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532 Chapter 12 Emotion Regulation in Autism Spectrum Disorder Jonathan A. Weiss, Priscilla Burnham Riosa, Carla A. Mazefsky, & Renae Beaumont Autism spectrum disorder Autism spectrum disorder (ASD) is a pervasive neurodevelopmental disorder characterized by deficits in social communication, along with restricted, repetitive patterns of behavior, interests, or activities (American Psychiatric Association [APA], 2013). These symptoms must be present in the early developmental period, though may not become impairing until later in life. The changing nosology from DSM-I╉ V to DSM-â5•‰ involved a considerable shift in the amalgamation of Pervasive Developmental Disorder subtypes into one diagnosis of ASD (Lord & Bishop, 2015). The focus on autism as a “spectrum” largely reflects the lack of reliability found in distinguishing past subtypes (e.g., Asperger’s disorder vs. PDD-N╉ OS vs. Autistic disorder with no intellectual impairment) (Bennett et al., 2008; Lord et al., 2012; Woodbury-âS•‰ mith et al., 2005). As well, DSM-I╉V subtypes were largely being used as proxies for patient overall severity of impairment in multisite trials, rather than consistently taking specific diagnostic subtype criteria into consideration (Lord et al. 2012). Long before the publication of the DSM-â5•‰ , authors were observing a preference in using the singular term “Autism Spectrum Disorder” in the scientific literature over the reporting of DSM-I╉ V subtypes (Bebko et al., 2008). The notion of a spectrum is an important consideration in understanding the expression of ASD and of emotion dysregulation in this population. The primary conceptualization of a spec- trum relates to the overall severity of ASD symptomatology and the level of impairment in these domains, as evidenced in the three severity level specifiers proposed in the DSM-â5•‰ (APA, 2013). Level Three (“requiring very substantial support”) is reserved for severe deficits in social commu- nication, along with extreme restricted/r╉epetitive behaviors. Level Two is less severe (“requiring substantial support”), with marked deficits in social communication and frequent difficulties with restricted, repetitive behaviors. Level One is meant to reflect the least severe degree of impairment (“requiring support”), where social communication difficulties are still apparent when there is a lack of support, and when there are difficulties with behaviors that are not considered as fre- quent or as severe as in Level Two. There are considerable reservations in approaching severity in such a discrete ordinal manner, given that severity categorizations across adaptive, cognitive, and autism symptomatology have been found to be discrepant at mild or moderate levels (Weitlauf et al., 2014), leaving authors to caution for the need for greater research in categorical specifier use (Lord & Bishop, 2015). It is clear though that the expression of ASD symptom severity ranges from mild to severe across the population, and to some extent has variability within the individual over time and across contexts. The spectrum also applies to considerations of intellectual functioning and related adap- tive behavior. Intellectual disability (ID) is characterized by significant limitations in cognitive
632 236 Emotion Regulation and Autism Spectrum Disorder functioning (approximately two standard deviations below what would be expected based on someone of the same chronological age), as well as commensurate deficits in adaptive behavior across social, conceptual, and practical life areas. These impairments must have occurred prior to age 18 and be observed within the appropriate developmental period. Over time, prevalence estimates of ID in the ASD population have decreased, the result of greater numbers of youth being diagnosed with ASD without ID as well as potential diagnostic substitution. In the 2006 surveillance year, the Centers for Disease Control and Prevention (CDC, 2009) reported that 41% of eight-y ear-o lds with ASD had intellectual functioning in the ID range (ranging from 29% to 51% across sites). This rate decreased to 31% in the 2010 surveillance year (ranging from 18% to 37% across sites; CDC, 2014), though this latest surveillance suggests that an additional 24% of youth with ASD had low levels of cognitive functioning but not in the range of ID (with 23% in the borderline ID range). The spectrum can also be applied to one’s level of adaptive functioning—the ability to function independently in age appropriate domains of every-day life, including social (e.g., forming and maintaining interpersonal relationships, play and leisure skills), practical (e.g., dressing, grooming, toileting), and conceptual spheres (e.g., reading, writing, understanding time and money). There has been an apparent rise in prevalence rates in youth diagnosed with ASD over the last decade, with ASD affecting between one in 110 in 2006, to one in 68 in 2010 (CDC, 2007; 2014). Concerns over the methodology and interpretation of the latest rates have been noted, including the substantial cross-site variability (Mandell & Lecavalier, 2014). Lord and Bishop (2015) suggest a number of reasons for the increase in prevalence. First, given that the majority of the increase comprises youth without ID, higher rates could reflect the broader criteria now employed in the diagnosis of ASD (King & Bearman, 2009). Second, higher rates could reflect the greater availabil- ity of training and tools at clinicians’ disposal in the assessment of ASD. Third, many of these tools have low specificity in distinguishing ASD from other psychiatric or genetic disorders (Charman et al., 2007, DiGuiseppi et al., 2010, Hus et al., 2013), which could lead to children being misdiag- nosed with ASD. At the same time, Lord and Bishop (2015) suggest that prevalence rates of ASD may still continue to rise, as future work addresses the possible under-representation of females with ASD, the increasing awareness that can lead to more referrals, and the known disparities in rates across demographic characteristics (e.g., race, neighborhood). Emotional and behavioral problems, though not diagnostic, are also often associated charac- teristics in the clinical presentation of ASD. There is considerable data indicating that individuals with ASD are more likely to have clinically significant levels of these problems compared to both typically developing individuals of the same age, and individuals of the same cognitive ability (Leyfer et al., 2006; Simonoff et al., 2008; Totsika et al., 2011a; Totsika et al., 2011b). Using second- ary data analysis on a UK national survey (Millennium Cohort Study), Totsika and colleagues (2011a) examined rates of borderline/clinically significant mental health problems in 14,807 typi- cally developing five-year-olds, compared to 82 children with only ASD, 432 children with only ID, and 32 children with both ASD and ID, using a parent report questionnaire. Children with developmental disabilities, across diagnoses, were more likely to have significant hyperactivity, conduct problems, and emotional problems compared to the typically developing comparison group. In the ASD samples, 59% of five-year-olds with no ID had hyperactivity problems, 46% had conduct problems, and 38% had emotional problems. Higher rates were reported with regard to hyperactivity (88%) and similar rates for conduct problems (57%) and emotional problems (39%) in the youth with both ASD and ID. In another large scale UK population study, Totsika and col- leagues (2011b) compared mental health problems among 17,727 typically developing youth, to those of 47 youth with only ASD, 590 youth with only ID, and 51 youth with both ASD and ID, again using a parent report questionnaire about symptoms in the last six months. Compared to the expected 20% of the typically developing comparison group, youth with only ID had a two-to
732 Emotion regulation and autism spectrum disorder 237 three-âf•‰old increase in rates of emotional and behavior problems, and youth with ASD had a three-╉ to four-f╉old increase. Approximately 70% of youth with ASD had clinically significant emotional problems (compared to 42% of youth with only ID without ASD), and 65% had clinically signifi- cant conduct problems (compared to 46% of youth with only ID without ASD). Given the high rates observed in community samples, it is not surprising that many individu- als with ASD experience multiple co-âo•‰ ccurring mental health problems. In fact, 70% of youth with ASD meet criteria for at least one additional psychiatric disorder, and 40% for two or more, when using an adaptive structured interview to distinguish ASD symptoms from other psychi- atric symptoms (Leyfer et al., 2006; Simonoff et al., 2008). Given the overlapping manifestation among behaviorally-âb•‰ ased disorders, there is some concern that discrete psychiatric diagnoses could be overestimated, though even after focused examinations are taken into account, ASD symptom severity and psychiatric rates remain much higher than expected in the general popula- tion (Mazefsky et al., 2012). In community and clinically referred samples, levels of internalizing symptoms (i.e., depression, anxiety) are often moderately correlated with the expression of exter- nalizing symptoms (i.e., noncompliance, aggressive behavior, irritability; Gadow et al., 2006; Kim et al., 2000; Lecavalier, Gadow, DeVincent, & Edwards, 2009; Weisbrot et al., 2005), leaving many authors to suggest they may have an underlying basis in emotion dysregulation (Mazefsky et al., 2013; Weiss, 2014). Thompson (1994) defines emotion regulation as “the extrinsic and intrinsic processes respon- sible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals” (pp. 27–2╉ 8). This conceptualization is useful as it emphasizes the multiple strategies that may result in emotion regulation, and the notion that an emotion regulation process can be either adaptive or maladaptive, depending on whether it is successful in achieving the appropriate affective state and does not have negative long-t╉erm costs (Campbell-S╉ ills & Barlow, 2007). Gross and Thompson (2007) outline five broad classes of emo- tion regulation strategies: Situation Selection, Situation Modification, Attentional Deployment, Cognitive Control, and Response Modulation. The first four classes are considered “antecedent” to emotional disruption. If we are able to successfully influence the situations that may cause dis- tress, focusing on the most useful stimuli and having a good understanding of emotions, or alter- ing how we think about our experiences, then we are able to maintain emotion regulation without our affect ever becoming disrupted in the first place. However, when those strategies fail, and we end up with high levels of negative affect (i.e., dysregulation), then we are required to employ the last class, modifying our experience to regulate. Adaptive emotion regulation strategies are typi- cally voluntary in nature, being consciously initiated with effort and control, whereas maladap- tive strategies are often involuntary, being applied automatically in response to emotion-âe•‰ liciting stimuli (Aldao & Nolen-H╉ oeksema, 2010; Mazefsky, Borue, Day & Minshew, 2014). Emotion regulation and autism spectrum disorder Emotion regulation difficulties are common in youth and adults with ASD, including the funda- mental task of understanding emotion. Uljarevic and Hamilton (2013) conducted a meta-a╉ nalysis of 48 studies investigating differences in recognizing others’ basic emotions (fear, surprise, anger, disgust, happiness, and surprise) between children and adults with ASD and typically develop- ing peers. The majority of studies have indicated that individuals with ASD perform significantly worse than their typically developing counterparts on emotion recognition tasks, regardless of age or IQ, though emotion recognition difficulties may not be as evident as previously thought. For instance, Wright and colleagues (2008) found differences between youth with and without ASD on recognizing anger and happiness but not sadness, fear, surprise, or disgust. Interestingly, diffi- culty recognizing happiness was related to greater global emotion recognition difficulties. Beyond
832 238 Emotion Regulation and Autism Spectrum Disorder recognition, children with ASD report more difficulties with insight into their own emotional functioning and in interpreting their own emotional experiences, which is known as emotion awareness (Losh & Capps, 2006; Rieffe, Terwogt, & Kotronopoulou, 2007); difficulties that also extend to adults with ASD. Hill and colleagues (2004) surveyed 27 adults with ASD about three aspects of cognitive processing of emotions: Identifying emotions (e.g., “When I am upset, I don’t know if I am sad, frightened or angry.”), describing feelings (e.g., “I find it hard to describe how I feel about people.”), and externally oriented thinking (e.g., “I find examination of my feelings useful in solving personal problems.”), and found that compared to typically developing adults, adults with ASD reported significantly greater difficulties with overall emotion processing. Several studies have examined the specific strategies children and adults with ASD use to regu- late their emotions, with considerable evidence demonstrating they are less effective than their peers. Youth and young adults with ASD use adaptive strategies (e.g., problem solving, social support, cognitive reappraisal, cognitive distraction, acceptance, exercise, and relaxation) less frequently and maladaptive strategies (i.e., avoidance, expressive suppression) more frequently compared to typically developing peers (Konstantareas & Stewart, 2006; Samson, et al., 2015). Self-r╉eports of using more maladaptive coping strategies have also been found among children and adolescents with ASD compared to peers, and are associated with higher self-âr•‰eported lev- els of psychopathology (Mazefsky et al., 2014; Pouw et al., 2013). Jahromi and colleagues (2012) reported a higher ratio of maladaptive to adaptive strategies among children with ASD compared to controls, when employing a frustration task and coding ensuing strategies. Emotion regulation strategies used by children with and without ASD were coded as constructive/a╉ daptive (e.g., help-╉ seeking) and maladaptive (e.g., venting, avoidance). Not only did children with ASD use more maladaptive strategies across the frustration tasks, but they also more quickly resigned the task compared to their typically developing peers, and even more so when their parents were not avail- able to assist them, suggesting the potential role of parental co-âr•‰ egulation for children with ASD. The interplay between emotion regulation and ASD characteristics and impairment The accumulating evidence indicative of ineffective or maladaptive emotion regulation in ASD supports the need for a greater focus on emotion regulation as a core feature of the disorder. Although, like ID, emotion dysregulation is not a universal characteristic in ASD, its presence has important implications for the expression of ASD and functional outcomes. Adopting an emotion regulation framework can provide a mechanistic explanation for the many associated emotional and behavioral concerns in ASD, which may be more informative for developing interventions than attributing these concerns solely to psychiatric comorbidity (Mazefsky et al., 2013; Weiss, 2014). Further, by focusing on emotion regulation as the core disrupted process, the likely under- lying biological and cognitive factors contributing to poor emotional and behavioral functioning become more readily identifiable. Biological differences related to emotion regulation Although there are few neurobiological studies of emotion regulation in ASD, neuroimaging studies suggest atypical functioning and connectivity in regions that are involved in emotion reg- ulation, such as the amygdala and prefrontal cortex (Mazefsky et al., 2013). In addition, studies have identified disparate processing of emotional information at the neural level between children and adults with ASD and their peers (Harms, Martin, & Wallace, 2010; Kana et al., 2015). For example, Silani et al. (2008) examined fMRI activation in 15 adults with ASD and 15 age-m╉ atched peers without ASD who viewed positive, neutral, and negatively valenced stimuli, while rating the
