and be presented in a variety of ways, using multi-m╉ edia to reinforce concepts where possible (Mayer, 2005). Spaced or distributed practice (i.e., short, multiple practice sessions inter- spersed with other activities) is important for efficient learning and is much more effective than practicing a new skill less frequently, but for longer periods (Walker, Greenwood, Hart, & Carta, 1994). The implication of this is that, for example, shorter daily practice is preferable to more extended weekly practice. Some children may have difficulty with the abstract nature of CBT and discussion of concepts that are not in the “here and now.” Therefore, another important adaptation of CBT for children and young people is to present concrete examples in parallel with abstract concepts, to ensure transfer (Gentner, Rattermann, & Forbus, 1993). This may involve video, role-╉ play, use of stories, model characters, pictures and so on. CBT for children and young people needs to provide engaging, stimulating activities that are developmentally appropriate and align with current interests (Fuggle, Dunsmuir, & Curry, 2012). CBT for children generally combines behavioral and cognitive components (Weisz & Kazdin, 2010), although the degree to which each component is effective, is contestable (Weisz, McCarty, & Valeri, 2006). Similarly, both cognitive and behavioral methods are central to CBT with adults for depression, although the extent to which outcomes are influenced by the balance of these two components is uncertain (Gortner, Gollan, Dobson, & Jacobson, 1998). CBT for children; therefore, needs to be adapted to ensure that session content is accessible and addresses the level of metacognitive and executive functioning of the individual. This will require careful planning, adaptation and simplification of methods, and for many children, an emphasis on more concrete, behavioral components. As mentioned earlier, one common technique that has been success- fully integrated within small scale adolescent interventions for depression with positive out- comes is behavioral activation (BA) (Ritschel, Ramirez, Jones, & Craighead, 2011). BA involves the young person monitoring and recording daily activity and then exploring the relationship between mood and activity levels. Social factors are also taken into account due to their impact on emotional state. The thinking about reward in young people program (TRY) We will now describe a recently developed intervention that offers a promising approach to read- dress the disequilibrium occurring between positive and negative affect in adolescent depression. The (TRY; Cobbald & Dunsmuir, 2013; Rice et al., 2015) program combines BA within a modi- fied CBT model that seeks to build awareness of the relationship between physiological signs, thoughts, feelings and decisions. TRY encourages young people to consider alternatives to the negative cycles that can become established in affective disorders through focusing on positive affect and rewarding activities. There is an emphasis on the associations between cognitions and decision-m╉ aking. The intervention was developed following research suggesting that reward pro- cessing was altered in, and predicted risk for, adolescent depression, as previously described. The TRY intervention aimed to incorporate elements of rational reward-s╉eeking behavior, such as encouraging young people to consider the likelihood of good or bad outcomes in their reward-âs•‰ eeking behavior, based on evidence that low reward-s╉ eeking may be a causal risk factor for adolescent depression (Forbes et al., 2007; Rawal et al., 2013b). The intervention also aimed

581 Interventions for depression: CBT with children and adults 185 to encourage the use of happy autobiographical memories and engagement in enjoyable activi- ties, including social activities as emotion regulation strategies. TRY was developed for delivery to universal populations of young people aged 14–1​ 5 years, attending co-e​ ducational mainstream schools. It consists of eight 60-m​ inute sessions, designed to be delivered on a weekly basis by a facilitator during Personal Social and Health Education (PSHE) lessons. The session-b​ y-​session outline of the TRY program is detailed below: 1. Introduction; psychoeducation about stress and depression; rationale for the TRY program 2. Goal setting; introduction to the modified CBT model 3. Identifying rewarding experiences and happy memories 4. Identifying and evaluating thoughts 5. Decision making with regard to rewarding experiences and the impact on mood 6. Evaluation of positive experience and how this informs future decision making and practicing the TRY decision making process 7. The role of social support and managing conflict 8. Review of TRY program and personal goals Additional information and multi-m​ edia resources used in the TRY intervention can be accessed at http://w​ ww.ucl.ac.uk/​educational-p​ sychology/t​ ry.html. It is important to recognize that in order to deliver universal therapeutic interventions in schools, facilitators require a range of competencies. These include interpersonal skills, such as sensitivity and the ability to consult and negotiate with school staff (Kratochwill, Elliott, & Callan-S​ toiber, 2002; Zins & Erchul, 2002), as well as the ability to develop and maintain good relationships with young people (Shirk, Karver, & Brown, 2011). Facilitators also need to be appropriately trained, experienced and knowledgeable about the intervention and have good group management skills (Lendrum, Humphrey, Kalambouka, & Wigelsworth, 2009), factors all positively related to better pupil outcomes (Humphrey et al., 2008). To ensure appropriate standards of TRY program delivery, facilitators were all qualified educa- tional psychologists, regularly providing services to schools, who had received additional train- ing in CBT who had attended a one-​day training session in TRY implementation. In addition, and consistent with recommendations from the British Association of Behavioural and Cognitive Psychotherapies (BABCP), the Health and Care Professions Council (HCPC) standards of con- duct, performance and ethics (2012), the British Psychological Society (BPS) Code of Ethics and Conduct (2009), facilitators of the TRY intervention attended scheduled, two hour group supervi- sion meetings with an experienced CBT trainer three times during the eight week intervention. Supervision frameworks were based on several models of CBT supervision (Liese & Alford, 1998; Liese & Beck, 1997; Pretorius, 2006), within a structured, practical format and incorporating a didactic function to ensure consistency in the delivery of the intervention, and to share experi- ences of managing group dynamics and school personnel. As reported earlier, in a preliminary study, TRY was associated with a reduction in symptoms of depression and an increase in reward-s​ eeking and was more effective than standard CBT and mindfulness based CBT (Rice et  al., 2015). There is, therefore, preliminary evidence that this intervention, incorporating CBT and behavioral activation and focusing on enhancing reward-​ processing, may be an effective, accessible intervention that can be delivered in universal settings. Although psychological therapies are the intervention of choice for treating and preventing depression in children and young people, there is no single “gold-​standard” intervention package or approach. Basic research on emotion regulation has informed the development of interven- tion programs. It may be useful to consider the balance of both positive and negative affect when seeking to reduce depressive symptomatology and the impact of symptoms in children and young people.

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691 Chapter 10 Emotion Regulation and Eating Disorders Julian Baudinet, Lisa Dawson, Sloane Madden, & Phillipa Hay Eating disorders Eating disorders in children and adolescents differ from those in adults in prevalence of clinical syndromes and in the psychopathology of disorders. Bulimia nervosa and binge eating disorder have a later age of onset than anorexia nervosa and Avoidant/âR•‰ estrictive Food Intake Disorder (ARFID), which are the more common childhood problems. However, very little is known about ARFID and its treatment. Thus, this chapter will focus on anorexia nervosa and describe a new approach to emotion regulation in its management in adolescents. The diagnostic clinical features of common eating disorders (American Psychiatric Association, 2013) are listed in Box 10.1. Anorexia nervosa occurs in around one in 400 adolescent girls. In pre-âp•‰ ubertal children eat- ing disorders are less common and have a different sex distribution where almost a quarter of presentations manifest in boys (Madden, Morris, Zurynski, Kohn, & Elliot, 2009). ARFID is also common in children and boys; however, it is unclear if ARFID, or at least a proportion of ARFID cases of early onset, are a predecessor for anorexia nervosa or other eating disorders, or whether it is a distinct eating disorder with longitudinal studies needed to elucidate this. In children it often presents with significant weight loss in the context of somatic concerns such as nausea and full- ness, and in adults with a specific anxiety related to eating. In addition to differences in sex distribution, eating disorders of early onset also appear to have a greater responsivity to treatment and, in clinical samples, better long term outcomes than when onset presents in adulthood (Hay, 2015). A a strong body of research supports the efficacy of treatment in young people with eating disorders (See for example, Forsberg & Lock, 2015). The causes of eating disorders in children and adolescents are similar to those in adults; these include a family history of eating, mood and substance abuse disorders as well as obesity. Exposure to “anorexogenic” environments such as classical ballet and high levels of criticism and parental expectations are often associated with the onset and maintenance of disorders (Hay et  al., 2014; Hay & Claudino, in press; Zipfel, Giel, Bulik, Hay, & Schmidt, 2015). The pathway into an eating disorder is a complex interplay of biological/âg•‰ enetic, psychological vul- nerabilities and societal factors (Mitchison & Hay, 2014)  and recent research has pointed to the importance of gene-e╉ nvironment interactions and the role of epigenetics (Campbell, Mill, Uher, & Schmidt, 2011). Emotion regulation and eating disorders Interest in emotion regulation and processing in anorexia nervosa has been long-âs•‰tanding. Difficulty in identifying and describing emotions has been noted in individuals since 1973 (Bruch,

791 Emotion regulation and eating disorders 197 BOX 10.1╇ Clinical features of eating disorders in children and adolescents Anorexia nervosa Under-w╉ eight for age and height Intense fear of fatness/g╉ aining weight or behaviours to avoid weight gain Overvalued ideas of body weight/s╉ hape on self-âv•‰ iew or denial of seriousness of low weight Bulimia nervosa Recurrent binge eating-╉uncontrolled overeating Use of extreme measures to control their weight—p╉ urging/ân•‰ on-âp•‰ urging Overvalued ideas of body weight/s╉ hape on self-v╉ iew Normal weight or over weight Binge Eating Disorder Recurrent and distressing binge eating-╉uncontrolled overeating No regular use of extreme measures to control their weight—âp•‰ urging/ân•‰ on-âp•‰ urging Overvalued ideas of body weight/âs•‰ hape on self-âv•‰ iew not required Normal weight or over weight Avoidant/R╉ estrictive Food Intake Disorder Extreme disinterest in eating or food and/âo•‰ r food is avoided because of its colour, smell, taste or other sensory quality and/o╉ r or there is a fear of an eating consequence, e.g. choking Severe weight loss and/o╉ r specific nutritional deficiency and/o╉ r medically supported feeding and/╉or associated psychosocial functional impairment is present There is no associated weight/âs•‰ hape overvaluation or body image concern Absence of another medical or psychiatric disorder or cultural circumstance that explains the food avoidance 1973). This construct, defined as alexithymia, has been consistently reported by clinicians and demonstrated by researchers with rates as high 77.1% in individuals with anorexia nervosa com- pared to 6.7% in healthy matched controls. In addition, rates of comorbid depression and anxiety in anorexia nervosa are high (Hatch, Madden et al. 2010). Recent models of anorexia nervosa are increasingly emphasising the role of maladaptive emotion regulation strategies and difficulties with emotion identification as key precursors to the development and maintenance of anorexia nervosa (Haynos & Fruzzetti, 2011; Oldershaw, Lavendar, Sallis, Stahl, & Schmidt, 2015; Lavendar, et al., 2015). There is a small but growing body of evidence indicating that people suffering from anorexia nervosa show a greater use of maladap- tive emotion regulation strategies, such as avoidance, emotion suppression, inhibition, repression, rumination and self-d╉ estructive behaviors (Haynos & Fruzzetti, 2011). Furthermore, people strug- gling with anorexia nervosa use fewer adaptive strategies compared to healthy controls (Haynos &