932 The interplay between emotion regulation and ASD characteristics and impairment 239 valence of each image. Adults with ASD showed decreased brain activation in areas associated with emotional awareness compared to adults without ASD in their sample. Further, although the specific findings are inconsistent, studies largely indicate atypical patterns of neural reactivity dur- ing emotional face processing (Harms et al., 2010) and emotional language processing (Lartseva, Dijkstra, & Buitelaar, 2014) in ASD. The only two neuroimaging studies to explicitly investigate emotion regulation in ASD both utilized cognitive reappraisal tasks (Pitskel, Bolling, Kaiser, Pelphrey, & Crowley, 2014; Richey et al., 2015). Cognitive reappraisal tasks provide an opportunity to isolate neural reactivity that is due to regulation of emotion by requiring participants to increase or decrease their emotional reaction to various stimuli. Importantly, behavioral valence ratings from both youth with ASD (Pitskel et al., 2014) and adults with ASD (Richey et al., 2015) revealed significant differences between conditions which supports the use of cognitive reappraisal tasks as an emotion regula- tion probe in ASD. A consistent finding from both studies, despite the use of different stimuli, was the decreased ability to suppress amygdala activation in ASD compared to typically-d eveloping controls, which may provide one mechanistic account for impaired voluntary emotion regulation in ASD. Another possibility is that problems with emotion regulation stem from underlying dif- ferences in physiological arousal. There are a number of different measures of physiological reactivity that have been used to investigate arousal in ASD, including pupillometry, heart rate, heart rate variability, respiratory sinus arrhythmia, blood pressure, electrodermal activity, and cortisol. One question that has been explored using a variety of these methods is whether individuals with ASD have atypical baseline levels of physiological arousal, with some theories suggesting baseline levels would be increased and others hypothesizing decreased baseline arousal. A review of studies focused on baseline physiological reactivity found that approxi- mately half found no difference compared to controls across a variety of physiologic indica- tors, while the other studies were in both directions (Lydon, Healy, Reed, Mulhern, Hughes, & Goodwin, 2014). Currently, we may also infer conclusions about physiological differences associated with emo- tion regulation based on studies of related constructs such as the processing of emotional faces and response to stressors. One interesting conclusion from this work is that individuals with ASD may perceive their physiological activity differently than their typically-developing peers. For instance, Shalom et al. (2006) measured the concordance between a physiological measure of skin conductance in ten children with ASD, and ten children without ASD, who were presented with pleasant, unpleasant, and neutral pictures, and how pleasant and interesting they rated the images. While physiological results across the image types were comparable across children with ASD and those without, self-reported affect ratings were significantly different across the two groups, such that children with ASD reported more similar answers when rating the pleasant- ness and interestingness of unpleasant, pleasant, and neutral pictures when compared to children without ASD. These findings suggest that children with ASD may perceive and consciously report different experiences of emotional stimuli even though physiologically, they are comparable to children without ASD. Recently, a study of high-functioning adults supported the importance of the individual’s perception, by finding the perception of stress, but not physiological reactivity during a social stressor, was related to social outcomes (Bishop-F itzpatrick, Minshew, Mazefsky, & Eack, 2016). It is difficult to make firm conclusions about specific physiological reactivity differences in ASD as there have only been a few small studies employing different tasks, mostly with inconsistent findings. A focus on the higher quality studies does however, indicate discernable differences in physiological responses during stressor tasks in ASD and, in particular, suggests that further study
042 240 Emotion Regulation and Autism Spectrum Disorder of the limbic-âh•‰ ypothalamic-p╉ ituitary-âa•‰drenal (LHPA) axis system is warranted (Lydon, Healy, Reed, et al. 2014). This is of great relevance to emotion regulation, as the LHPA system is respon- sible for regulating the body’s response to stress and restoring homeostasis (Smith & Vale, 2006). Also intriguing is the notion that there may be high-╉and low-âa•‰ rousal subgroups in ASD (Schoen, Miller, Brett-G╉ reen, & Hepburn, 2008), which may play a role in the observed within-âA•‰ SD vari- ability in emotion regulation capacity. Cognitive and behavioral influences Although there is limited empirical evidence of an association between the cognitive and infor- mation processing style of individuals with ASD and emotion regulation impairments, theoreti- cal models have highlighted some of the characteristics that are likely to play a role (Mazefsky & White, 2014). Some of the most likely factors in ASD include alexithymia (difficulty identifying and labeling one’s own emotions), difficulty perceiving social and emotional cues, poor problem-╉ solving and reasoning ability, cognitive rigidity, and sensitivity to change and environmental stimulation (see Figure 12.1). Some have argued that emotional problems in ASD may be attributed entirely to the well-╉ documented occurrence of alexithymia (Bird & Cook, 2013). Indeed, the accurate identifica- tion of one’s own feelings is necessary in order to employ response-âf•‰ocused voluntary emotion regulation strategies, and accurate emotion identification and emotional language is essential for specific strategies such as talking to others or joint problem solving (Mazefsky & White, 2014). However, alexithymia may not be as relevant for more automatic and involuntary emotion regula- tion processes, and emotion regulation deficits have been found in ASD even when controlling for alexithymia (Samson, Huber, & Gross, 2012). This argues for alexithymia playing an important role in emotion regulation but not being the sole explanation for aberrant emotional functioning, as Bird and Cook (2013) proposed. Difficulty accurately perceiving other types of emotional and social cues in ASD may also interfere with emotion regulation. One prime example is deficits in theory of mind, or the Lower Poor Difficulty inhibition problem- reading Cognitive solving & social & rigidity; Poor abstract emotional flexibility reasoning cues Sensitivity to change & environmental stimulation Alexithymia, Emotion Biological Limited Dysregulation predisposition (physiological emotional in ASD arousal, neural language circuitry, genetics) Figure 12.1╇ Characteristics of ASD that may contribute to emotion dysregulation Reprinted from Child and Adolescent Psychiatric Clinics of North America, 23 (1), Carla A. Mazefsky and Susan W. White, Emotion Regulation Concepts & Practice in Autism Spectrum Disorder, pp. 15–24, http://dx.doi.org/10.1016/j.chc.2013.07.002 Copyright © 2014 Elsevier Inc., with permission from Elsevier.
142 Interventions to improve emotion regulation 241 ability to take other’s perspectives (Samson et al., 2012). Poor perspective taking could lead to misreading other’s intentions as negative or hostile, a perception bias that has been linked to increased negative affect in non-A╉ SD studies (Schultz, Izard, & Bear, 2004). Even if an individual with ASD knows the right emotion regulation strategies to use, they face several barriers in the effective implementation of these strategies. For example, problems with inhib- itory control (Geurts, van den Bergh, & Ruzzano, 2014), a tendency to be rigid and have dif- ficulty shifting (Granader et al., 2014), impaired abstract reasoning and poor problem solving (Williams, Mazefsky, Walker, Minshew, & Goldstein, 2014), may interfere with the timing of efforts as well as the generation of flexible solutions during novel situations (Mazefsky & White, 2014). A recent study found that repetitive behaviors were strongly correlated with the presence of emotion dysregulation among children and adolescents with ASD (Samson, Phillips, Parker, Shah, Gross, & Hardan, 2014). This is consistent with hypotheses that the tendency to be perseverative and difficulty shifting may lead to sustained emotional reactions and difficulty down-âr•‰egulating negative affect in ASD (Mazefsky, Pelphrey, & Dahl, 2012). Heightened sensory sensitivity may also interfere by decreasing the threshold for the experience of negative affect as well as creating a physiologic state of stress which makes voluntary emotion regulation efforts challenging (Dunn & City, 1997). Although this implies causality, the relationship is likely reciprocal. For example, increased repetitive behaviors or unusual sensory reactions may also occur as a consequence of problems with emotion regulation, and some have even argued that repetitive behaviors may be a coping mechanism (Turner, 1999), further complicating the dynamic relationship between regu- lation and expression of ASD symptomatology. Experiencing highly dysregulated emotion undoubtedly further impairs one’s ability to attend to and process information from the environment, including social information. Wood and Gadow (2010) proposed a model describing the reciprocal relation between ASD and anxi- ety that further illustrates this point. Specifically, they suggest that ASD-âr•‰ elated stressors (e.g., social confusion; peer rejections and victimization; prevention or punishment of preferred behaviors or interests; and frequent aversive sensory experiences) lead to increased overall negative affectivity, anxiety disorders (specific type dependent on the experiences), or depres- sion. In turn, such negative affectivity contributes to more ASD symptoms, conduct problems, and personal distress, which lead to even further ASD-âr•‰ elated stressors, completing a negative cycle. Although Wood and Gadow (2010) focused their model on the development of anxiety or depression, this dynamic cycle also applies to emotion dysregulation more broadly. As such, if interventions can effectively improve emotion regulation, there is an opportunity not only to support emotional well-b╉ eing and decrease distress, but also to improve the course of ASD and functional outcomes. Interventions to improve emotion regulation A variety of treatment strategies have been employed to address problems with emotion regula- tion in ASD, largely focused on targeting a particular manifestation of poor emotion regulation (e.g., irritability) or the presence of an anxiety disorder. There is a growing interest in transdiag- nostic treatment approaches that target the underlying mechanism (in this case, emotion regu- lation), rather than a specific disorder. Going beyond a disorder-âs•‰pecific approach can make it easier to address the common factors that can lead to multiple emotional problems and emotion- ally driven behaviors (Barlow et al., 2011), making it more likely to be effective in situations when patients exhibit combinations of anger, sadness, and anxiety. The primary forms of treatment that have received research attention thus far include psychopharmacological approaches and psycho- therapy. The current evidence for each is described below.
24 242 Emotion Regulation and Autism Spectrum Disorder There are only two psychopharmacologic medications with U.S. Federal Drug and Safety Administration approval for use in ASD. They are both indicated for the treatment of irri- tability, which is arguably a manifestation of emotion regulation failure. These medications include risperidone and ariprazole, antipsychotics with well-established evidence support- ing their efficacy despite some significant adverse effects including weight gain and metabolic changes (Marcus et al., 2011; McCracken et al., 2002). Off-label use of other medications is common in ASD with an estimated two-thirds of children with ASD on at least one psychotro- pic medication and over one-third on multiple medications (Spencer et al., 2013). Although the pace of clinical trials research has increased recently, a review concluded that there was insuf- ficient evidence to support the efficacy of mood stabilizers or serotonin reuptake inhibitors in ASD (Siegel & Beaulieu, 2012). Further, studies of serotonin reuptake inhibitors in ASD have focused on repetitive behaviors as the target symptom rather than anxiety, and there have actu- ally been no randomized controlled trials of psychotropic medication use for anxiety in ASD (Vasa et al., 2014). In contrast, there is now considerable evidence that cognitive behavior therapy (CBT) is effi- cacious in reducing symptoms of anxiety in youth with ASD who do not have ID, and there is emerging evidence of its efficacy in adults with ASD. Ung and colleagues’ (2015) systematic review and meta-analysis of 14 CBT trials for children and adults with ASD indicated moderate treatment effect sizes across studies. Studies compared CBT to a wait-list (N = 8), treatment as usual course (N = 3), or alternate treatment (N = 1). However, it is important to note, two of the 14 studies were open trials with no control condition. Seven studies were delivered individually either with or without parents, six studies were delivered in a group format, and one study incor- porated a combined individual and group format approach. Parents were involved in 11 of the studies. No difference in treatment response was found based on informant (parent, child, clini- cian) and modality (group and individual formats with and without parents). In summary, treat- ment effects typically translated into clinically significant changes for 50–70% of participants (Vasa et al., 2014). An earlier meta-a nalysis of eight randomized controlled trials of CBT with children with ASD and at least average intellectual functioning reported large effect sizes for parent-and clinician-reported child anxiety, and small effect sizes for child-reported anxiety (Sukhodolsky, Bloch, Panza, & Reichow, 2013). Danial and Wood (2013) reviewed intervention studies focus- ing on mental health problems for children five to 18 years of age with high-functioning autism spectrum disorder (HFASD), and included randomized trials, group comparison studies, and multiple baseline designs. Similar to other systematic reviews, they found CBT for anxiety to be a promising treatment. Reviews also suggest that we know almost nothing about the long-term effectiveness of CBT treatment in this population, even with reference to anxiety, where up to 44% of youth who improve post intervention show some reduction in gains at follow-u p ten to 26 months later (Selles et al., 2015). CBT studies to date have almost exclusively focused on anxiety. Only one randomized trial exists on the efficacy of CBT to address anger problems in youth with ASD. Sofronoff and col- leagues (2007) reported on a waitlist controlled trial of a six-week CBT intervention for anger management among 45 ten-to 14-y ear-old children with ASD with at least average IQ, while parents attended a concurrent parent group to review session material. Parents in the interven- tion group reported significant decreases in child anger and increased confidence in managing child anger compared to parents in the waitlist group. Children in the intervention generated more appropriate coping strategies when given the hypothetical scenario, “Dylan is being Teased” (Attwood, 2004) compared to those on the waitlist. Until further well-c ontrolled studies are done though, the efficacy and effectiveness of CBT for externalizing problems among youth with ASD remains unclear (Danial & Wood, 2013).
342 Interventions to improve emotion regulation 243 Research on the psychotherapeutic treatment of emotional concerns in adults with ASD lags behind research on children and adolescents. A recent systematic review identified six studies that used CBT to treat mental health conditions in adults with ASD, and included case studies and case series, quasi-experimental designs, and randomized controlled trials (Spain, Sin, Chadler, Murphy, & Happe, 2015). All participants were diagnosed with ASD with at least average intel- lectual functioning, and treatment was focused on treating anxiety disorders, mood disorders, or self-h arm. Four studies provided CBT individually and two delivered it in a group format. No parents or caregivers were reported to be involved. In their narrative synthesis of the find- ings, Spain et al. (2015) reported decreases in self-and clinician-reported mental health symptom severity. However, because of the lack of methodological rigor of the extant literature, results must be interpreted with caution. Although most of the psychotherapeutic studies in ASD have focused on CBT as the treatment modality, there is emerging evidence in support of mindfulness-based interventions for anxiety and depression in ASD. Spek, van Ham, and Nyklicek (2013) conducted a randomized waitlist controlled trial to examine changes in anxiety, depression, and rumination following a nine-week mindfulness-based therapy for adults ages 18 to 65 years old (M = 44 years) with ASD and average verbal ability. Two clinicians facilitated the group and session content included body scans, medi- ations, breathing exercises, and movement exercises. Compared to adults in the waitlist group, adults in the mindfulness group reported a reduction in anxiety, depression, and rumination and increases in positive affect. Research examining the effects of mindfulness-b ased strategies with children and youth is also surfacing. De Bruin, Blom, Smit, van Steensel, and Bogels (2015) evaluated a mindfulness training intervention for youth 11 to 23 years old (M = 15.8 years) and their parents who participated in a parallel mindful parenting group, using a pre-post design without a control condition. Youth and their parents completed measures of mindfulness, worry, depressed mood, ruminations, quality of life, and ASD symptoms before the intervention, after the intervention, and at follow-up. Youth reported an increase in quality of life and a decrease in rumination following the intervention, but no change in worrying, ASD symptoms, or mindfulness. Parents reported increases in mind- ful parenting (i.e., attentive listening, emotional awareness, self-regulation, and nonjudgmental acceptance) at post-intervention and follow-u p. They also reported significant improvements in their children’s social responsiveness at follow-u p. In a multiple-baseline design across participants, Singh et al. (2011) examined the effects of Meditation on the Soles of the Feet on aggressive behavior of three youth (all male) ages 14, 16, and 17 years with ASD without ID. At the start of the training, youth-m other dyads practiced the meditations together. Once the youth learned the basics of the meditation, an audiotape was provided for self-guided practice. Over the course of the meditation training, results indicated a decreasing trend in aggressive behavior across all three participants, according to parent and sib- ling reports of observed aggression. Once participants met the criterion of no aggressive behav- iors for four weeks, there were reports of only one or two aggressive acts within the three-y ear follow-up period. Results from these preliminary evaluations provide support for mindfulness- based skills training as a component of interventions to address emotion regulation difficulties among youth with ASD. In addition to studies examining mindfulness practices with youth with ASD themselves, indirect effects of parent mindfulness training on child externalizing problems have also been reported. For example Singh, Lancioni, et al. (2006) investigated the effects of a 12-week parent mindfulness training intervention on child behavior problems. They found that following par- ent training, parents reported decreases in their children’s externalizing problems. These results highlight that the children’s externalizing symptoms were reported to decrease, without any direct
42 244 Emotion Regulation and Autism Spectrum Disorder intervention with the children. It is possible that the intervention influenced parent perceptions of their child including unconditional acceptance and non-judgment rather than the externalizing symptomatology itself. Nonetheless, this shift in perspective appears to have positive implications on the parent-child dynamic and additional well-c ontrolled studies are needed to elucidate how parent mindfulness-b ased interventions help individuals with ASD and their parents. Given high rates of ID among those with ASD, additional studies are needed to examine treatments to help children and adults with ASD and ID cope with stressors and manage their emotions. Frequently using single-subject designs, behavioral interventions using exposure and desensitization have consistently shown to be effective in treating anxiety in this population (Lang et al., 2011). Jennett and Hagopian (2008) reviewed treatments for phobic avoidance among chil- dren and adults with ID; approximately one third of the participants in included studies also had ASD, and all studies involved exposure to the feared stimulus and reinforcement of appropriate behaviors, specifically approaching the feared stimulus. Results consistently indicate a high degree of effectiveness, leaving the authors to conclude that behavioral treatments can be considered well- established for phobic avoidance in this population. More recently, Lydon, Healy, O’Callaghan, et al. (2014) systematically reviewed treatments for fears and phobias, including three studies (one case study and two single-subject designs) in which participants had both ASD and ID. Authors reported positive treatment outcomes with all of the behaviorally-b ased interventions: Reinforced practice (Chok et al., 2010), contingent reinforcement and systematic exposure (Schmidt et al., 2013), and stimulus fading and differential reinforcement (Shabani & Fisher, 2006). Behavioral interventions have been used to teach relaxation strategies to address disruptive behaviors as well. In a multi-element single subject design, Mullins and Christian (2001) examined the effects of progressive muscle relaxation strategies to decrease disruptive behaviors of a 12-year-old male with ASD and ID during unstructured leisure activities. There was a decrease in the duration of disruptive behaviors when relaxation strategies were cued before leisure activities, suggesting that the training had a positive impact on his problem behaviors. Given the central role that emotion regulation plays in the onset or maintenance of emotion disorders, and the high degree of emotion regulation difficulties in individuals with ASD, it is surprising that few studies exist on evaluating the treatment of emotion regulation deficits. The vast majority of studies focus exclusively on symptoms of anxiety in ASD, neglecting the need to also target co-o ccurring depression or anger. Scarpa and Reyes (2011) evaluated a modified CBT program to address emotion dysregulation in five six- to eight-year-old children with ASD and average intellectual functioning compared to six children in a delayed treatment condition. Using one-tailed tests of significance, the authors suggest improvements in child reported coping strate- gies in response to vignettes, and parent reported child negativity/lability and emotion regulation. More recently, Thomson, Burnham Riosa, and Weiss (2015) evaluated the feasibility of the Secret Agent Society-Operation Regulation (SAS-OR; described in detail below) in addressing emotion regulation in 13 youth with ASD, eight to 12 years of age, and their parents. All children had at least average intellectual functioning and parent-reported problems with anxiety, depression or anger/a ggression. The SAS-OR program was found to have high participant and therapist satisfac- tion and therapeutic alliance, excellent treatment adherence across sessions (including homework completion and child engagement), and face validity. Results revealed parents reported significant improvements in child emotional lability, internalizing symptoms, behavioral dysregulation, and adaptive behavior. Independent clinician evaluation indicated significant improvements in child overall severity and number of psychiatric diagnoses. Children reported significant improvement in inhibition and dysregulation across anger, anxiety, and sadness, as well as in generating emo- tion regulation strategies to hypothetical vignettes. An RCT of the SAS-OR program is currently underway (ISRCTN67079741), and the details regarding each session and the treatment approach are articulated below.
542 PROMOTING SKILL LEARNING AND APPLICATION 245 The Secret Agent Society-âO•‰ peration Regulation program The SAS-O╉ R program is a spy-ât•‰hemed emotion regulation intervention delivered individually to children and their parent(s). The program, comprised of ten weekly one-âh•‰ our sessions, aims to teach children with ASD a core set of mindfulness-âb•‰ ased CBT emotion regulation skills that can be applied to a range of feelings in different contexts. Specifically, it targets the potentially modifi- able characteristics of ASD that may contribute to emotion regulation difficulties, as shown in Figure 12.1. Program content aims to teach children how to recognize and understand emotional experiences in themselves and others by attending to and accurately interpreting social-âe•‰ motional clues, to think more flexibly about distressing situations, to use mindfulness strategies to tolerate unpleasant sensory experiences and uncomfortable situations, and to successfully apply a step-âb•‰ y-╉ step formula to solve social dilemmas. Therapists work collaboratively with children and their parents to determine core goals for ther- apy at the outset. These typically involve symptom reduction and/o╉ r better coping skills in one or more emotional domains (i.e., anger, anxiety, or depression). The SAS-O╉ R Facilitator Manual guides the therapist in how to tailor the program to individual client needs and preferences (e.g., focusing on anger management strategies for children with behavioral challenges versus anxiety management for children with comorbid anxiety disorders). The SAS-âO•‰ R program content draws from and expands on the emotion recognition and emotion regulation strategies and multime- dia resources featured in the evidence-b╉ ased Secret Agent Society group social skills program for children with ASD (Beaumont, 2010), which is published and distributed worldwide by Social Skills Training Pty Ltd. (www.sst-âi•‰ nstitute.net), a subsidiary of the Cooperative Research Centre for Living with Autism (www.autismcrc.com.au). The program and its variants are designed for children with ASD who have an IQ at least within the average range. Promoting skill learning and application SAS-O╉ R features several core elements to promote children’s skill learning and application to home and school. Visually engaging child resources (e.g., the SAS-OR Cadet Handbook that features full-âc•‰olor character illustrations of skill steps and concepts; pocket sized collectable Relaxation Gadget Code Cards featuring color images of relaxation and mindfulness techniques; the SAS compute game), active session activities, skill demonstrations and discussions aim to optimize children’s interest and engagement in the learning content by catering to all learning styles (visual, verbal, and kinesthetic). The SAS computer game (a resource from the Secret Agent Society group social skills training program) also capitalizes on the affinity that individuals on the spectrum often have for technology (Odom et al., 2014). As skill generalization is a common challenge for children with ASD (Church et al., 2015), SAS-╉ OR engages parents and school staff as co-t╉herapeutic agents to optimize children’s skill applica- tion to daily life. Where possible, parents are involved in session activities and games to help them to become fluent in the program “language” and to provide them with a model of how to talk to their child about emotions. Parents are provided with the SAS-âO•‰ R Parent Workbook that summarizes core concepts and provides tips and strategies on how to help children to apply skills from the program outside of formal therapy sessions (e.g., through the use of incidental teaching, modelling and rewarding child skill usage). Weekly teacher tip sheets are also included in the program materials to provide a child’s teachers and other school support staff with a brief sum- mary of the skills that they are learning in the program, and tips on how they can support their student in applying these skills in class and at break time. An example Teacher Tip Sheet is shown in Figure 12.2. A Home-âS•‰ chool Diary (see Figure 12.3) is also included in the program materials to allow par- ents and school staff to track children’s progress in using their emotion regulation skills at home
642 Figure 12.2 An example Teacher Tip Sheet from the SAS-O R Program Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-i nstitute.net)
Figure 12.3 The Home School Diary used in the SAS-OR Program Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-institute.net)
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842 248 Emotion Regulation and Autism Spectrum Disorder and at school each day. Parents and teachers are encouraged to award a child a diary point when they use their target skill for the week at home and at school (based on the child’s self-r eport). If the child reaches their daily points “target,” which is negotiated between the parent and therapist at each session, their points can be exchanged for a home-b ased reward. The child is also given weekly “home missions” to complete with parent support between sessions, which involve prac- ticing the skills that they are learning at home, at school and when they are out. After completing each mission, the child is asked to answer questions in the Secret Agent Journal section of their SAS-OR Cadet Handbook. These questions help the child to understand the benefits of using their SAS-O R skills, building their intrinsic motivation to do so in the future when the Home-S chool Diary reward system is gradually phased out. Children are also given full-c olor pocket-s ized collector “Code Cards” throughout the program, and a Code Card holder. Each card features an image of a different relaxation and/or mindfulness technique, and a description of what level of anxiety or anger it is best used for and where it is best used (at home, at school and/or when the child is out). Children are encouraged to secretly refer to their Code Cards to remind them of the strategies they can use to feel happier, calmer, and braver and to make smart choices just before entering situations where they are likely to feel uncomfort- able or distressed (with adult help where available). An example Relaxation Gadget Code Card is shown in Figure 12.4. Each SAS-O R session typically commences with a ten-minute review of how the child and parent(s) did with completing the home missions and using the Home-School Diary during the week. Any challenges are problem-solved to set the child and family up for success in completing Figure 12.4 An example Relaxation Gadget Code Card from the SAS-O R Program (Front and Back of Card shown) Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-i nstitute.net)