891 198 Emotion Regulation and Eating Disorders Fruzzetti, 2011; Oldershaw, et al., 2015). This is important because less adaptive emotion regula- tion strategies are suggested to result in more overall emotional problems whilst contributing to psychological co-m╉ orbidity (Haynos & Fruzzetti, 2011)—a╉ factor now recognized as a barrier to family based treatment (FBT) outcomes (Lock, Courtourier, Bryson, & Agras, 2006). Preliminary findings suggest emotion regulation difficulties may persist following weight restoration (Haynos, Roberto, Martinez, Attia, & Fruzzetti, 2014). Furthermore, they can moderate against treatment efficacy, contributing to the maintenance of anorexia nervosa (Racine & Wildes, 2015), with poor emotion regulation techniques related to relapse (Federici & Kaplan, 2008). Evidence-â•b‰ ased treatments The first treatments developed for eating disorders were for anorexia nervosa. Early trials included adults as well as adolescents. The seminal study of psychological therapies were those of Russell, Szmukler, Dare, and Eisler (1987) and Eisler, Dare, Russell, Szmukler, le Grange, and Dodge (1997). This was a post weight-r╉estoration outpatient psychotherapy trial where indi- vidual therapy was compared to family therapy. While there were no differences in outcomes between the two treatment arms, secondary analysis revealed better outcomes with family ther- apy in participants who had an eating disorder for less than three years and were under the age of 18. Although predominantly a trial of anorexia nervosa, this study also included participants with bulimia nervosa. Two further trials have looked at treatment interventions in study samples of adults and adolescents (Crisp, Norton, et al. 1991; Ball and Mitchell 2004), while there have been nine randomized controlled trials that have specifically studied the efficacy of psychologi- cal therapies for children and adolescents with anorexia nervosa which have included weight restoration in aims and outcomes. There have been five randomized control trials of manualized family based therapies with a predominant behavioral focus, as in FBT. The first of these was by Robin et al., (1999). This was a small non-b╉ lind trial with unclear allocation concealment and thus, had a high risk of bias. Thirty-âs•‰even participants were randomized to either a families systems therapies or to an ego-╉ orientated individual therapy. Those in the family therapy arm had significantly greater weight gain at the end of treatment and at a one-ây•‰ ear follow up. Similarly, the second (Eisler et al. 2000; Eisler, Simic, Russell, & Dare, 2007) also had risk of bias in that there was unclear allocation, concealment and blinding. In this study, forty participants were randomized to either family based treatment, conjointly or individualized therapy where the parents were seen separately from the child with anorexia nervosa. Similarly in this study, there were no differences between the groups in outcomes at any point up to a five-ây•‰ ear follow up with the exception that where there were maternal criticism participants showed significantly higher levels of improvement when therapy was separated. Three trials that controlled for bias with adequate allocation concealment that involved inde- pendent or blind outcome assessments were conducted by Lock, Agras, Bryson and Kraemer (2005), Lock et al. (2010) and Agras et al. (2014). In Lock et al. (2005), 86 participants were ran- domized to either ten sessions over six months or 20 sessions over 12 months of FBT. Although there were no between group differences, the longer treatment led to greater improvements in people with higher levels of obsessive compulsive symptoms and those with non-i╉ntact families. Agras et al. (2014) compared FBT with systemic family therapy in 164 participants. There were no differences in weight or other primary outcomes. However, there was earlier weight regain and fewer hospitalizations in participants who were treated with family based treatment. On the other hand, systemic family therapy led to better outcomes with those who had higher levels of obsessive compulsive symptoms. Finally, Lock et al. (2010) randomized 121 participants to FBT

91 Evidence-based treatments 199 or individual, adolescent focused controlled psychotherapy. This singular study reported higher remission rates and greater weight gain at both end of treatment and a one-​year follow up in those randomized to family treatment. Other studies done in the treatment of children and adolescents include research by Geist, Heinmaa, Stephens, Davis, and Katzman (2000) who randomized participants to family therapy where the families were seen for eight sessions with the patient, the patients parents and siblings or to a family group psycho-e​ ducation arm where groups of families were seen in a workshop design for eight sessions. In this study of 25 participants, there were no significant differences between groups. This study also had risk of bias, as there was no blinding. Another study by Gowers et al. (2007) compared a specialist outpatient, manualized cognitive behavioral thearapy treatment intervention with separate parental counselling and non-​manualized supportive and family care. This study found no differences between groups. Godart et al. (2006), in a high quality randomized control trial, compared a non-​manualized psychodynamic systemic family therapy to usual specialist care in 60 adolescent participants. This trial reported significantly improved weight-​gain and other outcomes in those who received the additional family therapy. These trials of FBT have formed the basis for the leading evidence based therapy in chil- dren and adolescents with anorexia nervosa. It is notable that the majority was conducted with female participants and that only two found significant improvements in primary outcomes. It is also important to note that although there were minimal differences in symptomatic out- comes, family based treatment in the trial by Agras et  al. (2014) was associated with lower financial costs and hospitalization rates. When compared with other non-f​amily based treat- ments, FBT also demonstrated improved remission rates at follow-​up (Courtourier, et al., 2010 Forsberg & Lock, 2015). It has to be acknowledged however, that although FBT and other fam- ily therapies have strong evidence for treatment of children and adolescents with anorexia ner- vosa (Zipfel et al., 2015) their efficacy for adolescents with bulimia nervosa is less established with mixed or inconsistent findings. In addition, there have been no trials in ARFID or binge eating disorder (Hay et al., 2014). As previously highlighted, FBT has become established as the leading treatment for adolescents with anorexia nervosa. The treatment has been manualized (Lock & Le Grange, 2015) and dis- seminated internationally. The treatment includes three phases. Phase I focuses on empowering parents to manage all anorexia nervosa related behavior until the adolescent is weight restored. Following a period of weight maintenance, Phase II focuses on working with the adolescent to return to an appropriate level of control over food and eating. Phase III then focuses on life cycle events that may have been interrupted by the eating disorder. Research indicates that FBT is effective for anywhere from approximately 30–​60% of young people struggling with anorexia nervosa at the end of treatment, with these findings improved upon at follow-u​ p (Forsberg & Lock, 2015). While this data is encouraging, particularly when compared to poor response rates to adult treatments (Bulik, Berkman, Brownley, Sedway, & Lohr, 2007), it is now clear that FBT is not effective for a substantial minority of young people who con- tinue to struggle or do not complete treatment. Furthermore, remission is often defined within the literature as reaching a specified weight range, which does not always correspond with full psychological recovery. Given a lack of effective alternative treatments, this leaves a substantial proportion of adolescents with anorexia nervosa at high risk of becoming chronically unwell. Research is beginning to investigate possible factors associated with poor treatment responses or drop out in FBT. Initial findings have identified a range of family factors related to emotional expression and management that are associated with poorer outcomes or dropout. These include high expressed emotion, family conflict and criticism (Eisler, Simic, Russell & Dare, 2007; Lock, Coutourier, Bryson, & Agras, 2006; Russell, Szmukler, Dare, & Eisler; Le Grange, Eisler, Dare,

02 200 Emotion Regulation and Eating Disorders & Russell, 1992), with parental warmth being related to good outcomes (Le Grange, Hoste, Lock, & Bryson, 2011). These findings are important, as Phase I of FBT can be very stressful and emotionally challenging for all family members as parents actively and consistently challenge the symptoms of anorexia nervosa. Accordingly, this often results in young people and families being faced with extremely distressing events on a regular basis with, potentially, reduced emo- tion regulation capacities. The treatment often requires this to be repeated consistently for many weeks to months. Several individual factors have also been identified that are associated with poorer outcomes in FBT. Recent findings suggest that adolescents with more severe eating disorder psychopathology and those struggling with co-m╉ orbid Axis I  and/o╉ r emerging Axis II psychological difficulties have a greater likelihood of dropout and may require a longer duration of treatment (Forsberg & Lock, 2015). This is important, as co-âm•‰ orbidity rates in anorexia nervosa remain high, with more than 50% experiencing a co-âm•‰ orbid anxiety disorder (Kaye, Bulik, Thornton, Barbarich, & Masters 2004)  and between 50 and 70% and experiencing a major mood disorder (Godart, et al., 2006). Emotion regulation and eating disorder treatments The development of emotion regulation difficulties is hypothesized to be the result of numerous factors. These include biological factors, attachment and attunement difficulties within family sys- tems (Zeman, Cassano, Perry-âP•‰ arish, & Stegall, 2006), as well as traumatic childhood events (Dvir, Ford, Hill, & Frazier, 2014). Preliminary investigations are now being conducted into how best to include emotion regulation interventions into anorexia nervosa treatment. This has included the development of new treatments, such as the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA; Schmidt et al., 2012) and Emotion Acceptance Behavior Therapy (EABT; Wildes, Marcus, Cheng, McCabe, & Gaskill, 2014), as well as the modification or adaption of evidence based treatments from other areas of clinical psychology, such as Dialectical Behavior Therapy (DBT; Linehan, 1993). Research into the use of DBT for eating disorders in adults is promising, although yet to be rigorously researched and tested in adolescents (Bankoff, Karpel, Forbes, & Pantalone, 2012). Radically-O╉ pen DBT (RO-D╉ BT) is a modified DBT treatment spe- cifically designed to target emotion expression and the maladaptive strategy of emotional over control in anorexia nervosa (Lynch et al., 2013). The efficacy of RO-D╉ BT has also yet to be tested in anorexia nervosa. These emotion-f╉ocused interventions are being trialed in various modes of delivery ranging from individual and group, to family and multi-f╉amily interventions. Some examples include adding specific DBT informed emotion focused modules as an adjunct to FBT (Robertson, Alford, Wallis, & Miskovic-W╉ heatley, 2015), integrating emotion regulation ideas and techniques throughout FBT (Federici & Wisniewski, 2012; Robinson, Dolhanty, & Greenberg, 2015) or offer- ing skills training group based interventions as one of a range of interventions provided in the context of a day program (Girz, Robinson, Foroughe, Jasper, & Boachie, 2013). Emotion regulation difficulties have been identified as maintenance factors in anorexia nervosa and as a barrier to effective FBT. Given emotion regulation is influenced and impacted by envi- ronments and relationships (Oldershaw et al., 2015), it has been proposed that simultaneously addressing established interpersonal patterns may be an important part of treatment (Treasure & Schmidt, 2013; Oldershaw et al., 2015). Thus, taken together the literature suggests that while FBT is effective for the majority of adolescents, there are compelling arguments that adjunctive treat- ments targeting emotion regulation in the young person, as well as family members, may help in improving outcomes for those identified as at risk of poor treatment outcomes.

102 THE CHILDREN’S HOSPITAL AT WESTMEAD TREATMENT PROGRAM 201 The Children’s Hospital at Westmead Treatment Program The day program at The Children’s Hospital at Westmead operates five days per week. It is a pro- gram designed for adolescents and those who are not responding to outpatient FBT. The pro- gram offers three supported meals per day, adolescent group therapy each afternoon, weekly family therapy, individual therapy as needed, medical and psychiatric monitoring, a weekly par- ent group, multi-âf•‰amily groups, and educational support. The program is designed to provide increased intensity for adolescents and their families who are not responding to FBT by providing additional inputs to care. It is designed as an adjunct to FBT to facilitate its effectiveness, rather than a new treatment. Accordingly, interventions for emotional regulation are not the sole focus of treatment, but are rather an essential component of a much larger treatment program. The aim of the program is to broadly address emotional regulation difficulties across a number of domains in the context of treating anorexia nervosa using FBT-âi•‰nformed systemic framework. The program is designed to specifically address disturbances in the experience of emotions for children and adolescents with anorexia nervosa. The program is based on increasing emotional awareness and reducing emotional avoidance by supporting young people to develop adaptive emotional regulation strategies and the capacity to select how and when to implement these. Based on the dimensions of Gratz and Roemer’s (2004) multidimensional model of emotion regu- lation and dysregulation, the program specifically aims to help young people to: 1 . Appropriately and flexibly managing distress 2 . Maintain behavioral control in the face of distress 3 . Increase emotional awareness, clarity, and acceptance 4 . Explore willingness to tolerate difficult emotions in order to pursue a fulfilling life A multidimensional approach to addressing these goals is used, including: 1. Specific skills-b╉ ased groups (drawn from DBT, CBT, and ACT) 2. Experiential/b╉ ehavioral opportunities to manage distress 3. Effectively utilising process and the structure of a day program (e.g., creating the right milieu for the group, engagement, validation, boundary setting, normalising, use of language) 4. Encouraging a life beyond anorexia nervosa /âa•‰ dolescent development Appropriately and flexibly managing distress Patients are taught a variety of specific techniques to modulate the duration and intensity of their emotional responses. Mindfulness is a key intervention in emotion regulation, with young people introduced to mindfulness at the commencement of their treatment and prac- ticed daily at the beginning of all therapeutic groups. Mindfulness practice includes mindful breathing, mindfulness of objects, music, and mindful games. How mindfulness can be an effective tool for managing distress is discussed and the ways it can be employed is problem solved by staff and patients. It is particularly encouraged after more challenging meals as a way to be in the present moment, non-j╉udgementally, and not to dwell on the meal that has just past or is upcoming. Participants are also taught other ways to manage distress including distraction, self-s╉ oothing, using intense sensations, and radical acceptance. Young people create their own “self-âs•‰oothing kits” by collecting objects that can be accessed in the moment of distress or remind them of strat- egies to use. Using such multiple emotion regulation methods flexibly (not relying on only one method) is encouraged, with patients assisted to match challenging situations with appropriate emotion regulation strategies.

20 202 Emotion Regulation and Eating Disorders Central to this, is teaching young people how to identify the early signs of their distress and the importance of intervening early in distress management. Creating “distress thermometers,” where participants map the physical, psychological and emotional changes that occur as their distress increases from zero out of ten (no distress) to ten out of ten (high distress), is part of this. Following this, young people then match strategies with differing levels of distress intensity. As distress becomes exponentially harder to manage the more it intensifies, staff focus on and sup- port young people to intervene early in their distress management. Young people are encouraged to involve family and other support as needed. Additionally, patients’ beliefs about their capacity to effectively manage emotions are chal- lenged. Many young people in the program have strong beliefs that they do not possess adequate skills to effectively and adaptively modulate emotional experiences—âa•‰ common experience in anorexia nervosa (Lavender, et al., 2015). Situations where young people effectively manage dis- tress are identified and amplified by staff with young people supported to identify and label their own skills to help increase self-âe•‰ fficacy. Maintaining behavioral control The ability to maintain behavioral control in the context of heightened negative emotional arousal is an important component of emotional regulation. While within-s╉ ession experiential emotional arousal has been argued as essential for addressing emotional dysregualtion (Greenberg & Pavio, 1997), creating such experiences in outpatient treatment is generally challenging, not least because those with anorexia nervosa are often highly emotionally avoidant, scared of emotion, and lack motivation to change (Hoetzel, von Brachel, Schlossmacher, & Vocks, 2013). In traditional FBT the meal session is a good opportunity for this, however, such a session generally occurs just once in treatment. The meal session is also often based around a food challenge and offers a lot of coaching by the therapist for parents, but less for the young person. The three meals per day provided in the day program provide patients with extensive practice at experiential emotional arousal in a therapeutic context. Meals are utilized not only as a means of pro- viding young people with anorexia nervosa with sufficient energy requirements, but also as an oppor- tunity to provide young people with repeated exposure to distressing events and a means to practice and utilize emotion regulation skills learned in the program. This is done explicitly by reminding and encouraging young people to use specific emotion regulation in response to food and challenging eating disorder rules or behaviors during meals, and implicitly by establishing an environment that aims to be less clinical than traditional inpatient settings. While clear boundaries remain, humour and engagement is utilized to create an adolescent-âa•‰ ppropriate environment. For example, meal times always include music, conversation, jokes, or games with all young people being equally engaged. While all eating disorder inpatient treatments provide meals, there are benefits to providing this in combination with a complementary psychological treatment (for those who are well enough to no longer require inpatient care). This is supported by Oldershaw and colleagues (2015), who suggest that interventions for people with anorexia nervosa should include and seek a balance between behavioral or experiential components and cognitive components. The meals provide opportunities to help young people manage their distress in vivo by drawing on psycho-e╉ ducation and distress tolerance skills. During meals, the young people must inhibit dysfunctional behaviors when distressed, such as refusing to eat, absconding, eating slowly, or hiding food. If someone does become distressed they are encouraged to draw upon skills they have learnt and other young people are invited to also encourage the young person struggling and provide advice.

302 THE CHILDREN’S HOSPITAL AT WESTMEAD TREATMENT PROGRAM 203 Beyond food and eating, behavioral/âe•‰xperiential opportunities to manage distress are also encouraged, planned for and debriefed. Young people are encouraged to practice managing many distressing situations, particularly those related to adolescent development e.g., turning to par- ents when distressed (practicing openness) and attending social events that might be anxiety-╉ provoking. Young people are also encouraged to tolerate changes to their body occurring with weight gain. Emotional awareness, clarity, and acceptance Many young people with anorexia nervosa are inattentive to their own emotional experiences and struggle to understand their emotions and the ability to differentiate between affective states. They also often have difficulty accepting emotions and often reject emotional experiences. Accordingly, therapeutic groups that specifically target understanding and accepting your feelings are an essen- tial component of the program. Groups to support this focus on identifying and labelling emotions, differentiating between the intensity of different emotions, exploring primary and secondary emotions, investigating the function of emotions, the pros and cons of having feelings, and challenging myths about emotions are utilized. Young people have opportunities to practice recognising their own emotions as well as those of others. Outside of specific skills-âb•‰ ased groups, participants are encouraged regularly to identify, label, and reflect on their emotional experiences. Each morning young people are asked about the pre- vious night and asked to describe how they felt, label the feeling, rate the intensity of the feeling, identify how it affected them, how the feeling was managed and how they would like to manage it next time. Experiencing emotions, including distress, is normalized. Staff model healthy emo- tional regulation by helping young people label their emotions as well as normalising and vali- dating the young person’s emotional responses (e.g., “I can understand why you felt that,” “when I have that feeling it also feels pretty bad”). Psycho-âe•‰ducation about the impact of suppressing and avoiding emotions is provided. This includes the functional aspects of using starvation to avoid experiencing difficult emotions and the long-ât•‰ erm consequences of this and how rejecting emotional experiences can result in second- ary negative affective states regarding the primary emotional response. Willingness to experience emotional distress Throughout the program, normal adolescent development is encouraged, as staff actively sup- port young people to value and remain on their normal adolescent developmental trajectory. For example, conversations are had about gaining independence from parents, learning to drive, attending school dances and what life after high school may look like. Staff emphasize the impor- tance of being willing and able to tolerate aversive emotional experiences in the context of pur- suing activities that are meaningful to the individual. Young people are encouraged to explore what it will mean to them now and in their future lives if they do not pursue recovery by avoiding emotional distress and contrast this with the impact of pursuing meaningful life activities (e.g., school, study, careers, sport, friendships and relationships). Activities are linked to specific eat- ing disorder symptoms, for example, what will it mean for young people if they are unable to eat in front of or with others. Activities include exploring the pros and cons of having an eating disorder, living a valued life and completing pie charts for now and the future without anorexia nervosa.

402 204 Emotion Regulation and Eating Disorders Case example The case of Emma outlined below is a combination of several patients and their families who have completed the day program. The case is used for two purposes; firstly, to give an example of the way emotion regulation interventions can enhance standard family based treatments and secondly, to illustrate the importance of not only providing young people with a forum to learn skills, but also highlighting the importance of ensuring there are the appropriate structures and therapeutic processes working in tandem to facilitate skill implementation. Emma Emma first presented with anorexia nervosa when she was 16-ây•‰ ears-o╉ ld. She weighed 41kg, was 156 cm tall and presented with medical complications of her weight loss including bradycardia (low heart rate) and hypothermia (low temperature). She resided with her mother, Leanne. Her father had been living in a separate house since the acrimonious breakdown of her parents’ mar- riage 18 months prior her 19 year-o╉ ld brother had moved out of the family home at the comple- tion of high school. Emma had an eight-âm•‰ onth history of food restriction and compulsive exercise resulting in a 7kg weight loss. She reported a six-m╉ onth history of amenorrhea. Emma described experiencing significant mood difficulties for the previous nine to twelve months, with reduced sleep, increased social isolation and anhedonia. Emma had been engag- ing in deliberate self-h╉ arm of superficial cutting on her wrists and hip up to twice a week for the previous three months. She described passive suicidal ideation, denying any active plans or will to commit suicide. Her presentation occurred in the context of ongoing, severe bullying at school and her grandmother passing away nine months prior with bowel cancer. Emma also described experiencing separation anxiety from her mother, Leanne, up until early primary school. Emma was admitted to an inpatient paediatric ward for medical stabilisation and psychologi- cal containment. Following her discharge FBT was provided by a clinical psychologist. After nine months of treatment Emma’s weight had slowly been reducing and family conflict continued to escalate. This had resulted in several occurrences of Emma running away from home during meals and physically intimidating her parents by threatening to hit them and on two occasions assaulting them. At this point the day program was offered to Emma and her family to contain Emma’s weight loss, stop the escalation of dangerous behavior, provide skills training to Emma around emotion regulation and increase systemic empathy and understanding. The aim of the admission to day program was to break the vicious cycle of Emma’s experience of parental invalidation resulting in Emma’s emotional distress and behavioral escalation. Over the course of her admission in the day program, emotion regulation and distress tolerance were key treatment interventions for Emma. Emma’s goal was to find ways of not becoming so angry that she needed to run away during meals or become threatening to her mother; something that made her feel very guilty. The daily adolescent group provided the most direct method of equipping Emma with the specific knowledge and skills around how to regulate her emotions. Box 10.2 outlines the selected skills Emma was taught in the group. Emma initially struggled with participating in group, often saying very little or saying she had tried everything and it did not help. While this was challenging to staff initially, through validation, encouragement and genuine interest in her difficulties staff were able to engage Emma in the process of group discussions, even though content remained difficult to engage with. In tandem with skills group, the day program context provided an opportunity for staff to prompt the early identification of signs of distress, the communication of difficult emotions and the appropriate use of skills in different contexts throughout the day, such as during difficult meals

502 Case example 205 BOX 10.2  Skills Group Content Provided to Emma Skills below are shared with parents during family sessions to ensure families are actively involved in skill implementation outside of program hours. Mindfulness ◆ Mindful observation using ◆ Anchoring oneself to the 5 senses present moment (e.g., using counting) ◆ breathing ◆ Finding “wise mind” Emotion ◆ Psycho-e​ ducation around the function of emotion Identification ◆ Guided practice on noticing internal experiences ◆ Emotion labelling, observation, distancing and acceptance ◆ Riding the wave of emotion Communicating ◆ Psycho-​education on communication styles Emotions ◆ Using words vs behaviours to communicate emotions ◆ Practice with role playing helpful communication styles and behavioural experiments Distraction ◆ Group discussion around the difference between skilful distraction and unhelpful avoidance ◆ Generation of a list of distraction techniques and pairing with appropriate times they can be used (e.g., drawing, board games/c​ ards, fidget toys/k​ inetic sand, time outs and engaging in conversation) Self-S​ oothing ◆ Design and creation of toolbox to have at home filled with items to self-s​ oothe using all five senses (e.g., music, motivational statements, meaningful gifts/​items, hand cream, nail polish, perfume, etc.) Opposite Action ◆ Identification of usual responses to each particular emotion and practice doing the opposite Replacements ◆ Holding ice Techniques for ◆ Cold shower Self-​Harm ◆ Rubber band on wrist or following stressful events. By ensuring group sessions involved practical elements, in vivo tasks or experiments and homework tasks, the environment ensured Emma experimented with skills, albeit begrudgingly. This slowly allowed her to experience some mild benefits from skill imple- mentation, which then allowed her to generalize them from their use on the program to life out- side of the program. Staff consistency in their relationship with Emma facilitated a safe space for her to feel accepted, despite frequent emotional outbursts. This allowed her to feel more comfort- able in trying new things and reduced feeling of shame or embarrassment. Importantly, other therapeutic aspects of the program, which were not directly related to emo- tion regulation skill development, were seen as key to helping Emma improve her ability to regu- late her emotions. Family and multi-​family sessions provided an opportunity for Emma to involve Leanne in emotion regulation skill development and planning could be done with the therapist