942 Promoting skill learning and application 249 their home missions and using the Home-âS•‰ chool Diary the following week. For example, if a child struggled to differentiate feelings of anger from anxiety and rates the intensity of their emotions one week, they may just be asked to practice detecting when they feel happy or upset the follow- ing week. After reviewing home missions and the Home-S╉ chool Diary with the child and parent(s), the therapist facilitates a series of espionage-ât•‰hemed games and activities (including playing assigned sections of the SAS computer game) that teach the child how to recognize and manage their emo- tions (see below for further details). Based on literature showing that children with ASD often struggle to accurately identify emotions in themselves and others (e.g., Rieffe et al., 2007; Uljarevic & Hamilton, 2013), initial session content predominantly focuses on teaching children emotion identification skills, as they are a prerequisite for them to be able to use their emotion regulation strategies when needed. Sessions end with a review of the home missions to be completed during the coming week and discussing the target behavior(s) and points target for the Home-âS•‰ chool Diary with the child’s parent(s). Session content In the first session of the program, the child and parent(s) are introduced to the aims of the inter- vention (i.e., “to help them to feel happier, calmer, and braver”) and create a Challenge Card fea- turing a picture of the child’s favorite fictional or real life hero or role model who has to be brave, face their fears and do things that they do not want to do at times. On the card, the child creates a hierarchy of boring, scary, or difficult things that they have to do in their own life (ranked from “least” to “most” challenging). As the program progresses, the child is asked to use the emotion regulation skills that they are learning to cope with unpleasant feelings and to face these fears or challenges between sessions. Session rules and an in-âs•‰ ession reward system for following the ses- sion rules are negotiated in the first session. Children receive points for following the rules in each session (e.g., trying their best) and if they reach their points target for the session, their points are exchanged for an end of session reward. A rewards menu is negotiated with the child in the first session, listing up to five different types of rewards that they would like to receive if they reach their session points target. Recommended points targets for each session are provided in the SAS-╉ OR Facilitator Manual, although these can be adjusted as the therapist sees fit. In Session One, the child is introduced to activities in the SAS computer game that teach them how to recognize emotions in other people from facial expression and body posture/âm•‰ ovement clues (“Spot the Suspect” and “The Line Up” games), fostering emotional awareness based on cues and context. They also practice the mindfulness technique of being aware of their own breath (“The Breath Analyzer”), introducing them to attention shifting from negative emotions. At the end of the first session, the therapist spends time alone with the child’s parent(s) explaining the Home-S╉ chool Diary monitoring and reward system. Home missions for the coming week include the child practicing their mindful breathing (the Breath Analyzer Mission) and detecting how other people feel from face and body clues (the Secret Spy Mission) with parent and school staff support. After the Home-S╉ chool Diary and home mission review, Session Two commences with a cha- rades game (“Detection of the Expression”) where the child, therapist and parent(s) take turns acting out and guessing how each other feels from facial expression and body posture clues. The child subsequently plays a SAS computer game activity (“Voice Verification”) that involves detect- ing how people feel from the pitch, pace, and volume of their voice. They then play a game that involves saying and listening to different secret messages said in different voice tones with their parent(s) and the therapist, before learning the mindfulness technique of scanning their bod- ies for physical sensations in the moment (“Body Scan”). Home missions for the week include
052 250 Emotion Regulation and Autism Spectrum Disorder practicing body-scanning and detecting how other people feel from their tone of voice with the help of their parent and teacher mentors. Session Three involves the child playing computer game activities that teach them the body clues and thoughts that signal emotions of happiness, sadness, anxiety and anger within them- selves (“Detective Laboratory”) and learning that different body clues signal different emotional intensities (“Degrees of Delight and Distress”). Children draw their own body clues that signal target emotions on body outlines, and play a game similar to statues with their therapist and parent(s) to practice quickly identifying emotion body clues (“The Body Clues Freeze Game”). They repeat the Body Scan activity introduced in Session Two before planning to practice this skill for their weekly home mission with parent support, practicing awareness of their own arousal through a focus on their internal cues. In Session Four, the child creates anxiety-, anger-and/o r sadness “Emotionometers” (pocket- sized emotion scales featuring stickers showing the body clues and situations where they feel low, moderate and high levels of the target emotion). They then learn how to piece together face-, voice-, body-and situational clues that signal how someone is feeling in the “Secret Agent Viewing Panel” SAS computer game activity, and plan how they can use their Emotionometers to detect the type and strength of their emotions during the week. Learning to rate degrees of emotions is common across all CBT interventions, and here is applied to internalizing and externalizing emo- tional states to promote understanding and differentiation across emotions. Session Five involves the child learning about relaxation “gadgets” to help them to feel hap- pier, calmer and braver and to make smart choices. This concept is initially introduced to the child through the first virtual reality mission in Level Three of the SAS computer game. Each of the virtual reality missions in Level Three of the game involve the child choosing how their avatar can cope with a challenge (e.g. trying something new, performing poorly at a game or competition), with both appropriate (take some slow breaths, think helpful thoughts) and less appropriate (scream and shout, run away) choices available (see the screenshot in Figure 12.5). The child discovers the consequences of different response options for their avatar, allowing them to learn through a depersonalized self-discovery process that using skills to stay calm and cope typically leads to better outcomes than aggressive outbursts, avoidance, or escape behaviors. After the child finishes playing the first Level Three virtual reality mission in Session Five, the therapist helps them to choose Relaxation Gadget Code Cards illustrating the gadgets or strate- gies that they would like to use to feel happier and calmer in the situations shown on their anxi- ety, anger and/o r sadness Emotionometers. The child and parent(s) learn and rehearse the “O2 Regulator Gadget” (slow, mindful breathing) in session, before planning how they will use this and other Relaxation Gadgets during the week in situations featured on the child’s Challenge Card (created in Session One). In Session Six, the child plays the second Level Three virtual reality mission in the SAS computer game, which introduces them to the “Fire Engine” Relaxation Gadget (doing a physical activity to burn up anxious or angry energy when really upset). They also learn about the “Relaxation Radar” gadget—being on high alert for relaxing or friendly things around you (e.g., friends smiling at you while you are giving a talk in front of the class). The possible role of sensory items (e.g., a piece of fabric or scratch and sniff stickers) as Relaxation Gadgets is also explained to children in this ses- sion, transforming sensory-s eeking behaviors or interests that are common in children with ASD (Little, Ausderau, Sideris & Baranek, 2015) into an adaptive coping skill. The child is introduced how to use their five “super-s enses” (sight, touch, smell, taste, and sound) to be aware of their sur- roundings as well as their internal body sensations with the “Enviro-Body Scan” gadget, and they attach stickers illustrating their chosen Relaxation Gadgets to the backs of their Emotionometers.
152 Promoting skill learning and application 251 Figure 12.5 Screenshot from a Level 3 Virtual Reality Mission in the SAS Computer Game Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-institute.net) Their home mission for the coming week involves using their Relaxation Gadgets to continue climbing the hierarchy of situations featured on their Challenge Card. Cognitive strategies for coping with emotional discomfort are taught in Session Seven of the SAS-O R program, aimed at enhancing cognitive control. These include “shooting down” unhelp- ful thoughts with more helpful alternatives (the “Helpful Thought Missile” Gadget) and being aware of unhelpful thoughts and allowing them to pass when ready, as if they were printed on the wings of an SAS spy plane or blimp (the “Thought Tracker”). Children continue rehearsing the Enviro-Body Scan mindfulness activity introduced in Session Six, practicing their awareness of physiological arousal and body cues as well as cues in the environment. They also plan their home missions of being on “unhelpful thought alert” and continuing to progress up their Challenge Card situational hierarchy, using their Relaxation Gadgets to help them cope. Session Eight involves the child learning how to be a “Losing Champion”—that is, learning how to use their Relaxation Gadgets to stay calm when they are losing at a game or competition, just like their role model or hero does at times. Coping with uncontrollable situations like losing is a common challenge for children with ASD that contributes to their friendship difficulties (Hebron, Hunphrey & Olfield, 2015). This concept is introduced with the third Level Three SAS computer game virtual reality mission, and then rehearsed in session with the child playing a game with their therapist and parent(s). The child is asked to practice being a losing champion when play- ing games with family, classmates and other friends as their home mission for the week, provid- ing them with opportunities to practice using their Relaxation Gadgets during ecologically valid social experiences. In Session Nine, the child is taught how to use their Relaxation Gadgets and other strategies to cope with another social challenge often faced by children on the spectrum–identifying, pre- venting and managing bullying (Rowley et al., 2012). These skills are introduced to the child in the final computer game virtual reality mission. The child learns clues to help them differentiate friendly joking from mean teasing (e.g., whether the person says sorry or follows your instruc- tions when you tell them to stop) and makes their own customized Bully Guard Body Armor
25 Figure 12.6 Summary of the D.E.C.O.D.E.R Problem-Solving Steps Reprinted with the permission of Social Skills Training Pty Ltd (www.sst-institute.net)
352 Conclusion 253 Code Card featuring stickers showing the bully blocking strategies that they intend to use. The child is encouraged to put these skills into action during the week (with the help of their parent mentor) as their home mission. Session Ten, the final session of the program, involves the child and parent(s) learning how to use a step-âb•‰ y-s╉tep problem-âs•‰olving formula (the “D.E.C.O.D.E.R”) to change situations that are causing them distress. As children with ASD often struggle to detect social problems when they first arise due to their challenges with recognizing how others feel and knowing the implicit social rules for different situations (Rowley et al., 2012), the formula focuses on helping them detect social problems in the first instance based on their own internal emotional state and other people’s facial expressions, voice tones, body postures and movements, what they say and do and the situ- ation that they are in. For example, if a child accidentally says something that offends someone, they need to detect this before they can determine the best way to respond. The formula also focuses on the child developing a detailed plan for their chosen solution with adult support before putting it into action, including planning and rehearsing the Relaxation Gadgets that they will use to stay calm. A summary of the D.E.C.O.D.E.R steps is shown in Figure 12.6. After the D.E.C.O.D.E.R formula is introduced in Session Ten, the child, therapist, and parent(s) play a ball game to review the skills that have been taught in the SAS-O╉ R program, plan how they can use these skills to cope with future challenges and schedule weekly home review meetings of session content. The child finishes the final level (Level four) of the SAS computer game, and is presented with a graduation medal to reward them for their efforts throughout the program. Finally, the child and parent(s) plan how the child can use the D.E.C.O.D.E.R steps to solve an upcoming problem for their final home mission, and the parent(s) are given tips on how to sup- port their child in continuing to develop their emotion regulation skills (e.g., gradually phasing out the Home-S╉ chool Diary, continuing to prompt and reward skill usage when needed with the help of visual supports). As described, preliminary trial results of the SAS-âO•‰ R intervention have been encouraging, with parents and children reporting high program acceptability ratings, and children on the spectrum showing improvements in their emotion regulation skills (Thomson, Burnham, Riosa, & Weiss, 2015). Future research will inform how the user-âf•‰ riendliness and effec- tiveness of the program can continue to be improved. Conclusion There is robust evidence indicating that we can address a common outcome of emotion dysregula- tion in youth with ASD (i.e., anxiety), and growing interest in targeting core underlying emotion regulation skills, primarily based on mindfulness and cognitive behavioral approaches. As we progress toward building this evidence base, an improved understanding of a transdiagnostic approach that is not solely focused on symptom reduction will likely emerge, and with it, more effective interventions that can address a broader array of profiles and deficits. Understanding the dynamic process of emotion regulation through the lens of ASD symptomatology, and in the face of ASD-âr•‰ elated stressors, is important to support individualized skill development and improved outcomes. References Aldao, A., & Nolen-•âH‰ oeksema, S. (2010). Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy, 48(10), 974–‰9â• 83. American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
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952 Chapter 13 Emotion Dysregulation in Adolescents with Borderline Personality Disorder Carla Sharp & Timothy J. Trull Borderline personality disorder The achievement of independent emotion regulation without external regulation by caregivers is considered a crucial milestone of adolescence (Steinberg et al., 2006). However, adolescence is characterized by dramatic social-âe•‰ motional developmental changes that include the creation of an independent social network of stable friendships, the development of romantic relationships while not neglecting maintaining closeness to family members, and honing the capacities required for education and work tasks (Allen et al., 2006; Roisman, Masten, Coatsworth, & Tellegen, 2004). These social demands coincide with significant functional and structural brain changes in brain areas highly relevant to emotion regulation (Hare et al., 2008; Monk et al., 2003). For instance, Monk et al. (2003) showed that the emotional content of social stimuli appeared to drive activa- tion more strongly in the amygdala in adolescents than in adults. In other words, social-âe•‰ motional developmental tasks become salient at exactly the same time adolescents become more strongly motivated by emotional content, thereby placing adolescents at risk for disorders of emotion reg- ulation. One such disorder, which is often described as the quintessential disorder of emotion regulation, is Borderline Personality Disorder (BPD). The aim of this chapter is to shed light on emotion dysregulation in BPD in adolescents in terms of its understanding and treatment. We begin by highlighting the main characteristics of BPD in adolescents. Next, we discuss developmental theories of BPD that place emotion dysregulation at its center. We then discuss definitional ambiguities for the constructs of emotion, emotion regulation and emotion dysregulation to justify the use of a multi-c╉ omponent model of emotion dysregulation in BPD (Carpenter & Trull, 2013). We then review the empirical literature on each component of this model (emotional sensitivity, intense negative affect, inadequate emotion regu- lation strategies and maladaptive regulation strategies), completing the chapter with a review of the latest evidence-âb•‰ ased intervention approaches for BPD, and providing an in-âd•‰ epth example of one of these treatment approaches. Borderline personality disorder in adolescents DSM-5╉ criteria for BPD In contrast to other disorders described in the fifth edition of the Diagnostic and Statistical Manual of Psychiatric Disorders (American Psychiatric Association, 2013), the personality disor- ders (PDs), which include BPD, are categorized in two sections. BPD is first categorized in Section II of the DSM-â5•‰ , alongside nine other personality disorders. Table 13.1 summarizes the diagnostic criteria as defined in Section II.
062 260 Emotion Dysregulation in Adolescents with Borderline Personality Disorder Table 13.1╇ Diagnostic criteria of BPD as defined by the DSM-5╉ (Section II) A pervasive pattern of instability of interpersonal relationships, self-âi•‰mage, and affects, and marked impulsivity, beginning by early adulthood and present in a variety of context, as indicated by five (or more) of the following: 1. Frantic efforts to avoid real or imagined abandonment. (Note: Do not include suicidal or selfmutiliating behavior covered in Criterion 5). 2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. 3. Identity disturbance: markedly and persistently unstable self image or sense of self. 4. Impulsivity in at least two areas that are potentially self-âd•‰ amaging (e.g. spending, sex, substance abuse, reckless driving, binge eating: (Note: Do not include suicidal or self mutilating behavior covered in Criterion 5.) 5. Recurrent suicidal behavior, gestures, or threats, or self-âm•‰ utilating behavior. 6. Affective instability die to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). 7. Chronic feelings of emptiness. 8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). 9. Transient, stress-âr•‰elated paranoid ideation or severe dissociative symptoms. While Section II represents the traditional categorical perspective that PDs are qualitatively distinct clinical syndromes, an alternative to the categorical approach is articulated in Section III of the DSM-5╉ . Section III contains “Conditions for Further Study” and includes those for which scientific evidence was deemed unavailable to support widespread clinical use. PDs are concep- tualized in Section III from a dimensional perspective, such that PDs represent maladaptive vari- ances of personality traits that lie on a continuum from normal to abnormal. DSM-5╉ Section III requires clinicians to consider two sets of criteria (Criteria A and B) in the assessment of BPD. Criterion A requires judgment of the severity of problems in identity, self-âd•‰ irection, empathy, and intimacy. Criterion B is used to situate an individual within a dimensional personality disorder space, such that an individual’s functioning may be profiled across five PD trait domains (negative affectivity, detachment, antagonism, disinhibition and psychoticism) and 25 PD facets (emotional lability, anxiousness, separation insecurity, submissiveness, hostility, perseveration, depressivity, suspiciousness, restricted affectivity, withdrawal, intimacy avoidance, anhedonia, manipulative- ness, deceitfulness, grandiosity, attention-âs•‰eeking, callousness, irresponsibility, impulsivity, dis- tractibility, risk-t╉aking, rigid perfectionism, unusual beliefs/e╉ xperiences, eccentricity, cognitive/╉ perceptual dysregulation). The typical trait profile suggested for BPD requires moderate to greater impairment in personality functioning manifested by difficulties in two of Criterion A features (poorly developed identity, problems in self-d╉ irection, compromised empathy and interpersonal hypersensitivity, and problems in intimacy). In addition, for Criterion B, high ratings on four or more of the following seven pathological personality traits are required: Emotional lability, anxiousness, separation insecurity, depressivity, impulsivity, risk-t╉ aking, and hostility; of which at least one must be impulsivity, risk taking, or hostility. Applying DSM criteria to adolescents There has been longstanding, general consensus (as early as the DSM-I╉I; American Psychiatric Association, 1968) that BPD symptoms usually first become apparent in adolescence (Chanen & Kaess, 2012a; Shiner, 2009). Accordingly, Section II of the DSM-â5•‰ states that the diagnosis of BPD may be applied to children or adolescents when “the individual’s particular maladaptive personal- ity traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental
162 Borderline personality disorder in adolescents 261 stage or another mental disorder” (American Psychiatric Association, 2013, p. 647). In contrast to the two years necessary for an adult PD to be diagnosed, only one year is necessary for child/╉ adolescent PD. Section III of the DSM-5╉ states that impairments in personality function are stable over time and onset can be traced back to “at least adolescence or early adulthood” (American Psychiatric Association, 2013, p. 762). In addition, the trait facets incorporated in Section III of the DSM-â5•‰ mirror developmental findings from maladaptive personality trait frameworks (e.g., De Clercq, De Fruyt, et al., 2014; De Clercq, Decuyper, & De Caluwé, 2014). The ICD-1╉ 1, and national treatment guidelines for the U.K. (National Institute for Health and Clinical Excellence, 2009) and Australia (National Health and Medical Research Council, 2013) also “legitimize” the diagnosis of BPD in adolescence. In all, current official classification systems for mental disorders support the evaluation and diagnosis of BPD in adolescents. Despite these advances, there has been a general reluctance among clinicians to diagnose BPD in adolescence due to fear of stigma and concerns that personality is not stable in adoles- cence. The five-f╉old increase in research on BPD in adolescents over the last ten years (Sharp & Tackett, 2014) is addressing some of these fears, and researchers agree that BPD is a valid and reliable diagnosis in adolescents (Chanen & Kaess, 2012b; Chanen & McCutcheon, 2013a; Miller, Muehlenkamp, & Jacobson, 2008; Sharp & Fonagy, 2015; Sharp & Kalpakci, 2015; Sharp & Kim, 2015; Stepp, 2012). For example, the extant literature supports the construct of adoles- cent BPD in terms of its clinical description (Chanen & Kaess, 2012b; Fossati, 2014), correlates and causes (e.g. Carlson, Egeland, & Sroufe, 2009; Sharp et al., 2011), studies that delimitate the disorder from other related syndromes (e.g. Chanen, Jovev, & Jackson, 2007), follow-âu•‰ p studies that demonstrate a prototypical course and outcome of the symptoms (e.g. Bornovalova, Hicks, Iacono, & McGue, 2009; Chanen et al., 2004; Cohen et al., 2008), and twin/f╉amily studies that aim to identify a genetic basis of the biological phenomena associated with adolescent BPD (Distel et al., 2008). Summary BPD is a valid and reliable disorder in adolescence and can be assessed categorically using DSM-╉ 5 Section II, and dimensionally using DSM-5╉ Section III. Prevalence studies have shown that adolescent BPD occurs at rates around 1% (Michonski, Sharp, Steinberg, & Zanarini, 2013) to 3% (Zanarini et al., 2011; Johnson, Cohen, Kasen, Skodol, & Oldham, 2008) in community samples. In clinical samples, rates are 11% in outpatients (Chanen et al., 2004), 33% (Ha, Balderas, Zanarini, Oldham, & Sharp, in press) and 43–â4•‰ 9% in inpatients (Levy et al., 1999). BPD is, therefore, not a transient condition of adolescence, but should be diagnosed and treated to prevent youngsters from a lifelong trajectory of increasingly severe psychopathology. Emotion dysregulation and BPD: Developmental theories As evident in Table 13.1, BPD is characterized by dysregulation in several functional domains including behavior, identity, interpersonal relationships, cognition and emotion (Carpenter & Trull, 2013). Of these, dysregulation in emotion is identified as a central mechanism in all develop- mental theories of BPD. Linehan’s biosocial theory (Linehan, 1993) and recent extensions thereof (Crowell, Beauchaine, & Linehan, 2009; Selby, Kranzler, & Panza, 2014), most prominently places emotion dysregulation at the core of borderline pathology and describe dysregulation in other domains as secondary. Linehan (1993) posits that children with a genetically-b╉ ased, emotion- ally sensitive, and reactive temperament are at an elevated risk of developing BPD when reared in an invalidating (e.g., neglectful, abusive, and/âo•‰ r dismissive) early family environment. These children are suggested to experience higher levels of negative affect across contexts and situations, but instead of being matched with a family environment that scaffolds the child in regulating these intense, negative emotions, the environment fails to impart adequate emotion management
26 262 Emotion Dysregulation in Adolescents with Borderline Personality Disorder skills, so the individual often resorts to short-t╉erm avoidance strategies (e.g., self-h╉ arm, impulsive behavior, etc.) when experiencing unpleasant internal states. Crowell and colleagues recently extended Linehan’s biosocial theory to develop a developmen- tal psychopathology model with a specific focus on trait impulsivity. In their model, biologically determined negative affectivity and high emotional sensitivity interact with trait impulsivity and parental factors (invalidation and ineffective parenting) early on in development to confer increased risk for impulse control deficits as development progresses. Impulse control deficits are then further reinforced by the same parenting factors over time, culminating in BPD. In another extension of Linehan’s biosocial theory, Selby and colleagues suggest, in their Emotional Cascade Model (Selby & Joiner, 2009), that rumination (and catastrophization as future-âo•‰ riented rumination) potentiates the magnitude of biologically determined negative affect which, in sequence, amplifies the level of rumination, initiating a vicious, self-âp•‰ erpetuating cas- cade of negative emotions. This biologically determined deficit in emotional functioning interacts with an invalidating family environment over time, from which a full syndrome of BPD emerges. Fonagy and colleagues’ developmental theory of BPD (Fonagy, Gergely, Jurist, & Target, 2002; Fonagy & Luyten, 2009; Sharp & Fonagy, 2008) describes emotion dysregulation as a core interac- tive component with developing mentalizing capacity which, in the context of disrupted attach- ment relationships, may foster poor self-o╉ther differentiation culminating in BPD over time. This model of BPD is firmly rooted in the developmental psychology of emotion regulation. Specifically, secure attachment and mentalizing capacity evolve when a parent communicates contingent, marked, and ostensive cues to an infant/âc•‰ hild. The brains of infants are presumed to be hard-âw•‰ ired to preferentially attend to these cues (Fonagy et al., 2002; Kim, in press). Marked communication (Fonagy, Gergely, & Target, 2007) refers to communication where a parent understands the infant’s internal state, while concurrently signaling that the parent’s expression of emotion concerns the infant, not the parent him/âh•‰ erself. The expression of emotion is marked by modifying (e.g., exaggerating or slowing down) the display of the child’s affect, such that the parent’s emotional expression resembles, but also modulates the child’s emotion simultaneously. Ostensive communicative cues (Csibra, 2010; Gergely Csibra & Gergely, 2011) refer to the process of calling attention to what the parent is about to communicate, for instance by making direct eye contact with the child while calling the child by name, and/o╉ r speaking with a “motherese” into- nation. These ostensive cues signal to the child that the parent’s emotion expression concerns the child and is of importance. In all then, it is not essential that the adult is perfectly accurate every time that he/âs•‰he guesses what might be going on in the mind of the child; the point is that the adult is genuinely interested in the child´s mind and this enables the child to develop a separate sense of self and adequate emotion regulation capacity (Sadler et al., 2006). If these developmental processes fail, a child is at risk for developing inadequate mentalizing, emotion dysregulation and disturbed self-âo•‰ ther processing—âi•‰n short, BPD. Summary All developmental theories of BPD include a strong focus on emotion dysregulation. Moreover, all theories emphasize the family and/o╉ r attachment context as highly relevant to the child’s develop- ing emotion regulation capacity. Theories furthermore converge to suggest a reciprocal relation between emotion dysregulation and other domains of functioning. Emotion dysregulation and BPD While the presence of emotion dysregulation in BPD is undeniable, research in the field contin- ues to be plagued by definitional ambiguities (Bloch, Moran, & Kring, 2010; Carpenter & Trull, 2013). It is essential for researchers to commit to a particular working definition in this regard, as