602 206 Emotion Regulation and Eating Disorders as to how Leanne could best support Emma with skill use. Additionally, with Leanne spending less time providing meals for Emma, this enabled her to plan more specifically around the meals she was supervising. This allowed her to feel more prepared and confident, leaving her more able to tune into Emma’s needs, reduce criticism and provide much needed validation during the meals. Similarly, multi-âf•‰amily groups and meals were also beneficial for Emma as they provided repeated opportunity for staff to model and coach Leanne on how to support Emma with consis- tent warmth and firmness, as well as skill use and implementation. Effective skill implementation only really began to result in noticeable changes for Emma four to five weeks after she commenced treatment. Through the process of staff using a firm but kind approach, with consistent boundaries and communication across all activities, Emma settled enough to attempt learnt techniques. She described finding it helpful being “checked-i╉n” with frequently and said it provided the opportunity to test out expressing her more difficult emotions. She also said the experience of interacting with staff in multiple therapeutic context (e.g. meals, groups, family therapy) was beneficial. She said this exposure to staff across settings, as well as staff being able to engage in adolescent appropriate conversations, use humour, model appropriate eating, and tolerate high affect allowed Emma to feel able to accept and engage in the program. It was then through this connection that Emma described feeling able to experiment with alternate ways of managing her emotions and tolerating feelings of worthlessness and hopelessness. Emma was discharged from the day program after completing 11 weeks. She was discharged within her healthy weight range after having gained four kilograms. While she continued to feel distressed around meals and many eating disorder behaviors persisted, she and her family said they felt much better equipped to continue to make gains in outpatient treatment. Both Emma and Leanne said that it was the combination of Emma learning new ways to regulate her emotions with Leanne being able to validate, understand and provide support around skill use that made them feel less stuck and able to move forward in treatment. Summary A growing body of literature indicates FBT is an effective treatment for adolescents with anorexia nervosa. Nevertheless, FBT is not effective for everyone, with a significant minority continuing to respond poorly to even the best available treatments. Given the role emotion regulation difficul- ties are hypothesized to play in the development and maintenance of anorexia nervosa, modifica- tions to FBT that target emotion dysregulation are emerging. The case of Emma highlights a few key factors to consider when designing and implementing emotion regulation focused adjuncts or modifications to treatment. It highlights the importance of matching skills training with a consistent program structure and a positive group milieu. It is through the combination of these three factors that progress in treatment is hypothesized to occur. In the case of Emma, without the structure or milieu, skills training was unlikely to have been meaningfully attempted poten- tially adding to her feelings of hopelessness and helplessness. It was through the combination of all three elements that psychoeducation was delivered in a format and environment that allowed Emma to make meaningful treatment gains. This approach to improving emotional regulation in adolescents with anorexia nervosa is in the early stages of assessment and further investigation and controlled trials are needed. Further research is also indicated to investigate the best approach to young people with other eating disorders including bulimia nervosa and binge eating disorder where individuals may have con- comitant problems with impulsivity and emotion regulation. There is a small body of research supporting the efficacy of a modified individual outpatient form of dialectical behavior ther- apy in adults with bulimia nervosa or binge eating disorder (Safer, Telch & Agras 2001; Safer

702 Summary 207 Robinson, & Jo, 2010) and trials are now being run in adolescents. Although research is promis- ing, it is in the early stages and further investigation is required involving large-s╉ cale unbiased studies. However, it is important to note, treatment outcomes have high success rates (20–6╉ 0%) when eating disorders are treated in childhood and adolescence; which is imperative, as adult anorexia nervosa is one of the most challenging psychiatric illnesses to treat effectively with one of the highest morbidity rates. References American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th Ed.). Arlington, VA: American Psychiatric Publishing. Agras, W. S., Lock, J., Brandt, H., Bryson, S. W., Dodge, E., Halmi, K. A., … & Woodside, B. (2014). Comparison of 2 family therapies for adolescent anorexia nervosa: a randomized parallel trial. Journal of the American Medical Association Psychiatry, 71(11), 1279–•1≠286. Ball, J., & Mitchell, P. (2004). A randomized controlled study of cognitive behavior therapy and behavioral family therapy for anorexia nervosa patients. Brunner-M╉ azel Eating Disorders Monograph Series, 12(4), 303–â‰3• 14. Bankoff, S. M., Karpel, M. G., Forbes, H. E. & Pantalone, D. W. (2012). A systematic review of dialectical behaviour therapy for the treatment of eating disorders. Eating Disorders, 20, 196–â•2‰ 15. Bruch, H. (1973). Eating disorders. Obesity, anorexia nervosa and the person within. New York: Basic Books. Bulik, C., Berkman, N. D., Brownley, K. A., Sedway, J. A. & Lohr, K. N. (2007). Anorexia Nervosa Treatment: A Systematic Review of Randomized Controlled Trials. International Journal of Eating Disorders, Vol. 40 (pp. 310–â3•‰ 20). Campbell, I. C., Mill, J., Uher, R., & Schmidt, U. (2011). Eating disorders, gene–╉environment interactions and epigenetics. Neuroscience Biobehavior Reviews, 35(3), 784–‰7•â 93. Couturier, J., Isserlin, L. & Lock, J. (2010). Family based treatment for adolescents with anorexia nervosa: A dissemination study. Eating Disorders, Vol. 18 (pp. 199–â2•‰ 09). Crisp, A. H., Norton, K., Gowers, S., Halek, C., Bowyer, C., Yeldham, D., … & Bhat, A. (1991). A controlled study of the effect of therapies aimed at adolescent and family psychopathology in anorexia nervosa. British Journal of Psychiatry, 159(3), 325–‰â•333. Dvir, Y., Ford, J. D., Hill, M., & Frazier, J. A. (2014). Childhood Maltreatment, Emotional Dysregulation, and Psychiatric Comorbidities. Harvard Review of Psychiatry, 22(3). 149–•â1‰ 61. Eisler, I., Dare, C., Hodes, M., Russell, G., Dodge, E., & Le Grange, D. (2000). Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41, 727–‰•â736. Eisler, I., Dare, C., Russell, G., Szmukler, G., le Grange, D., & Dodge, E. (1997). Family and individual therapy in anorexia nervosa: A 5–ây•‰ ear follow-u╉ p. Archives of General Psychiatry, 54, 1025–â1‰• 030. Eisler, I., Simic, M., Russell, G. F. M., & Dare C. (2007). A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-ây•‰ ear follow-âu•‰ p. Journal of Child Psychology and Psychiatry, 48, 552–â5‰• 60. Eisler, I., Simic, M., Russel, G. & Dare, C. (2007). A randomised controlled treatment trial of two forms of family therapy in adolescent anorexia nervosa: a five-y╉ ear follow-âu•‰ p. Journal of Child Psychology and Psychiatry, 48(6), 552–‰5â• 60. Federici, A. & Kaplan, A. (2008). The Patient’s Account of Relapse and Recovery in Anorexia Nervosa: A Qualitative Study. European Eating Disorders Review, 16, 1–•â‰10. Federici, A. & Wisniewski, L. (2012). Integrating dialectical behavioral therapy and family-b╉ ased treatment for multidiagnostic adolescent patients. In Alexander, J. & Treasure, J. (Eds.), A collaborative approach to eating disorders (pp. 177–1╉ 88). New York: Routledge. Forsberg, S. & Lock, J. (2015). Family-âb•‰ ased treatment of child and adolescent eating disorders. Child and Adolescent Clinics of North America, 24, 617–•â‰629.

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Chapter 11 Emotion Regulation and Substance Use Disorders in Adolescents Thomas A. Wills, Jeffrey S. Simons, Olivia Manayan, & M. Koa Robinson Substance use disorders This chapter considers the role of emotion regulation with regards to vulnerability to substance use disorders in adolescence. While a number of young people only experiment at low levels with tobacco, alcohol, or other substances in early adolescence (11–1╉ 4 years of age), a proportion of these escalate their frequency and intensity of use over time (Colder et al., 2002; White et al., 2002; Windle & Wiesner, 2004). In later adolescence (15–1╉ 8 years of age), frequent substance users are more likely to transition to substance use disorder, though a sizable proportion do not (Harrison, Fulkerson, & Beebe, 1998; Simons, Carey, & Wills, 2009; Wills, Sandy, & Yaeger, 2002). Emotion regulation processes are implicated in the likelihood of transitioning from frequent use to the development of a disorder. Yet, while theoretical papers have outlined conceptual approaches to understanding how emotion regulation relates to risk for substance abuse (Khantzian, 1990; Southam-G╉ erow & Kendall, 2002), there is still little direct evidence on this question from adolescents. The purpose of this chapter is to provide a conceptual approach to understanding how emo- tion regulation is involved in vulnerability vs. protection for adolescent substance abuse. It is important to emphasize that many questions about the relation of emotion and substance use are not settled at this time. For example, it remains unclear how emotional distress is causally related to disorder (Cheetham et al., 2010; Swendsen & Le Moal, 2011), how negative affect and substance use are related in daily life (see for ex. Kassel & Veilleux, 2010; Simons, Wills, & Neal, 2014), and how the physical effects of substances may contribute to the dysregulation of emotion (Baker et al., 2004; Koob & Le Moal, 2008). These topics will be illuminated by discussing current questions about emotion and its regulation and then showing how these are relevant for clinical research and practice with adolescents. An initial review of the data will highlight the prevalence of tobacco, alcohol, and marijuana use among adolescents, summarize the prevalence of sub- stance use disorders in late adolescence, and discuss clinical issues in diagnosing these disorders in the adolescence populace. Once prevalence rates have been addressed, the emotion regulation processes relevant for substance use disorders will be discussed and reviewed. Clinical implica- tions will be outlined, with a focus on a preventive intervention based on emotion regulation concepts that has demonstrated efficacy in reducing substance abuse issues. Finally, the current state of the area will be summarized and directions for future research will be discussed. Prevalence of substance use Data on the prevalence of substance use among adolescents is available from several US national studies. The Monitoring the Future (MTF) project has been conducted annually since 1975