362 Borderline personality disorder in adolescents 263 neglecting to do so may lead to a vague and non-s pecific discussion of problems in emotion regu- lation related to specific disorders. Given the developmental nature of this volume, and that this chapter is concerned with emotion dysregulation as it relates to BPD, we will draw on literature in developmental psychology, developmental psychopathology, and the psychology of emotion to set the definitional parameters for the remaining discussion. While several definitions of emotion have been put forward, they all converge on the central idea that emotions have evolutionary utility—that is, they prepare us biologically to appraise and respond rapidly and flexibly to situations in service of our survival. Consistent with this view, emotions are defined in the developmental psychology literature as “appraisal-a ction readiness stances, a fluid and complex progression of orienting toward the ongoing stream of experience” (Cole, Martin, & Dennis, 2004, p. 320). In this sense, emotions are always context-dependent, although this context may include both the external and internal world. From a developmental psychology perspective, and highly relevant to BPD, the family environment and the caregiving relationship is regarded as the most relevant context influencing young children’s emotions. As children mature into adolescence, peer-and romantic-relationships emerge as additional contexts of high emotional salience (Cole et al., 2004). While most psychiatric disorders are characterized by disturbances in emotions, emotions in and of themselves are not pathological. However, too much or too little emotion may be indicative of pathology; we will return to how this bears on the definition of emotion dysregulation later in this section. Emotion regulation is defined in developmental psychology as either regulating or regulated (Cole et al., 2004). Emotion as regulating refers to instances during which emotion regulates another system or another person (e.g., a child’s sadness leads to a mother picking her up). Emotion as regulated refers to a change in a particular emotion (e.g., a mother picking up a child makes the child calm down). For the purposes of the current chapter, we will focus solely on emotion as regulated. Consistent with the concept of emotion as regulated, is Gross’s (Gross, 1988) definition of emotion regulation as the processes by which individuals (or context) influence the type, tim- ing, experience and expression of emotion. This definition was expanded by Gross and Thompson (2007) to define emotion regulation as the automatic or controlled, conscious or unconscious pro- cesses by which emotions in self and/o r others are influenced. Gross (1998) defines five regulat- ing “processes” which include situation selection, situation modification, attentional deployment, cognitive change, and response modulation. This definition implies that in order to effectively regulate one’s emotions, one has to have available a set of skills to adopt in a particular situation (e.g. when upset, an individual may know that turning to a loved one for support would help calm him/h er down), as well as implementing the skill appropriately (e.g., suppressing one’s anger when expressing it would lead to negative consequences). Keeping in mind the definitions of emotion and emotion regulation discussed above, emotion dysregulation denotes instances where emotion regulation processes are derailed, or, put differ- ently, the inability to flexibly enhance or suppress emotional expression in accord with situational demands (Bloch et al., 2010; Bonanno, Papa, Lalande, Westphal, & Coifman, 2004). Because too much or too little emotion may be indicative of pathology, emotion dysregulation, within a devel- opmental psychopathology framework, includes not only problems in emotion regulation, but also affect dysfunction (Cicchetti, Ackerman, & Izard, 1995). The inclusion of affect dysfunction in the definition of emotion dysregulation has meant that a wide variety of constructs are stud- ied under the umbrella of emotion dysregulation in BPD (Carpenter & Trull, 2013) including emotional sensitivity, emotion reactivity, affectivity lability, prolonged emotional responses and emotional intensity, to name a few. For conceptual clarity, it has been suggested that emotion dys- regulation be viewed as a process, consisting of many interactive components, rather than an end- state (Werner & Gross, 2010). To this end, Carpenter and Trull have developed a multi-component
462 264 Emotion Dysregulation in Adolescents with Borderline Personality Disorder Stimulus Emotion sensitivity Heightened and labile negative affect Inadequate Maladaptive appropriate regulation regulation strategies strategies Emotion dysregulation consequences Figure 13.1╇ Multi-c╉ omponent model of emotion dysregulation in BPD Note. Multi-âc•‰ omponent model of emotion dysregulation in BPD (Carpenter and Trull, 2013) Individuals with BPD are theorized to be sensitive to emotional stimuli from birth. Experiencing a negatively valenced stimulus (or interpreting a stimulus in a negative way) in the environment leads to increases in negative affect and affective instability. Heightened and unstable negative affect both makes it difficult to learn and to employ appropriate emotion regulation strategies and leads to an increase in maladaptive and impulsive regulation strategies. Emotion dysregulation consequences occur as a result, which, in turn, reinforce vigilance toward negatively valenced stimuli in the environment. Reproduced from Current Psychiatry Reports, Components of Emotion Dysregulation in Borderline Personality Disorder: A Review, 15 (1), p. 335, doi:10.1007/âs•‰ 11920-â0•‰ 12-â0•‰ 335-â2•‰ , Ryan W. Carpenter, Timothy J. Trull, Copyright © 2012, Springer Science + Business Media New York. With permission of Springer. model of emotion dysregulation relevant to BPD (see Figure 13.1). In this model, the experience or subjective perception of a negatively-v╉ alenced stimulus in the environment leads to increases in negative affect and affective instability. Heightened and unstable negative affect, in turn, impedes the use of appropriate and effective regulation strategies, instead leading to increases in the use of maladaptive strategies. The emotion dysregulation consequences that occur, as a result, reinforce emotion sensitivity for negatively-v╉ alenced stimuli in the environment that maintains a vicious, self-p╉ erpetuating cycle from which a full syndrome of BPD emerges. While this model is unmis- takably rooted within Linehan’s (1993) biosocial theory of BPD, here, we infuse the model with ideas from Fonagy and co-w╉ orker’s attachment-b╉ ased theory of BPD, to suggest that it is most often attachment-╉and relationship-b╉ ased events that will provide the most evocative stimuli for the initiation of this multi-âc•‰ omponent process of emotion dysregulation. Adolescent BPD: Empirical evidence Based on the depth, reach, and influence of developmental theories of BPD that place emotion dysregulation at its center, the lack of prospective, longitudinal research to test the interactive
562 Borderline personality disorder in adolescents 265 and causal effects of affective dysfunction and emotion regulation problems on the development of BPD is surprising (Matusiewicz, Weaverling, & Lejeuz, 2014). While this research is lacking, there is a growing body of cross-s╉ectional research focused on emotion dysregulation among adolescents with BPD. While the latter does not provide a test of the causal relations inherent in developmental models, it does provide an important starting point that can guide future work (Matusiewicz et al., 2014). In this section, we use the Carpenter and Trull (2013) model of emo- tion dysregulation in BPD to organize the empirical literature for each component of the model. Emotional sensitivity Emotional sensitivity is defined as heightened emotional reactivity to social and non-âs•‰ ocial stim- uli (Carpenter & Trull, 2013); or, emotional sensitivity may be defined as the tendency to have emotional responses to low-âi•‰ntensity stimuli (Matusiewicz et al., 2014). While findings are mixed, several studies have demonstrated heightened emotional sensitivity in adults (see Carpenter & Trull, 2013; Daros, Zakzanis, & Ruocco, 2013 for a review). Specifically, Daros et al. (2013) con- cluded, in a recent meta-a╉ nalytic review, that patients with BPD have a sensitivity for rejection-╉ related stimuli (captured in facial expressions of anger and disgust), which interferes with their capacity to adequately regulate their emotions. Two studies have investigated emotional sensitivity in adolescents, operationalized as atten- tional bias to emotional stimuli. Jovev et al (2012) used a modified dot probe task in 21 subjects between the ages of 15–2╉ 4, who met three or more criteria of BPD, compared to 20 healthy con- trols. The aim of the task was to assess whether emotion cues in facial stimuli interfered with a simple discrimination task. Results showed that youth with borderline features had an attentional bias for fearful faces that reflected difficulty in disengaging attention from threatening informa- tion during the preconscious stages of attention. Similarly, Von Ceumern-L╉ indenstjerna et al. (2010) demonstrated a correlation between current mood and attentional bias to negative faces, suggesting an inability to disengage attention from negative facial expressions during attentional maintenance when in negative mood. Together, these findings suggest a diminished capacity for affect regulation in the presence of negatively-âv•‰ alenced social stimuli. Another way to operationalize emotional sensitivity is to evaluate whether individuals with BPD accurately identify emotional expressions at earlier stages of expression (i.e., lower thresh- olds of facial expressivity across all emotional valences). Findings in adolescents, like those in adults, are mixed. Jovev et al. (2011) used a facial morphing task in which faces morph from neu- tral to each of the six basic emotional expressions. No evidence of heightened sensitivity to emo- tional facial expressions was found in the BPD group compared to the community control group. Using a similar face morphing task, Robin et al. (2012) demonstrated that adolescents with BPD were less sensitive to facial expressions of anger and happiness, i.e., they required more intense facial expressions than control participants to correctly identify these two emotions. However, they did not exhibit any deficit in recognizing fully expressed emotions. A third way to operationalize emotional sensitivity is through evaluating the valence and inten- sity of emotional reactions to aversive social or interpersonal events, in particular situations dur- ing which there are perceived or real rejection and/o╉ r invalidation. While several social rejection/╉ invalidation studies of BPD have been conducted in college-âa•‰ ge young adults (Ruocco et al., 2010; Tragesser, Lippman, Trull, & Barrett, 2008; Woodberry, Gallo, & Nock, 2008), only one study has included adolescents (Lawrence, Chanen, & Allen, 2011). This study examined the effect of social exclusion, with the use of a Cyberball task, upon mood in a sample of young people (aged 15–2╉ 4) presenting for treatment early in the course of BPD, as compared with a healthy control group. Cyberball is an experimental task designed to assess the effects upon mood of being excluded or ignored without explanation in a social context (Williams & Jarvis, 2006). Results showed that
62 266 Emotion Dysregulation in Adolescents with Borderline Personality Disorder ostracism did not selectively induce negative mood in adolescents with BPD; nor did borderline adolescents show more difficulty in regulating their mood back to baseline; however, the BPD group rated their mood as more intense across all mood states and across time compared to the control group. While more research is clearly necessary to further examine emotional sensitivity in adoles- cents with BPD, two conclusions can be drawn from the emotional sensitivity literature thus far. First, there seems to be preliminary evidence in support of emotional sensitivity among this group in the form of a “negativity bias” manifested as hyper-r esponsiveness (hypersensitivity) to negative emotions like anger and fear. This bias may not be specific to social-emotional stimuli as several studies (see von Ceumern-Lindenstjerna et al.) have demonstrated negative biases in borderline patients for non-s ocial stimuli. Therefore, it may be that the negative bias for social stimuli is part of this general bias toward negative emotion. This proposed hypervigilance for negative emotion (or emotion in general according to Frick et al., 2012) is thought to associate with reduced amygdala volume and enhanced amygdala responding to emotional stimuli, such as negative facial expressions, coupled with regulatory deficits of the orbital and prefrontal cortices (Domes, Schulze, & Herpertz, 2009; Frick et al., 2012). Indeed, three neuroimaging studies uti- lizing adult samples have explicitly investigated neural responses to emotion recognition in BPD and have confirmed this hypothesis. Donegan et al. (2003) showed that borderline patients dem- onstrated significantly greater left amygdala activation to the facial expressions of emotion (vs. a fixation point) compared to healthy control subjects. (Minzenberg, Fan, New, Tang, & Siever, 2007) found that borderline patients exhibited changes in fronto-limbic activity in the process- ing of fear stimuli, with exaggerated amygdala response and impaired emotion-modulation of anterior cingulate cortex (ACC) activity. Similarly, Frick et al. (2012) demonstrated stronger activation of the amygdala in response to affective pictures, regardless of valence, compared to healthy controls. Second, while research in adolescents is still lacking, research in adults suggest that more com- plex emotion recognition tasks more consistently distinguish BPD from non-BPD groups. For instance, in the Minzenberg, Poole, and Vinogradov (2006) study, where facial, prosodic (the aspect of speech that communicates meaning by variation in stress and pitch independent of lexi- cal and syntactic content) and integrated facial/p rosodic stimuli were used, borderline patients showed no problems with isolated facial or prosodic emotion, but instead demonstrated deficits in higher order integration of social information. Similarly, Dyck et al. (2009) investigated the ability of individuals with BPD to recognize negative and neutral emotions in both timed and untimed trials. They found that individuals with BPD were significantly impaired in their recogni- tion when the task was timed; however, no such difficulty was noted when the participants were not timed. Thus, the participants with BPD were significantly impaired when under time pressure and were less able to correctly judge negative or neutral affect in a hasty manner. It is possible therefore, that borderline patients have emotion recognition deficits when tasks require the inte- gration of different modes of processing (emotion recognition and speed of response), or when tasks are presented in the context of heightened emotional arousal (Dixon-G ordon, Chapman, Lovasz, & Walters, 2011b). Crucial for future research, in this regard, is the inclusion of psychiatric control groups, as studies typically compare adolescents with BPD with healthy controls. The specificity of emo- tional sensitivity to BPD, beyond mere “caseness” or neuroticism is, therefore, not clear. Moreover, the use of psychophysiology and neuroimaging to assess emotional sensitivity beyond subjective self-report in adolescents is completely absent and there is an urgent need for biologically-b ased studies. Finally, it is highly probable that attachment-relevant interpersonal situations will evoke stronger emotional reactions than more general social contexts. For instance, stimuli that include
762 Borderline personality disorder in adolescents 267 the faces or other identifying characteristics of actual attachment figures would increase emo- tional salience in theoretically relevant ways. Intense negative affect As formulated by Carpenter and Trull (2013), the second component in the emotion dysregula- tion process in BPD is the experience of intense, negative and labile affect. Intense, negative and labile affect is seen as a direct result of emotional sensitivity to subtle events that may seem benign to the casual observer, but which can cause rapid change in mood to an individual with BPD. Typically, Ecological Momentary Assessment (EMA) methods, by which a research participant repeatedly reports on symptoms, affect, behavior, and cognitions close in time to experience and in the participants’ natural environment (Stone & Shiffman, 1994), provide the richest data in this regard as it can track context-d╉ ependent (i.e., ecologically valid) valence, intensity and moment-╉ by-âm•‰ oment change in emotion, although trait-b╉ ased approaches have also been used (Solhan, Trull, Jahng, & Wood, 2009). In adults, EMA studies have generally supported greater negative affective lability in BPD (see Nica & Links, 2009 for a review). Only one study has used EMA methodology to assess negative affect in the context of adoles- cent BPD (Scott et al., 2015). The study assessed the covariation of daily experiences of shame and anger-âr•‰elated affects/âh•‰ ostile irritability and borderline symptoms in a community sample of adolescent girls while they were going about their daily lives. Results generally supported the hypothesized associations between shame and anger-âr•‰ elated affects in those with greater border- line features, such that, over the course of one week, shame (but not guilt) was associated with greater hostile irritability, but only in girls with high levels of borderline symptoms. Inadequate emotion regulation strategies The third component of emotion dysregulation in BPD, as articulated by Carpenter and Trull (2013), is a deficit in appropriate emotion regulation strategies. Here, the focus is on a lack of adaptive strategies as opposed to the use of maladaptive strategies. In Gross’s (1998) definitional terms discussed earlier, this deficit relates to the unavailability or access to skills, rather than the capacity to implement skills appropriately. Both the deficit in appropriate emotion regulation strategies and the use of maladaptive strategies are crucial components of the emotion dysregu- lation model of BPD, because they provide clear, malleable treatment targets. In other words, while it is counter-âp•‰ roductive to tell an individual with BPD that their emotions are too intense or that they are overly sensitive (in fact, this will reinforce their experience of invalidation which originally contributed to the development of the disorder), learning emotion regulation skills to manage intense, negative and labile emotions is a feasible alternative, which we return to in the section on evidence-âb•‰ ased intervention approaches. An important first step to adequate emotion regulation is the accurate identification and dif- ferentiation of one’s emotions. Adult patients with BPD have demonstrated difficulties in identify- ing, differentiating and labeling emotions (Coifman, Berenson, Rafaeli, & Downey, 2012; Leible & Snell, 2004; Suvak et al., 2011; Tomko, Lane, Pronove, Treloar, Brown, Solhan, Wood, & Trull, in press). Adults with BPD have also been shown to have problems in distress tolerance suggest- ing a lack of coping strategies to manage negative affect (Bornovalova, Matusiewicz, & Rojas, 2011; Gratz, Tull, Baruch, Bornovalova, & Lejuez, 2008). Borderline patients also report limited access to emotion regulation strategies (Salsman & Linehan, 2012) as well as general difficulties in employing emotion regulation strategies (Glenn & Klonsky, 2009; Gratz et al., 2008). Studies such as these, that have used self-r╉ eport to evaluate inadequate emotion regulation strategies, have typically used the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004) which has become a popular assessment tool given its brevity and low cost. The DERS is a 36-i╉tem
862 268 Emotion Dysregulation in Adolescents with Borderline Personality Disorder measure and subjects are asked to rate the frequency of each statement using a Likert-t╉ype scale ranging from 1 = “Almost Never” to 5 = “Almost Always.” A total score of emotion dysregulation is derived by summing all responses (indicating greater difficulty) with additional emotion regula- tion domains assessed for including 1) awareness and understanding of emotions; 2) acceptance of emotions; 3) the ability to engage in goal-âd•‰ irected behavior, and refrain from impulsive behav- ior when experiencing negative emotions; 4) access to emotion regulation strategies perceived as effective; and 5) the flexible use of situationally appropriate strategies to modulate emotional responses. To our knowledge, there are no studies, in adolescents with BPD, using experimental mea- sures to evaluate identification and differentiation of their own emotion. There are also no avail- able studies of distress tolerance in adolescents with BPD. There are, however, a few studies that have utilized the DERS in adolescent samples. In a sample of inpatient adolescents, Sharp, Ha, Michonski, Venta, and Carbonne (2012) showed that adolescents who met DSM-âI•‰V defined criteria for BPD evidenced higher total DERS scores compared to adolescents not meeting cri- teria for BPD. In addition, DERS total scores correlated positively with a self-âr•‰eport measure of borderline features. In another study, difficulties in emotion regulation were shown to relate to social-âc•‰ ognitive (mentalizing) capacity (Sharp et al., 2011). Moreover, difficulties in emo- tion regulation mediated the relation between impairment in social cognition and borderline traits. In a study contrasting difficulties in emotion regulation strategies (DERS), with the use of positive emotion regulation strategies, as measured by the Cognitive Emotion Regulation Questionnaire, (CERQ; Garnefski, Kraaij, & Spinhoven, 2002) along with assessments of mater- nal and paternal attachment security, Kim, Sharp, and Carbone (2014) showed that difficulties in emotion regulation strategies and the use of positive emotion regulation strategies were dif- ferentially implicated in the link between attachment insecurity and BPD features. Attachment security functioned as a buffer against adolescent BPD by enhancing positive emotion regula- tion strategies, while difficulties in emotion regulation strategies served to dilute the protec- tive effect of attachment and positive regulation strategies, culminating in clinically significant levels of borderline traits. In all, two conclusions can be drawn from the above literature. First, like their adult counter- parts, adolescents with BPD seem to experience a similar lack of emotion regulation strategies. Second, this impairment appears to relate to attachment insecurity and also affect functioning in other relationship-âr•‰elevant domains, like social cognition. As with the other components of Carpenter and Trull’s (2013) model of emotion dysregulation in BPD, more research is clearly needed in this area. Research in adults highlight the need for considering the interaction between components of emotion dysregulation, which should also be a goal of research in adolescent BPD. For instance, research focusing on inadequate emotion regulation strategies in BPD would be sig- nificantly enhanced if intense, negative affect is routinely assessed and controlled for in studies. In so doing, one can begin to parse out the validity of different components of emotion dysregulation to arrive at a more nuanced model of emotion dysregulation in BPD. Maladaptive emotion regulation strategies The fourth and final component of Carpenter and Trull’s (2013) emotion dysregulation model of BPD is perhaps the component most closely associated with the concept of maladaptive emotion regulation strategies. These are easily observable behaviors in individuals with BPD and include problems in substance use and other impulsive behaviors like aggression towards others or self-╉ directed aggression (Carpenter & Trull, 2013), most notably, self-i╉njurious behavior (SIB), with several studies demonstrating that SIB serves an emotion regulation function in adults with BPD (Klonsky, 2007).
962 Borderline personality disorder in adolescents 269 Maladaptive emotion regulation strategies may also include unobservable maladaptive cogni- tive strategies that are employed to help manage intense and negative emotion. For instance, con- sistent with the Emotional Cascades Model discussed above, adults with BPD have been shown to engage in intense rumination, thereby increasing the magnitude of the negative affect that caused the rumination in the first place, culminating in dysregulated behavior in order to distract from rumination (Selby, Anestis, & Joiner, 2008). Individuals with BPD have also been shown to engage in experiential avoidance (EA) (Dixon-âG•‰ ordon, Chapman, Lovasz, & Walters, 2011a; Gratz, Rosenthal, Tull, Lejuez, & Gunderson, 2006; Iverson, Follette, Pistorello, & Fruzzetti, 2012). EA is defined as an “unwillingness to remain in contact with uncomfortable private events (e.g., thoughts, emotions, sensations, memories, urges)” that often manifests in behaviors that serve to avoid unpleasant experiences (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996, p. 1154). Typical EA behaviors include thought suppression, denial, self-âd•‰ istraction, substance abuse, and self-i╉njury. While these behaviors alleviate distress in the short-t╉erm, avoidance of unpleasant thoughts and sensations actually increases the likelihood of experiencing them again in the future, elevating physiological arousal and distress (Chawla & Ostafin, 2007). This sets into motion a vicious cycle of using more avoidance-âb•‰ ased strategies, thereby thwarting healthy and effective emotion regulation. While studies are generally lacking in adolescents on the use of maladaptive emotion regulation strategies, there is an emerging literature for SIB as an emotion regulation strategy in adoles- cents with BPD. Consistent with Crowell and colleagues’ developmental psychopathology model of BPD, SIB and BPD appear to co-âo•‰ ccur in adolescence (see Gratz, Dixon-âG•‰ ordon, and Tull, 2014 for a review). Adolescents with a history of deliberate self-h╉ arm also report higher levels of overall emotion dysregulation on the DERS and a specific impairment in access to effective emo- tion regulation strategies (Perez, Venta, Garnaat, & Sharp, 2012). Studies in adolescents have also shown that adolescents who engage in SIB exhibit reduced respiratory sinus arrhythmia (RSA) at baseline, greater RSA reactivity during negative mood induction, and attenuated peripheral serotonin levels (Crowell et al., 2005). These studies suggest that SIB may serve a similar emotion regulation function for adolescents with BPD as suggested for adults. Similarly, at least two studies have demonstrated EA is associated with BPD in adolescents. In a community sample of 881 adolescents (Sharp, Kalpakci, Mellick, Venta, & Temple, 2014) a prospective relation between EA & BPD was demonstrated and, measured one year after baseline, controlling for symptoms of anxiety and depression. In adolescent inpatients with BPD, Schramm, Venta, and Sharp (2013) found that EA made a significant and independent contribution to the variance in borderline features, while partially mediating the relation between difficulties in emo- tion regulation and borderline features. The results of these studies were interpreted in the context of a mentalization-b╉ ased account of BPD (Fonagy & Luyten, 2009) in which the capacity to be open and curious about one’s own mental states, without becoming distressed by them or trying to control them (that is, EA), comes about in the context of secure attachment with primary caregiv- ers. Indeed, in another study, we have shown that disorganized attachment predicted EA, which in turn predicted the capacity to accurately assess mental states in others (Vanwoerden, Kalpakci, & Sharp, 2015). Summary A major limitation of the emerging research on emotion dysregulation in BPD (beyond the mere lack thereof), is the fact that research is not particularly developmentally sensitive and relies heav- ily on self-âr•‰ eport. Most of the emotion dysregulation measures are downward extensions of adult measures and generally, few studies have employed experimental paradigms of emotion dysregu- lation. Importantly, few studies have adopted a prospective design and it is unclear to what extent