(Johnston et al., 2015). This project is a repeated series of cross-âs•‰ectional school-âb•‰ ased surveys, with the same set of questions given every year to comparable age groups. Trends for prevalence of tobacco, alcohol, and marijuana use delineated in the MTF survey have also been observed in other national surveys with different sampling and data collection methods, such as the Youth Risk Behavior Surveillance Study (Frieden et al., 2014) and the National Survey on Drug Use and Health (Center for Behavioral Health Statistics, 2015). The 2014 MTF survey included about 41,600 students who were in eighth, tenth, or twelfth grade in public or private secondary schools across different areas of the United States. In this survey, the lifetime prevalence for any alcohol use was 27%, 49% and 66% for eighth, tenth, and twelvth graders, respectively. Rates of alcohol use within the past 30 days, an index of regular use, were 9%, 24% and 37% for these same age groups. Hence, the prevalence of alcohol use was shown to be substantial, particularly in later adolescence. Consistent with other surveys, the MTF study has found marijuana to be the most widely used illicit drug over the 40-y╉ ear history of the survey (Johnston et al., 2015). In the 2014 survey, the prevalence for ever-âu•‰ se of marijuana or hashish ranged from 12% to 35% among eighth to twelfth graders, and the prevalence of use during the past 30 days was 6%, 17%, and 21% for these same age groups. Thus, it is observed that usage rates increase steadily by age for all substances. The study also provided information regarding differ- ing patterns of use with regards to gender, ethnicity, and socioeconomic status; however, detailed discussion of this data is beyond the scope of the present chapter. With regard to secular trends, the absolute level of cigarette use has declined steadily over the last decade. The most recent MTF survey found that cigarette use among adolescents is now at the lowest level recorded in the history of the survey (30-âd•‰ ay prevalence of 4%, 7%, and 14% for eighth, tenth, and twlveth graders, respectively). Although MTF data on adolescents shows rates of marijuana use that have remained stable in recent years, Hasin et al. (2015) noted that the rate of marijuana use in the U.S. adult population has doubled in the past ten years. MTF data have shown a steady decline in perceived risk of marijuana use among adolescents, and because of policy changes in some U.S. states, rates of teenage use are being watched with concern. Prevalence of substance use disorder Although many adolescents experiment with alcohol or marijuana use, only a proportion prog- ress to developing a substance use disorder (SUD; Wills et al., 2002). The differentiating charac- teristics of substance use disorders involve physiological, behavioral, and cognitive changes in the user and continued use despite negative, substance-r╉elated consequences (American Psychiatric Association, 2013). Studies conducted during the past two decades to determine the prevalence of disorders in the U.S. adolescent population are summarized in Table 11.1. The researchers used DSM-âI•‰ II or DSM-âI•‰ V criteria for diagnoses and reported separate prevalences for substance abuse and substance dependence. (The term Substance Use Disorder has been recently adopted as the sole diagnostic term in the DSM-5╉ .) Kilpatrick et al. (2000) were the first to assess the prevalence of substance use and abuse, as defined by DSM-I╉ V guidelines, in a U.S. national sample. Data were collected through telephone interviews with a sample of adolescents ages 12–â1•‰ 7 years, recruited through random-d╉ igit dial- ing. Hard drugs were defined as cocaine, heroin, inhalants, LSD, or prescription drugs. This study found a 12-âm•‰ onth prevalence of 8% for alcohol abuse/âd•‰ ependence, 7% for marijuana abuse/╉ dependence, and 2% for hard drug abuse/âd•‰ ependence. In a study by Merikangas et al. (2010), face-ât•‰o-f╉ace interviews were conducted in households by trained research staff with a sample of 10,123 adolescents ages 13–â1•‰ 8 years. This study used a modified version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) designed to be better suited to the lifestyles and experiences of adolescents. This

21 212 Emotion Regulation and Substance Use Disorders in Adolescents Table 11.1╇ Studies on Prevalence of Substance Use Disorder among Adolescents Citation Sample N Alcohol Marijuana Illicit Drug Any Substance 4,023 Abuse/ Abuse/ Abuse/ Disorder 10,123 17,046 Dependence Dependence Dependence —╉ Kilpatrick et al., 2000 National 8%A 7% 2% 11% Merikangas et al., 2010 National 6%B n.a. 9% 5.0 SAMHSA, 2014 National 2.7A 2.7 3.5 A 12-m╉ onth prevalence. B Lifetime prevalence. study revealed the most-r╉ eported illegal drugs used were marijuana, cocaine, and illicit prescrip- tion drugs (Swendsen et al., 2012). These investigators reported a lifetime prevalence of 6% for alcohol abuse/d╉ ependence, 7% for illicit drug abuse/d╉ ependence, and 11% for any substance use disorder. Thus, consistent with Kilpatrick et  al. (2000), there was an appreciable prevalence of substance use disorder observed in the adolescent population. The National Survey on Drug Use and Health (NSDUH) is an annual survey of the US population and most recently has used DSM-I╉V criteria with a 12-âm•‰ onth time frame. Data for the 2014 survey for adolescents aged 12–1╉ 7 years (Center for Behavioral Health Statistics, 2015) showed that 2.7% of the sample had an alcohol abuse diagnosis, 2.7% had a marijuana abuse diagnosis, and 3.5% had an illicit drug abuse diagnosis (including marijuana but also cocaine, heroin, inhalants, and non-âp•‰ rescribed prescription drugs). Overall, 5.0% of the ado- lescent population was indicated as having any kind of substance use disorder. NSDUH data have shown declines in rates of disorder from 2002 to 2012, though most rates have been stable for 2013 and 2014. Across studies, a higher prevalence of SUD was found for adolescent boys when compared to adolescent girls of the same age demographic. All studies saw an increase in SUD prevalence with age, particularly between the ages of 14–â1•‰ 7. Overall, lower rates of substance abuse and depen- dence were found in minority ethnic groups compared to Caucasians (Kilpatrick et al., 2000, Merikangas et al., 2010). Although rates of substance use disorders among adolescents are not as high as for depression and anxiety disorders, studies have shown a significant comorbidity of SUDs and other psychopathological conditions (Cheetham et al., 2010). Diagnosis of substance use disorder: Adolescents The latest diagnostic criteria in DSM-5╉ (American Psychiatric Association, 2013) define SUD as a pattern of substance use that substantially interferes with social, occupational, or interpersonal functioning. The occurrence of only two symptoms from a heterogeneous set of 11 symptoms is required. Symptoms may be broadly clustered into domains of 1) impaired control over use (e.g., using larger amounts or over a longer period of time than intended; craving), 2) social impairment (e.g., failure to fulfill role obligations in work, school, or home; interpersonal conflict), 3) hazard- ous use (e.g., drinking and driving), and 4) pharmacological indicators of tolerance or withdrawal. The pharmacological criteria notwithstanding, the syndrome may be broadly conceptualized as an inability to effectively regulate substance use. In this regard, SUD is characterized by failed efforts to control consumption, resulting in interference with social functioning, accumulating negative consequences, and repeated, substantial risks to the self.

312 Emotion regulation strategies 213 There has been debate in the clinical literature about diagnosing SUD in adolescence. There are two primary concerns regarding the appropriateness of SUD criteria to younger adolescents. Firstly, younger adolescents generally have less opportunity to use substances due to parental monitoring and restricted access; hence, use may be less frequent and more sporadic, which substantially reduces the likelihood of symptoms such as withdrawal and of use interfering with social role obligations (Kaminer & Winters, 2015). Moreover, the hazardous-u╉ se criteria often reflect drinking and driving, which younger adolescents typically are precluded from (Winters, 2013). Finally, several criteria require fairly sophisticated executive functions and self-a╉ wareness, such that individuals need to identify and set use limits; and impaired control is then inferred by failure to meet these limits. However, the cognitive development of children and younger adoles- cents reflects a period of heightened reward-âs•‰ eeking and socio-âe•‰ motional functioning prior to the maturation of executive control functions (Steinberg, 2008). Hence among adolescents, substance use may be severely dysregulated in the sense that they do not have high control over it, yet they are not using more than “intended” nor displaying failed efforts to “cut down or control” use (Chung & Martin, 2005). Thus the standard diagnostic criteria could miss patterns of substance use in children and adolescents that are of clinical relevance. Second, even modest substance use by children and adolescents is highly likely to cause con- flict with parents, educators, and law enforcement. This may be particularly pronounced with female adolescents, who are more likely to report drinking despite interpersonal problems than their older peers (Harford, Grant, Yi, & Chen, 2005). Furthermore, children and adolescents are in the midst of a period of shifting peer groups, struggles with emotional and behavioral regula- tion, and transitions in their involvement in school and recreational activities; and some have yet to develop long-ât•‰erm commitments to educational and occupational pursuits. Thus, there is the risk that experimental, essentially normative, substance use during this dynamic period may be mislabeled as an SUD (Winters, 2013). Indeed, many individuals mature out of risky sub- stance use patterns in young adulthood (Jochman, Fromme, & Scheier, 2010; Reich, Cummings, Greenbaum, Moltisanti, & Goldman, 2015); for example, the frequency of binge drinking tends to decline in the mid-â2•‰ 0s (Reich et al., 2015). Although substance use frequency may decline, some research suggests that observed declines in SUD with age reflect decreases in new cases and lower risk of relapse rather than developmental changes in the persistence of SUD once estab- lished (Verges et al., 2013). In other words, transition in and out of problematic substance use is common (Compton, Dawson, Conway, Brodsky, & Grant, 2013), but the risk of developing new problematic patterns of use tends to decline with age. In summary, diagnosis and recognition of substance-âr•‰ elated problems in youth requires a balanced consideration of the potential increased vulnerability of the developing brain to substances (Spear, 2010), the potential for diagnostic cri- teria to underestimate the severity of the problem (Kaminer & Winters, 2015), and conversely a need to recognize that there is a certain amount of age-a╉ ppropriate drug experimentation that may not warrant costs associated with diagnosis and intervention (Winters, 2013). Emotion regulation strategies Research on specific emotion regulation strategies has focused on the regulation of negative emo- tions (anxiety and depression). There is of course a reason for this because there is a substantial comorbidity of affective disorders with substance use disorder (Kober, 2014). However, it should be noted that there is still debate about the causal interpretation of the comorbidity (Cheetham et al., 2010) and evidence is mixed on the relationship between negative affect and substance use in laboratory studies and in daily life (see Kassel, Hussong, et al., 2010; Mohr et al., 2010; Shrier, Ross, & Blood, 2014; Simons, Dvorak, Batien, & Wray, 2010; Sher & Grekin, 2007). It is possible

412 214 Emotion Regulation and Substance Use Disorders in Adolescents that substance disorder develops because of elevated negative affect. However, it is also possible that both substance use and affective disorder are attributable to an underlying, transdiagnostic vulnerability factor (dysregulation of behavior and emotion being a plausible candidate) and/╉ or that the biological and social disruptions occasioned by substance abuse themselves produce negative affect (Koob & Le Moal, 2008; Swendsen & Le Moal, 2011). A credible body of theory also points to deficiencies in positive affect as an important but understudied influence on the development of disorder (Gilbert, 2012). Low positive affect may occur because of a dispositional deficiency in the ability to experience positive mood (reward deficiency syndrome or hedonic capacity: Audrain-M╉ cGovern et al., 2012; Yacubian & Buchel, 2009) or because of lack of access to alternative reinforcers (Audrain-âM•‰ cGovern et al., 2010). Specific strategies for emotion regulation Emotion regulation is a multifaceted domain ranging from relatively automatic biological pro- cesses (e.g., vagal tone, amygdala) to effortful coping processes (e.g., reappraisal, breathing exer- cises etc.) and meta-e╉ motional constructs such as mindfulness (Brewer, Elwafi, & Davis, 2013; McRae et al., 2012). There have been a considerable number of studies conducted in which a specific emotion regulation strategy is related in a laboratory setting to a measure of a particular emotion (Webb et al., 2012). This research has produced a number of theory-t╉esting findings, for example, the finding that distracting oneself from the stressor can have beneficial effects; but generalization of the laboratory paradigms to risk for drug use or abuse remains unknown. Aldao, Noelen-âH•‰ oeksema, and Schweizer (2010) have considered studies conducted with distressed clinical samples of adults, some of which included substance use as an outcome (e.g., Noelen-╉ Hoeksema et al., 2007). In short, the strategies they examined include: Reappraisal, problem solv- ing, acceptance, avoidance, and suppression. Findings on these will be summarized below. Reappraisal involves changing one’s perception of a problem so that it is perceived as less serious or less threatening. The meta-a╉ nalysis by Aldao et al. (2010) concluded that on average this was a moderately effective strategy. Problem solving involves getting information about the problem, considering alternative solutions to a problem, and making an active effort to change the situation. Though it is behavioral, not emotional in nature, meta-a╉ nalysis has supported problem solving as an effective emotion regulation strategy (Aldao et al., 2010). Acceptance involves non-âj•‰udgmental acceptance of the distressed emotion and has been posited to prevent negative emotions from tak- ing over and overwhelming other coping efforts; it involves accepting sensations, such as craving, for what they are. Meta-a╉ nalyses so far have not shown strong evidence across psychopathology groups for acceptance as a single emotional regulation strategy (Aldao et  al., 2010). However, studies focused on drug abuse have shown mindfulness to be a significant protective factor against substance use and relapse (Brewer et al., 2013; Elwafi et al., 2013). Avoidance of negative emotions has been studied in clinical settings and across pyschopathol- ogy groups; it has been shown to have a strong adverse effect, creating emotional distress rather than reducing it (Aldao et al., 2010). Indeed, reducing avoidance is a central component of the unified protocol for treating emotion disorders (Moses & Barlow, 2006). However, although per- sistent avoidance appears detrimental, distraction appears to be an effective strategy for the initial response to high-i╉ntensity emotional stimuli (Sheppes et al., 2014). Suppression is a response-╉ focused emotion regulation strategy that has been linked to negative health outcomes. Trying to suppress unwanted thoughts and emotions has been examined in a number of laboratory and clinical studies and is consistently found to be an ineffective strategy (Aldao et al., 2010). Paradoxically, attempts to suppress emotion usually increase the occurrence of the unwanted thoughts and feelings (Webb et al., 2012).

512 General attributes of emotion regulation 215 General attributes of emotion regulation There are more studies that have related general attributes of emotional regulation to risk for substance use or disorder. In this section five key attributes will be considered, namely: reactivity, soothability, distress tolerance, affective variability, and emotional inertia accompanied by rumi- nation. These are summarized with sample measurement items in Table 11.2. It should be noted that these attributes can be delineated separately, but while recognizing that they are conceptually distinct, we note that they may be empirically intercorrelated. In relation to reactivity, the origins of vulnerability to substance use disorder are believed to be rooted in early temperament characteristics (Tarter et al., 1999; Wills, Sandy, & Yaeger, 2000). Indeed, temperament characteristics measured at three to five years predict risk for substance abuse and other psychopathology dimensions at age 21  years (Caspi et  al., 1996; Kirisci et  al., 2015). Temperament research with young children has distinguished irritability and reactivity to aversive stimulation as a basic dimension of temperament, which is predictive of substance use but may, however, be modulated by cognitive control (Rothbart, Ahadi, & Evans, 2000; Wills et al., 2000). Initial temperamental reactivity can be increased by early adversity (e.g., poverty, child abuse), which works to change hypothalamic–p╉ ituitary–âa•‰ drenal (HPA) functioning so as to make Table 11.2╇ Sample Items for General Attributes of Emotion Regulation or Dysregulation Reactivity (Angerability) When I have a problem at school or at home: I get mad at people. I yell and scream at someone. Anger Control When I am angry or upset: I stay calm and “keep my cool” when I’m feeling mad. I try to calmly deal with what is making me mad. Soothability I can easily calm down when I am excited or “wound up.” If I get upset or distressed, I can recover quickly. Sadness Control When I am feeling sad or down: I can control my sadness and carry on with things. I stay calm and don’t let sad things get to me. Distress Tolerance I can’t handle feeling distressed or upset. (Disagree) When I feel distressed or upset, I must do something about it immediately. (Disagree) Affective Lability My moods change a lot from day to day. I shift back and forth from feeling calm to feeling tense and “jittery.” Rumination I often find myself thinking about things that have made me angry. I get angry thinking about things that have happened in the past. Sources: Oliver & Simons, 2004; Simons & Gaher, 2005; Wills et al., 2006, 2011, 2013.

612 216 Emotion Regulation and Substance Use Disorders in Adolescents some individuals even more reactive to stress (Andersen & Teicher, 2009). Other things equal, persons who are more reactive to stress are at an increased risk for substance abuse and other disorders (Siegel, 2010, 2015; Sinha, 2008). Soothability, an additional key element related to substance abuse, is defined as the ability to reduce aversive arousal states through one’s own efforts. Khantzian (1990) originally noted that clients with drug use disorder experienced difficulty soothing or calming themselves when they were in stress-p​ rovoking situations. Khantzian (1990) suggested, in his self-m​ edication model, that this was a basic process in perpetuating drug consumption because persons with low soothability turned to drugs for more immediate relief. Effective implementation of self-​soothing produces lowered arousal, which makes it easier to pursue effortful, active coping efforts and has the additional benefit of not alienating supporters through lashing out in anger. Soothability, as a general attribute, may involve several of the specific strategies outlined above (e.g., attentional focusing, distraction, reappraisal). Research has demonstrated that measures of soothability are positively correlated with other indices of emotional control ability and are inversely related to substance use in early adolescence (Wills et al., 2006). Distress tolerance is another key element that is intricately tied to risk for substance use disor- der. The ability to reflect on feeling states and engage in adaptive coping responses may depend, in part, on an individual’s ability to tolerate distress. In this regard, distress tolerance may be considered a meta-​emotion construct that incorporates the perceived ability to withstand dis- tress; appraisal of distress; efforts to stop distress; and the tendency to become absorbed by dis- tress (Simons & Gaher, 2005). Low tolerance for distress has been linked to substance use (Leyro, Bernstein, Vujanovic, McLeish, & Zvolensky, 2011; Wray, Simons, Dvorak, & Gaher, 2012), to other indicators of dysregulated affect, such as deliberate self harm (Arens, Gaher, Simons, & Dvorak, 2014), and to psychopathology syndromes linked to dysregulated affect such as posttrau- matic stress disorder and borderline personality disorder (Gaher, Hofman, Simons, & Hunsaker, 2013; Vujanovic, Marshall-​Berenz, & Zvolensky, 2011). In addition, reduced ability to differen- tiate, label, and understand the source of emotion states (i.e., alexithymia) has been inversely associated with distress tolerance (Gaher et al., 2013). Both low distress tolerance and deficits in emotional awareness have been associated with poor behavioral control, especially when nega- tively aroused (Emery, Simons, Clarke, & Gaher, 2014; Gaher et  al., 2013; Shishido, Gaher, & Simons, 2013). Thus, the lack of understanding of emotional states and the inability to tolerate or accept aversive feeling states may increase the likelihood of incurring substance-r​ elated problems (Buckner, Keough, & Schmidt, 2007; Emery et al., 2014; Shishido et al., 2013), whilst also inter- fering with engagagement in substance use treatment (Daughters et al., 2005). Taken together, the findings suggest that the clarity of emotional experience and the ability to mindfully accept emotions are indicative of adaptive emotion regulation. In contrast, poor tolerance for distress and limited awareness of emotional experience (e.g., poor differentiation, poor labeling or under- standing) promote impulsive responding, efforts to suppress emotion, and maladaptive substance use outcomes. An additional factor that impacts substance use disorder is affective variability. In recent years, there has been increased understanding of the importance of the dynamic time course of emo- tion in studies of emotion regulation (Ebner-​Priemer, Eid, Kleindienst, Stabenow, & Trull, 2009; Fairbairn & Sayette, 2013; Simons, Wills, & Neal, 2014). Affective lability refers to the speed, fre- quency, and range of changes in affective states (Oliver & Simons, 2004). Studies on borderline personality disorder and depression have highlighted the importance of instability of affect, over and above mean levels, in contributing to pathology (Jahng et al., 2011). Similarly, research on substance use problems has indicated significant effects of affective variability, often over and above mean affect level, such that individuals who are more variable in mood show more alcohol

712 Emotion regulation and substance use/abuse in adolescence 217 and marijuana related problems and tobacco use (Dvorak & Simons, 2008; Mohr, Arpin, & McCabe, 2015; Simons & Carey, 2006; Simons et al., 2014; Weinstein & Mermelstein, 2013a). In respect to emotion regulation strategies for reducing affective variability, research indicates that the source (e.g., bottom-u╉ p vs. top-d╉ own) as well as the intensity of emotions influences the selection and effectiveness of emotion regulation strategies (McRae, Misra, Prasad, Pereira, & Gross, 2012; Sheppes et al., 2014). In this regard, cognitive strategies, such as reappraisal, appear to be more effective for emotions that are, in part, the result of cognitive evaluations (McRae et al., 2012). Cognitive reappraisal is more often utilized when individuals are experiencing rela- tively low-i╉ntensity emotions. In contrast, when emotions are of high intensity, strategies such as distraction, which minimizes emotional processing, are efficacious (Sheppes et al., 2014). Taken together, these results suggest that individuals who experience intense, unpredictable shifts in emotion may be predisposed towards relying on regulatory strategies that minimize awareness and processing of the emotional stimuli, making substance use an attractive option. This view is consistent with Khantzian’s (1990) hypothesis that the negative consequences experienced by individuals with a drug use disorder are less salient than the fact that he/âs•‰ he can control emotional states through drug use. A final factor influencing substance abuse is emotional inertia and rumination. Emotional iner- tia (i.e., the autocorrelation of emotion across time) has also been identified as a central construct in research on affect dysregulation (Kuppens et al., 2012) and substance use (Fairbairn & Sayette, 2013). In contrast, affective lability indicates an inability to maintain homeostasis and continu- ity in emotional responding. Emotional inertia is indicative of dysregulation in emotion, such that emotion is likely fixed by an inward, ruminative focus rendering the person disconnected from important contextual stimuli that the emotion is expected to vary in response to (Fairbairn & Sayette, 2013; Koval, Kuppens, Allen, & Sheeber, 2012). Research suggests that some of the reinforcing properties of alcohol may stem from alcohol’s ability to disrupt emotional inertia (Fairbairn & Sayette, 2013). Alcohol myopia theory (Steele & Josephs, 1988) predicts that tension-╉ reduction properties of alcohol are due, in part, to the effects of alcohol on limiting focus to immediately salient stimuli. Emotion regulation and substance use/a╉ buse in adolescence In this section representative studies relating emotion regulation attributes to risk for substance use or use disorder in young persons are highlighted (Table 11.3). There have been few studies conducted in early or middle adolescence (ages 12–â1•‰ 6 years); based on this fact, this chapter will include studies conducted in late adolescence or young adulthood (ages 17–2╉ 5 years). Initially, studies that have related a single emotional measure to substance use will be discussed. Following this, studies that used composite scores based on a dual-p╉ rocess approach (Gibbons et al., 2009; Wills et al., 2013) will be delineated. This approach posits distinct systems of regulation and dys- regulation, which have different antecedents and different consequences. Emotion dysregulation and motives for use Motives for substance use are a significant predictor of disorder (Wills & Ainette, 2010) and may derive from deficits in emotion regulation. Several recent studies have tested how the Difficulties in Emotion Regulation Scales (DERS; Gratz & Roemer, 2004; Weinberg & Klonsky, 2009) is related to high-r╉isk motives for use, particularly using drugs to deal with personal distress (i.e., coping motives). The DERS assesses difficulties in controlling emotion as well as dimensions of suppression and non-a╉cceptance of emotion. Dvorak et al. (2014) found that difficulties with controlling negative emotion were related to higher frequency of drinking and to more adverse

812 Table 11.3  Studies of Emotion Regulation and Substance Use, For Single Strategies and Dual-P​ rocess Constructs Citation Mean age (yrs) Findings General emotion regulation difficulties Difficulties with ER related to adverse alcohol consequences. Dvorak et al. (2014) 20.5 Limited ER strategies related to drinking to cope. Veilleux et al. (2014) 19.7 Tolerance related to fewer alcohol and cannabis Distress tolerance 18.7 problems. Buckner et al. (2007) Heavy-d​ rinking adolescents had lower distress tolerance. Winward et al. (2014) 17.7 Emotion dysregulation related to PTSD in SUD Emotion dysregulation and PTSD 35.5 sample. Weiss et al. (2013) Emotional intelligence inversely related to impulsivity, PTSD. Gaher et al. (2014) 28.9 Affective lability predicted alcohol dependence, Affective lability 19.6 but not abuse. Simons et al. (2009) Affective lability predicted smoking escalation among girls. Weinstein & 15.7 Mermelstein (2013b) Low hedonic capacity was related to escalation of 15.7 smoking. Hedonic capacity 49.7 Successful smoking quitters had more alternative reinforcers. Audrain-​McGovern et al. (2012) Mindfulness tendency inversely related to drug use/p​ roblems. Goelz et al. (2014) Mindfulness had indirect effect to smoking through less depressive affect, perceived stress. Trait mindfulness 19.9 Tarantino et al. (2015) Dysregulation had less impact on alcohol problems among persons scoring higher on self-​control. Black et al. (2012) 16.2 Emotional dysregulation had direct + indirect effects to dependence problems. Dual-p​ rocess studies 20.2 Emotional dysregulation had direct + indirect Dvorak, Simons, & Wray (2011) effects to both externalizing and internalizing symptomatology. Emotional self-​control had direct Wills et al. (2011) 16.0 effect to positive well-​being. Wills et al. (2016) 12.5