072 270 Emotion Dysregulation in Adolescents with Borderline Personality Disorder emotion dysregulation is normative in adolescence. Despite these limitations, there is enough evidence in support of each of the components of Carpenter and Trull’s (2013) multicomponent model of BPD to warrant further research in adolescence. There is also enough research to justify intervention approaches that focus explicitly on addressing problems of emotion regulation in adolescents with BPD. It is to this literature that we turn to next. Evidence-b╉ ased intervention for BPD in adolescents There are six intervention programs described in the literature, of which three have an evidence base (defined here as an intervention for which a randomized-c╉ ontrol trial [RCT] was conducted). Below, we describe all six interventions and indicate the strength of evidence in support of each. Perhaps most explicitly associated with targeting emotion dysregulation in BPD is Dialectical behavior therapy (DBT; Linehan, 1993). DBT incorporates a focus on change and acceptance; spe- cifically, to target difficulties in emotional dysregulation, distress tolerance, and interpersonal dif- ficulties in BPD. An RCT was conducted in Norway with adolescents with non-âs•‰ uicidal self-âi•‰njury (NSSI) and at least two DSM-âI•‰ V BPD criteria (plus the self-d╉ estructive criterion or at least DSM-╉ IV BPD criterion plus at least two subthreshold level criteria) randomized to DBT or Enhanced Usual Care (EUC) (Mehlum et al., 2014). Results demonstrated significant decreases in self-âh•‰ arm in the DBT group, but not in EUC, with differences emerging in the last third of the trial period. An RCT was also conducted in New Zealand in adolescents with a history of NSSI and suicide attempts (Cooney et al., 2012). Although this study was not focused on BPD specifically, DBT did not show any improvements at 6 months above TAU for the DBT group. Systems Training for Emotional Predictability and Problem Solving (STEPPS; Blum et al., 2008), is a 20-w╉ eek, manual-b╉ ased, group treatment program for outpatients with BPD that combines cognitive-âb•‰ ehavioral elements and skills training with a systems component specifically targeting emotion dysregulation in BPD. In fact, STEPPS refrains from using the word BPD when working with patients and prefer the term “emotional sensitivity.” While STEPPS has an evidence base in adults, it is yet to be evaluated in an RCT. Recently, STEPPS-A╉ was evaluated in a small-s╉ cale study in the United Kingdom in adolescents with BPD, and has shown strong potential for this popula- tion (Harvey, Blum, Black, Burgess, & Henley-C╉ ragg, 2014). Emotion Regulation Training (ERT) (Schuppert et al., 2009b) is an adaptation of STEPPS in the Netherlands for which two RCTs have been conducted in adolescents. It also includes additional elements of Cognitive Behavior Therapy and DBT. The first RCT showed no benefit of ERT post-╉ treatment (Schuppert et al., 2009a), while the second showed significant improvement for adoles- cents in the ERT condition at a six-╉month follow-u╉ p (Schuppert et al., 2012). While DBT, STEPPS and ERT are rooted firmly in the tradition of behaviorism, two evidence-╉ based intervention approaches have emerged with psychodynamic roots. Neither of these treat- ment approaches were designed to directly target emotion dysregulation and impulsivity, but they both increase emotion regulation and behavioral control indirectly. Cognitive analytic therapy (CAT; Ryle & Kerr, 2002), developed in Australia used in the Helping Young People Early (HYPE) program (Chanen, Jackson, et al., 2009; Chanen & McCutcheon, 2013b; Chanen, McCutcheon, et al., 2009), was the first individual therapy to be tested in an RCT for adolescent BPD and was evaluated in the context of an early intervention program. HYPE is a comprehensive and inte- grated indicated prevention and early intervention program for youth (15–â2•‰ 5 years of age); it includes adolescents who meet two or more BPD criteria, plus a childhood risk factor. More recently, inclusion criteria for HYPE have been specified as meeting three BPD criteria with no risk factors (Chanen, McCutcheon, & Kerr, 2014). HYPE includes both a service model and individual therapy, and incorporates the principles of CAT into both components. CAT is time-l╉imited and
172 Borderline personality disorder in adolescents 271 transdiagnostic, integrating elements of psychoanalytic object relations theory and cognitive psy- chology. Compared to treatment as usual, CAT has demonstrated effectiveness and more rapid recovery, although differences were not as marked at two-ây•‰ ear follow-âu•‰ p (Chanen, Jackson, et al., 2009). The CAT model is currently being disseminated in Europe. Mentalization-‰bâ• ased treatment (MBT; Bateman & Fonagy, 2009) shares many common features with CAT (Bateman, Ryle, Fonagy, & Kerr, 2007), and has been adapted for use in adolescents. This therapy assumes that the development of BPD in adolescence and its treatment is grounded in a phase-s╉pecific compromise in the capacity to mentalize that occurs during adolescence (Fonagy, Rossouw, et al., 2014). MBT for adolescents (MBT-A╉ ), which incorporates monthly ses- sions of MBT for families (MBT-F╉ ) has been shown to be effective in an RCT in a sample of self-╉ harming adolescents (most of whom met criteria for BPD; Rossouw & Fonagy, 2012). MBT-âA•‰ was more effective than treatment as usual in reducing self-h╉ arm and depression. This superiority was explained by improved mentalization and reduced attachment avoidance, and reflected improve- ment in emergent BPD symptoms and traits. Finally, transference-•‰fâ ocused psychotherapy (TFP; Clarkin et al., 2001) has been adapted for use in adolescents. TFP is based on contemporary psychoanalytic object relations theory as developed by Kernberg. TFP-âA•‰ is a manualized psychodynamic treatment for borderline adolescents deliv- ered in individual sessions, ideally twice a week but not less often than once a week (Normandin, Ensink, Yeomans, & Kernberg, 2014). Although commonly used with adolescents with BPD, TFP-╉ A has not yet been evaluated in an RCT, but also shows potential for indirectly affecting emotion dysregulation through the process of increasing self integration as therapy progresses. An in-depth look at MBT-A: Adolescents with BPD Central to MBT-âA•‰ is the construct of mentalizing, which refers to the capacity to reflect on own and others’ minds in the context of relationships, in order to make sense of ourselves and our rela- tionships. MBT-âA•‰ proposes that adolescence is the point at which vulnerabilities, resulting from early developmental difficulties, are exacerbated by neurodevelopmental changes, weakening mentalizing and mentalizing-âm•‰ ediated affect regulation, and by intense psychosocial and devel- opmental pressures that place greater demands on the capacity to represent the self and regulate affect (Fonagy, Rosssouw, et al., 2014). This combination of factors creates the conditions for the symptomatic expression of BPD. MBT-âA•‰ is therefore very much rooted in attachment theory and against this background, the primary aim of MBT-A╉ is to help young people and their families improve their awareness of their own mental states and the mental states of others by enhancing their capacity to mentalize within the attachment relationship. The emphasis is on improving their understanding of the mental states and processes that drive behavior and relational patterns. Treatment is divided up into four phases, all of which are derived from the original MBT model for adults (Bateman & Fonagy, 2004). Below, we summarize each of the phases briefly, but a more detailed description can be found in Fonagy, Rosssouw, et al. (2014). Assessment Intervention begins with a two-âw•‰ eek assessment period that includes all members of the family and focuses on the evaluation of psychiatric symptoms through observations, interview and standardized measures. The aim is firstly, to identify conditions that may require adjunctive treatments (such as medication), to highlight any comorbidities, and to make the therapist aware of any psychiatric conditions that can impair the ability to mentalize. In addition, assess- ment also aims to fully characterize the mentalizing capacity, cognitive, executive function and emotional regulation of the adolescent, as well as the general mentalizing capacity of family
27 272 Emotion Dysregulation in Adolescents with Borderline Personality Disorder members. The assessment of mentalizing in BPD patients will likely show that the adolescent is able to mentalize, but does so intermittently; therefore, in highly charged situations, often in the context of a family assessment session, the adolescent may show a temporary inability to recognize the feelings and experiences of others resulting in hypermentalization (that is, the over-âa•‰ ttribution of mental states to others). Assessment tools that may aid clinical assessment of mentalizing capacity in the adolescent include the Reflective Functioning Questionnaire for Youth (Ha, Sharp, Ensink, Fonagy, & Cirino, 2013), which was recently validated and provides an adequate measure of self-r╉ eport mentalizing capacity in adolescents. A questionnaire-b╉ ased measure of hypermentalizing is currently being evaluated for its’ validity, but has shown prelim- inary promise (Sharp, 2015). The Movie Task for the Assessment of Social Cognition (Dziobek et al., 2006) has been used in inpatient adolescent settings (Sharp et al., 2009) and has shown sensitivity to treatment outcome (Sharp et al., 2013). These measures provide valuable informa- tion for a mentalization-âb•‰ ased case formulation and may also be important in tracking change and outcome. Initial phase The assessment phase is followed by the initial phase which consists of two sessions. First, two parallel sessions with the adolescent and the family are carried out to share the mentalization-╉ based formulation. The aim is to make the adolescent and the family feel understood, and to use the formulation to plan treatment. During these sessions, a crisis plan is developed which identi- fies any triggers of emotional outbursts and/âo•‰ r impulsive behavior, including self-h╉ arm. In addi- tion, a treatment contract is developed which sets out the duration of treatment and commitment required from all those participating; it explains the importance of everyone’s engagement and the process of working together in the therapy. The family formulation session is followed by a psychoeducation session, which may be deliv- ered to the individual family or in a group format. This aims to help the family understand that behavior has meaning, that feelings arise in a relational context, and that people have a powerful emotional impact on one another. Psychoeducation may involve informal discussion with the family, using examples from everyday life, or in multifamily groups it may make use of group discussion, role-âp•‰ lay and videos. Middle phase The middle phase of MBT-âA•‰ can be seen as the remediation and rehabilitation phase of ther- apy, and lasts nine to ten months. It aims to enhance mentalization in the adolescent and family through the development of mentalizing skills (i.e. active reflection on the mind of self and oth- ers). This phase also aims to help the adolescent and family gain better emotion regulation and impulse control (as dysregulation and impulsivity undermines the development and use of men- talizing ability). MBT-A╉ sessions are unstructured and focus on the young person’s current and recent interpersonal experiences, while maintaining a constant focus on the mental states likely to have been evoked by these experiences. The main tool of the therapist is the “mentalizing stance” which is defined as an open, curious attitude towards the client. In addition, the therapist uses a number of specific techniques that include supportive and empathic interventions, clarification and elaboration techniques, basic mentalizing techniques, transference techniques, and inter- pretive mentalizing techniques. In general, interventions are simple, “soundbite” interventions that do not require excessive processing competencies on the part of the young person (Fonagy, Rosssouw, et al., 2014). They are affect-âf•‰ocused and current (e.g., love, desire, hurt, catastrophe, excitement), as these domains are most accessible for the construction of subjective states. To facilitate accessibility, the therapist often uses his/âh•‰ er own mind as a model; not in the sense of
372 Conclusion 273 self-d╉ isclosure, but as a normalizing influence suggesting to the young person how the therapist may feel or may think in the context the young person presents. Final phase The final phase of MBT-A╉ addresses separation issues along with managing anticipated challenges in a mentalizing manner. It aims to increase the adolescent’s independence and responsibility, and consolidate relational stability and a sense of mastery (as opposed to helplessness or passivity) in the adolescent and his/h╉ er family. In addition, a coping plan is created for the family, setting out what to do in the future if difficulties return. The final phase of MBT-A╉ lasts for approximately two months and commonly includes a tapering-o╉ ff of sessions at the end. Some families also find it helpful to return for one final family session a few months afterwards. The discussion of MBT-A╉ above was necessarily brief and readers are referred to the adult man- ual for treatment of BPD (Bateman & Fonagy, 2006) or Fonagy, Rosssouw, et al. (2014) for a more detailed discussion of MBT-A╉ for BPD in adolescents. Conclusion The aim of this chapter was to provide an overview of the construct of emotion dysregulation in the context of BPD in adolescents. Our review has demonstrated that BPD has been seen as the quintessential disorder of emotion regulation. While these conceptualizations have strong theoretical and clinical foundations, there is room for more empirical research to further support these ideas. In this regard, we identify two important goals for further research in adolescents. First, research should be guided by a process-o╉ riented and multi-âc•‰ omponent model of emotion dysregulation in order to assess the complex interactions involved in emotion dysregulation. Failing to do so will result in a piecemeal and potentially clinically meaningless understanding of emotion dysregulation in BPD. Second, it is important to study BPD in the context of other psychopathology. High comorbidity between BPD and other disorders has led authors to inves- tigate the location of BPD within the latent structure of psychopathology in general. It is impor- tant that these methods are combined with experimental approaches to emotion dysregulation, where feasible, to further harness the transdiagnostic potential of emotion dysregulation and its treatment. References Allen, J. P., Insabella, G., Porter, M. R., Smith, F. D., Land, D., & Phillips, N. (2006). A social-i╉nteractional model of the development of depressive symptoms in adolescence. Journal of Consulting and Clinical Psychology, 74(1), 55–‰6•â 5. doi:10.1037/‰â•0022-•0‰â 06x.74.1.55 American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: American Psychiatric Association. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association. Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization-âb•‰ ased treatment. Oxford: Oxford University Press. Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-b╉ ased treatment versus structured clinical management for borderline personality disorder. [Comparative Study Randomized Controlled Trial Research Support, Non-âU•‰ .S. Gov’t]. American Journal of Psychiatry, 166(12), 1355–‰1•â 364. doi:0.1176/âa‰• ppi.ajp.2009.09040539 Bateman, A. W., & Fonagy, P. (2006). Mentalization based treatment for borderline personality disorder: A practical guide. Oxford, UK: Oxford University Press.
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