912 Emotion regulation and substance use/abuse in adolescence 219 consequences (i.e., alcohol abuse) among college students. In addition, non-a╉ cceptance of emo- tion was related to more adverse consequences among the most problematic drinkers. Veilleux et al. (2014) found that lack of emotional control strategies and lack of clarity about emotion were both predictive of high-âr•‰isk alcohol use (drinking to cope). Furthermore, Simons et al. (2005a) have shown that expectancies about one’s competencies in the regulation of negative mood were inversely related to coping motives for marijuana use. Additional studies have related emotion regulation difficulties to substance-r╉elated problems in samples of college students (Chandley et al., 2014; Messman-âM•‰ oore & Ward, 2014) and clinical samples of individuals with substance use disorder (Buckholdt et al., 2014; Fox et al., 2008). Wong et al. (2013) found emotional suppression was positively related to prescription drug misuse and illicit drug use. In contrast, persons who actively coped with negative emotions had less illicit drug use and were more likely to also use other adaptive coping strategies, such as support-âs•‰ eeking and positive reappraisal. Distress tolerance Overall emotional experience may depend on the ability to tolerate negative emotions. This con- struct is often measured using the Distress Tolerance Scale (DTS, Simons & Gaher, 2005), which includes subscales termed Tolerance, Absorption, Appraisal, and Regulation (needing to act immediately when distressed). Buckner et al. (2007) found that a better ability to tolerate distress was related to lower frequency of alcohol use and was inversely related to alcohol and cannabis problems. They suggested that individuals with low distress tolerance are more likely to use sub- stances for regulating negative emotions. Winward et al. (2014) studied adolescents with heavy episodic drinking (HED) and matched controls. The HED adolescents initially had low distress tolerance but showed decreased emotional reactivity when they became abstinent. Other studies have shown distress tolerance inversely related to coping motives in a sample of current marijuana smokers (Zvolensky et al., 2009) and a sample of Posttraumatic Stress Disorder (PTSD)-âa•‰ffected young adults (Marshall-âB•‰ erenz et  al., 2011). One study found a laboratory measure of distress tolerance inversely related to alcohol use in a sample of younger adolescents (Daughters et al., 2009). These studies complement findings showing that low distress tolerance predicts lapse and relapse among smoking cessation clients (e.g., Brown, Lejuez, & Kahler, 2002). Emotion dysregulation, PTSD, and substance abuse Several studies have implicated poor emotion regulation in stress-âr•‰elated symptomatology and substance abuse in college students (Gaher et al., 2013; Goldsmith et al., 2013; Weiss et al., 2012) and victimized populations (Hellmuth et al. 2013; Sullivan et al., 2012). Of particular note from a clinical standpoint are studies showing how maltreatment in early childhood contributes to an increased risk for substance use disorder in adolescence. Studies have now implicated under- mining of self-âr•‰ egulation as a pathway for effects of maltreatment, alternately showing mediation of these effects through decreased problem solving (Shin, Hong, & Wills, 2012), through more affect dysregulation and PTSD (Oshri et al., 2015; Rosenkranz, Muller, & Henderson, 2014), or through alexithymia and impulsivity (Hahn, Simons, & Simons, 2015). Studies of trauma-âe•‰ xposed adult samples have consistently shown PTSD to co-o╉ ccur with ele- vated rates of substance abuse (e.g., Hellmuth et al., 2012, 2013). Recent studies have clarified how difficulties in emotion regulation may contribute to this comorbidity. Weiss et al. (2013) studied SUD inpatients using the DERS. Patients with PTSD scored higher on emotion dysregu- lation, with the strongest differences on the subscales for nonacceptance of emotion and limited emotion regulation strategies. Gaher et al. (2013) included an emotional intelligence measure in an experience sampling study with heavy-d╉ rinking military veterans. Between-p╉ erson analyses

02 220 Emotion Regulation and Substance Use Disorders in Adolescents showed alcohol problems were related to lower emotional intelligence and positively correlated with PTSD symptoms. On a repeated-m╉ easures basis, occurrence of PTSD symptoms during the day was related to increased alcohol use and associated problems the same night. Affective lability Some investigations of affective lability have used a dispositional measure, the Affective Lability Scales (ALS, Oliver & Simons, 2004); others have constructed statistical indices of variability in mood from repeated-m╉ easures data. The ALS was used in a longitudinal study with heavy-d╉ rinking college students by Simons, Carey, and Wills (2009). A structural modeling test of the influence of affective lability, controlling for behavioral dysregulation, found lability was not related to level of alcohol consumption but it did predict change in alcohol dependence symptoms. Behavioral dysregulation, in contrast, predicted abuse symptoms but not dependence symptoms. This find- ing was replicated in an experience sampling study in which daily reports were obtained over a two-y╉ ear period and variability was indexed by a statistical algorithm (Simons, Wills, & Neal, 2014). Here, lability in negative mood showed a direct relation to the likelihood of alcohol depen- dence symptoms. This research shows the value of distinguishing variability in mood over time from mean level of mood (see also Simons & Carey, 2002, 2006; Simons et al., 2005b). Notably, trait positive mood was related to a lower proportion of drinking days over the study period (cf. Gilbert, 2012); whereas, trait negative mood was related to a higher proportion of drinking days. Weinstein and Mermelstein (2013b) studied a sample of high school students through obtain- ing experience sampling reports on palmtop computers. Reports of smoking were obtained over one-âw•‰ eek periods on two occasions and variability in negative mood was determined by a statisti- cal algorithm. Greater mood variability predicted escalation of smoking in the subsample of girls, while mean level of negative mood (but not its variability) predicted escalated smoking among boys who scored higher on coping motives for smoking. This shows the value of including both gender and motives for use in research designs. Hedonic capacity and alternative reinforcers Emotion regulation processes may be particularly relevant for persons with lower capacity to experience pleasure from natural reinforcers. Low positive mood could be the stimulus for sub- stance use (Mohr et  al., 2008; Wills et  al., 1999)  but may be countered through active coping mechanisms such as a search for alternative reinforcers (Audrain-M╉ cGovern et al., 2010). A dis- positional measure of hedonic capacity, the Snaith-H╉ amilton Pleasure Scale (SHAPS, Franken et al., 2007) has been used in some studies. Audrain-âM•‰ cGovern et al. (2012) followed a sample of adolescents over four waves of observa- tion, measuring hedonic capacity with the SHAPS and indexing cigarette smoking at each assess- ment. Results showed lower hedonic capacity was related to greater likelihood of smoking in the past month and a greater rate of increase in smoking over time. Among adult smokers attempting to quit, Goelz et al (2014) found that those who successfully quit smoking showed higher levels of alternative reinforcers compared with persons who relapsed. These results complement find- ings showing declining levels of alternative reinforcers related to increases in smoking over time (Audrain-âM•‰ cGovern et al., 2010) and anhedonia related to a lower likelihood of smoking cessa- tion (Leventhal et al., 2009). Mindfulness and substance abuse Mindfulness training as an approach to emotion regulation has been tested in several intervention studies for smoking and alcohol use (Brewer et al., 2013). Dispositional measures are also avail- able including the Mindfulness Attention Scale (MAAS, Black et al., 2012).

12 Composite constructs and dual-process theory 221 Tarantino et  al. (2015) surveyed a sample of college students with the MAAS as a predictor and with measures of drug use and drug problems as outcome variables. Higher mindfulness tendency was correlated with behavioral self-âc•‰ ontrol and self-r╉einforcement, and was related to lower levels of drug use and problems independently of other coping strategies. A clinical study with a mindfulness-âb•‰ ased smoking cessation program (Brewer et al., 2011) found that those who practiced meditation more frequently showed a lower relation between craving and cigarette use (Elwafi et al., 2013). Also noteworthy is evidence showing neurological changes suggesting enhanced self-âr•‰ egulation as a result of mindfulness training (Tang et al., 2012). Composite constructs and dual-p╉ rocess theory Dual-p╉ rocess theory posits that there are two distinct systems for dealing with the environment, which have different antecedents and different consequences. The system for self-c╉ontrol (also termed controlled processing, reflection, or reasoned processing) is more deliberate, conscious, fact-b╉ ased, and slower. The system of reactive processing (also termed impulsiveness, disinhi- bition, or automatic processing) is faster but is based more on images, heuristics, and reward reactions rather than deductive reasoning. Dual-p╉ rocess theories have been developed for sub- stance abuse (Gerrard et al., 2008; Gibbons et al., 2009; Volkow & Baler, 2012; Wiers et al., 2007; Wills & Dishion, 2004) as well as for other health behaviors (Hoffman, Friese, & Strack, 2009; Rothman et al., 2009) and for depression (Beevers, 2005). The main propositions relevant to the present discussion focused on emotion regulation are that 1)  emotional self-c╉ontrol and emo- tional dysregulation will make independent contributions to outcomes (in different directions); and 2) emotional self-c╉ ontrol and emotional dysregulation will have different types of pathways to outcomes. Studies of younger adolescents have confirmed these propositions for behavioral measures, showing that self-âc•‰ ontrol and dysregulation constructs make independent contributions to entry-╉ level substance use and have different types of pathways to substance use outcomes (e.g., Wills et al., 2001). Pearson et al. (2013) showed that individuals scoring high on behavioral self-âc•‰ ontrol had fewer alcohol problems because they applied more protective behavioral strategies when drinking. In contrast, behavioral dysregulation was directly related to more alcohol-r╉ elated prob- lems, independent of level of use. A study by Wills et al. (2006) added constructs of emotional self-âc•‰ ontrol and emotional dysreg- ulation to behavioral constructs and found that these constructs showed similar types of relations to substance use among both younger adolescents and older adolescents. A subsequent study with high school students (Wills et  al., 2011)  used composite constructs for emotional self-c╉ontrol (soothability, sadness management, and anger management) and emotional dysregulation (affec- tive lability, angerability, and rumination). Behavioral and emotional constructs made indepen- dent contributions to outcomes and had different types of pathways. Emotional dysregulation had indirect effects to more substance problems through lower academic competence and more negative life events; it also had direct effects to more dependence and abuse problems. Is emotion regulation related to psychopathology before the onset of substance use problems? This question was examined by Wills et al. (2016) with a large sample of 12 to 13-y╉ ear old ado- lescents. Composite constructs for emotional self-âc•‰ontrol and emotional dysregulation were obtained, similar to those in previous studies, together with measures of externalizing and inter- nalizing symptomatology, both of which predict substance use disorder at later ages (Colder et al., 2010; Wills et al., 2005). Analyses including behavioral self-âc•‰ ontrol as a covariate indicated there were both direct and indirect effects, outlined schematically in Figure 11.1. Emotional dysregulation was related to psychopathology partly via indirect effects (through lower academic competence and more negative life events) and partly through direct effects to

2 222 Emotion Regulation and Substance Use Disorders in Adolescents Emotional Deviance-prone Externalizing dysregulation attitudes symptomatology Negative Internalizing life events symptomatology Emotional Developed Positive self-control competencies well-being Figure 11.1╇ A conceptual model of direct and indirect effects of emotion dysregulation and emotional self-control. Model emphasizes effects of emotional regulation via both socio- environmental and cognitive/attitudinal constructs. See Wills et al., 2016. more externalizing and internalizing symptomatology. Independently, emotional self-âc•‰ ontrol had several significant indirect effects (through less life stress and deviance-p╉ rone attitudes) and it also had a large direct effect to positive well-b╉ eing. This research indicates that these types of psychopathology are in some sense disorders of self-r╉egulation but it is also true that emotional regulation shapes level of exposure to environmental risk and protective factors. Example of emotion regulation intervention There have been few interventions conducted for substance use based directly on self-âr•‰ egulation constructs and most of these were done with adults (see Wills, Simons, & Gibbons, 2015). There will be discussion on a school-b╉ ased intervention for adolescents that was centered on emotion regulation strategies. School-âb•‰ ased interventions are an attractive venue for prevention research because they can access a general population and provide a unique environment for students to interact with facilitators (i.e., teachers) in both structured and unstructured settings (Diamond & Lee, 2011; Skara & Sussman, 2003). Conrod et al. have focused on a range of psychopathological symptoms, utilizing a preventive approach that aimed to prevent substance abuse by lessening its precursors. The risk factors considered in these studies were more individual in nature as opposed to contextual (O’Leary-B╉ arrett et al., 2013). All studies took place at high schools in the United Kingdom and Canada. A trained, school-╉ based facilitator and co-âf•‰acilitator administered the intervention, which consisted of two manual-╉ guided 90-âm•‰ inute sessions. The manuals consisted of three components: 1) A psychoeducational component, 2)  a motivational component, and 3)  a cognitive behavioral therapy component. Later editions of the manual also included real-âl•‰ife scenarios shared by high-r╉ isk British youth in focus group sessions (Conrod, Castellanos-âR•‰ yan, & Strang, 2010). Data were collected through self-âr•‰eport questionnaires distributed at baseline, at the completion of the intervention, and at six-âm•‰ onth intervals for two years post-i╉ntervention. Four personality profiles were targeted in these studies:  Anxiety Sensitivity, Hopelessness, Impulsivity, and Sensation Seeking (O’Leary-âB•‰ arrett et  al., 2013). Students who scored at least

32 Directions for further work 223 one standard deviation above the school average in one of these four subscales were categorized as high-âr•‰ isk. In earlier studies, all high-âr•‰ isk students were invited to participate in the intervention. In later studies, all consenting high-r╉ isk students were randomly assigned to either the interven- tion group or the control group. Two studies also included low-r╉ isk students in both the interven- tion and control groups (Conrod, Castellanos-âR•‰ yan, & Strang, 2010; Conrod, Castellanos-âR•‰ yan, & Mackie, 2011; Conrod et al., 2013). Internalizing symptom severity was measured using the Depression and Anxiety subscales from the Brief Symptom Inventory (BSI). Externalizing symptom severity was measured using the Conduct subscale from the Strengths and Difficulties Questionnaire (SDQ; O’Leary-B╉ arrett et al., 2013). Conrod et al. (2010) aimed to improve various cognitive and behavioral problems associated with specific high-r╉isk personality factors. For instance, the cognitive distortion termed over- generalization (i.e., when one makes universal assumptions based on experiences through one specific situation) is often found in individuals prone to depression (O’Leary-âB•‰ arrett et al., 2013). By targeting cognitive distortions such as these, it was proposed that a variety of internalizing and externalizing symptoms that may underlie substance use could be effectively addressed. Interventions were focused on assisting students in each personality profile to adopt more adap- tive coping mechanisms, so as to help students manage their personality risk in a way that does not promote problematic substance use (Conrod, Castellanos-R╉ yan, & Strang, 2010). The first part of the intervention involved a goal-âs•‰etting exercise that encouraged behavior change and development of new coping methods. Students were taught about their target person- ality variable and associated non-a╉ daptive coping responses (e.g., avoidance, aggression). They then learned about the cognitive-âb•‰ ehavioral therapy model and practiced applying it by analyzing emotional responses in sample scenarios, as well as their personal experiences. Students were encouraged to recognize and confront personality-âs•‰ pecific cognitive distortions that could induce risk behaviors. Post-e╉xercise discussions were held to focus on personality-s╉pecific thoughts, emotions, and behaviors (Conrod et al., 2010, 2013). Across all studies, significantly lower frequency and quantity of overall alcohol consumption, as well as binge drinking and rate of growth of binge drinking, were found at the completion of intervention for high-âr•‰isk adolescents assigned to the intervention group. In the 2013 study, benefits of the intervention were also apparent at the 24-âm•‰ onth follow-âu•‰ p, as displayed through lower growth in drinking quantity and binge drinking frequency, compared to non-i╉ntervention adolescents (Conrod et al., 2013). The intervention was also associated with a reduced likelihood of marijuana and cocaine use (Conrod, Castellanos-R╉ yan, & Strang, 2010). Conrod’s approach did not directly target substance misuse. Rather, the intervention targeted individuals who displayed personality risk factors previously shown to correlate with substance use disorders. By using specific personality profiles, the individuals learned which strategies of emotion regulation were most beneficial, as well as which strategies were more detrimental in relation to their personalities. By doing so, Conrod et al. addressed, at a more selective level, the emotion dysregulation that is often proximal to substance use, or is involved with motivational processes that inspire substance use. Directions for further work In this chapter, both specific strategies for controlling emotion and general attributes of emotion regulation have been discussed and the available evidence about emotion regulation and sub- stance use disorder has been reviewed. Although there is a sizable body of evidence on emotion regulation from laboratory studies, unsettled questions remain about its applicability to clinical and community samples. Progress has been made in research on substance use among adolescents

42 224 Emotion Regulation and Substance Use Disorders in Adolescents but a strong understanding of exactly how emotion regulation contributes to the development of substance use disorder has not yet been fully delineated. Further, while emotion regulation has often been considered as a single dimension, a body of evidence indicates that emotional self-╉ control and emotional dysregulation are distinct constructs, not opposite ends of a single dimen- sion. The following section discusses major themes in the chapter and their clinical implications. Emotion regulation and its relation to risk This chapter has highlighted the considerable evidence that demonstrates a connection between emotion dysregulation and substance use disorder in adolescence and young adulthood. Findings on prospective associations between early temperament characteristics and later risk for substance use also suggest that emotional dysregulation may be present well before the onset of disorder, thereby making it a true predisposing factor (Wills et al., 2000, 2016). The new research discussed here has been consistent with the proposition that substance use disorder is one manifestation of behavioral dysregulation and that dysregulation in emotion, behavior, and cognition are interre- lated processes. Furthermore, this chapter has focused on constructs such as negative life events, social functioning, and academic engagement as intermediate factors, such that these environ- mental consequences of dysregulation partly mediate the association between emotion regulation and disorder (Wills et al., 2011; 2016). The latest research has revealed complexities that were not evident in earlier studies. Several aspects of emotion regulation and dysregulation have been delineated, including emotional reactivity, affective variability, and low distress tolerance as key risk factors, while emotional soothability, alternative reinforcers and positive affect may serve as protective factors (Leventhal & Zvolensky, 2015; Simons et al., 2014). Emotional dysregulation may create dependent stress (Liu & Alloy, 2010), creating reciprocal associations between emotional dysregulation and envi- ronmental context. Aside from individual differences, the environmental context appears to affect drug involvement, both as a source of drug-âr•‰elated opportunities and as a source of drug-╉ free reinforcement (Audrain-M╉ cGovern et al., 2010; Yurasek et al., 2015). In addition, cognitive research has shown how excessive drug use may bias responses toward drug-r╉elated reinforcers, interfering with the normative development of emotional regulation (Lisdahl, Gilbart, Wright, & Shollenbarger, 2013; Wills et al., 2015). Early experience is important Evidence regarding the impact of early experiences continues to accumulate. It is clear from sev- eral types of research that early adversity (e.g., family poverty or child maltreatment) is related to increased risk for substance abuse in adolescence and adulthood (Andersen & Teicher, 2009, Sinha, 2008; Swendsen & Le Moal, 2011). The impact of early adversity extends to psychological disorders including PTSD, which itself has a strong co-o╉ ccurrence with substance abuse (e.g., Gaher et al., 2013; Goldsmith et al., 2013). Recent research is beginning to clarify how the disrup- tion of behavioral and emotional regulation may contribute to this effect (Hahn et al., 2015; Oshri et al., 2015; Shin et al., 2012). What is less clear is what aspects of emotion dysregulation are modifiable factors and how they should be targeted to reduce substance use in at-risk adolescents. There is reason to believe that family dynamics shape the development of self-âr•‰egulation (Farley & Kim-âS•‰ poon, 2014; Siegel, 2013; Wills, Forbes, & Gibbons, 2014). However, there is also evidence that individual differ- ences in self-âc•‰ ontrol and dysregulation stem, in part, from genetic predisposition (Kreek et al., 2005; Yacubian & Buechel, 2009; Yamagata et al., 2005). Yet, how genetic vulnerabilities interact with early environmental context and parenting characteristics to shape self-âr•‰ egulation is not well

52 Summary 225 studied, and understanding biological variables as well as social learning factors will be impor- tant for informing the design of future prevention and treatment efforts (Beauchaine, 2015). The extent to which substance use disorder in adolescents can be reduced via training individuals to have better emotion regulation skills is an open question, though there are promising results in this regard (see for example: Conrod et al., 2013; Southam-G╉ erow, 2013; Wills et al., 2015). Behavioral and emotional regulation A variety of excellent measures have been developed for studying specific aspects of behavioral and emotional regulation or dysregulation. However, empirical studies that include both types of mea- sures have consistently shown a high correlation between the behavioral and emotional domains (Wills et al., 2011; 2013, 2016). From a methodological standpoint, this is an important issue because studies of emotion regulation typically have not controlled for behavioral regulation, hence they may overestimate the effect sizes for emotional regulation variables (Wills et al., 2016). This still leaves unanswered the question: Why are behavioral and emotional regulation so strongly correlated in the first place? This issue may in part be a matter of definition (e.g., Aldao et al. (2010) recognized that problem solving, a cognitive-âb•‰ ehavioral process, has a significant role in emotion regulation) but it also raises the question of why individuals who are behaviorally dysregulated (e.g., impatient, dis- tractible, having short time horizons) also show substantial dysregulation of emotion. Such research is needed to help inform the design and implementation of prevention programs. From a conceptual standpoint, the behavioral-e╉ motional correlation raises important questions for the design of prevention and treatment programs, particularly in view of the fact that there are several aspects of emotional self-c╉ ontrol or dysregulation. For example, should a prevention program focus more on improving emotional self-âc•‰ontrol, or on implementing cognitive and behavioral strategies to mitigate the impact of a tendency for dysregulation. If aiming to enhance overall emotion regulation, should one focus more on characteristics related to mean level of affect (e.g., distress tolerance) or would it be better to focus on reducing variability in affect? A dialogue on these kinds of questions would be most valuable for helping to link prevention researchers with adolescent treatment specialists. Previous prevention programs have focused largely on behavioral regulation and there is evidence of their effectiveness (Bukoski, 2015; Griffin & Botvin, 2010). Given the close association between behavioral and emotional regulation and the importance of related contextual factors (e.g., peer groups, dependent stress, academic engage- ment) in promoting or reducing substance use, it is likely that prevention programs may be most effective when they take a holistic approach that promotes self-r╉egulation (e.g., incorporating both behavioral and emotional regulation aspects) and provide opportunities for, and the skills to access, the development of social environments conducive to positive outcomes (e.g., high degrees of drug-f╉ree reinforcers, healthy peer norms). Summary Adaptive emotion regulation is essential for well-b╉ eing and successful adaption in all aspects of life. Hence, programs that successfully enhance emotional regulation in youth have the potential to have far-r╉eaching benefits in addition to reducing substance use behavior. For this reason, it is an important target for intervention programs. The multifaceted nature of emotion regulation provides both challenges and opportunities for the development of prevention programs. Thus, future research is needed to identify specific components of emotion regulation that are the most amenable to intervention and have the broadest impact on non-t╉argeted emotion regulatory pro- cesses. Phrased differently, the key question remains: How can research find the optimal interven- tion target that has the largest cascading effects throughout the regulatory system?

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