Emotion regulation and psychopathology in children and adolescents ( PDFDrive )

673 376 Children Exposed to Traumatic Stress mild). The prevalence rate of PTSD symptom severity for children exposed to Hurricane Andrew decreased over time with 29.8% of children reporting severe to very severe levels at three-m╉ onths post-âd•‰ isaster 18.1% at seven-âm•‰ onth follow-âu•‰ p and 12.5% at ten-m╉ onth follow-âu•‰ p (La Greca et al., 1996). In an even more recent, systemic review of 7920 youth exposed to war-âr•‰ elated events (e.g., armed conflict), probable PTSD diagnosis ranged from 4.5 to 89.3% (pooled estimate of 47%) and variability was mainly attributable to either study location, measurement methods or duration since initial war exposure. For example, Weems et al. (2010) found no significant decline in PTSD symptom severity among urban minority youth exposed to hurricane Katrina from two to two and a half years following the storm. Other posttraumatic stress outcomes Although PTSD symptoms are the most often studied of posttraumatic stress outcomes (Furr et al., 2010), a growing body of research has shown that trauma-e╉ xposed youth experience other outcomes such as anxiety, depression, aggression, grief, somatic complaints, poor academic achievement, social problems, and sleep problems (e.g., Brown et al., 2011; Hensley & Varela, 2008; Marsee, 2008; La Greca et al., 2002; Osofsky et al., 2009; Roberts et al., 2010; Terranova, Boxer, & Morris, 2009a; Weems et al., 2013). Conversely, certain youth may also exhibit resil- ience in the face of adversity and even experience posttraumatic growth or positive adjustment following a traumatic event (Tedeschi & Calhoun, 2004; Prati & Pietrantoni, 2009; Weems & Graham, 2014). One possible mechanism that may explain this wide range of posttraumatic stress outcomes is individual differences in youths’ ability to regulate their emotional experi- ences and expressions. Traumatic stress exposure and negative outcomes Previous models of child traumatic stress (La Greca et al., 1996; Lanius et al., 2010; Masten, & Narayan, 2012; Pynoos, et al., 1999; Weems & Overstreet, 2008) and published research (Jeney-╉ Gammon et al., 1993; Kithakye et al., 2010; Marsee, 2008; La Greca et al., 1996; Polusny et al., 2011; Punamäki et al., 2014; Russoniello et al., 2002) have emphasized the central role of heightened emotional reactivity and dysregulation in the emergence of PTSD symptoms and other negative posttraumatic stress outcomes, such as greater anxiety and aggression. Research has provided ini- tial support for a concurrent mediational path from traumatic stress exposure to PTSD symptoms (Polusny et al., 2011) and aggression (Marsee, 2008) via experiential avoidance and dysregulated emotional expression. Drawing largely from this past theoretical and empirical knowledge base, we present a theoretical framework in Figure 18.1 of childhood traumatic stress exposure, which posits emotion regulation as a potential mediating and causal pathway from mass traumatic stress exposure to both PTSD symptomology and other negative outcomes (e.g., internalizing and exter- nalizing problems, academic difficulties). We posit that emotional dysregulation is an inherent aspect of PTSD and related negative out- comes (e.g., PTSD symptoms, anxiety, and aggression), and involves maladaptive attempts at regulating positive and negative emotions and emotion regulation deficits across neurobiologi- cal, cognitive, and behavioral systems. As outlined in Figure 18.1, Trauma Exposure (direct or indirect) may lead to Immediate Posttraumatic Stress Reactions, that include the emergence of negative cognitions (lack of perceived control over self or environment), heightened physiologi- cal arousal (e.g., faster heart rate), and negative affect (feelings of anxiety, anger, or shame). In turn, these Immediate Posttraumatic Stress Reactions may become problematic as youth rely on maladaptive automatic and effortful emotion regulation or dysfunctional emotion regulatory pro- cesses, at multiple levels of the individual, for immediate reduction of this distress (see Emotion

Mass Trauma Immediate Posttraumatic Automatic Exposure Stress Reactions Emotion Regu • Natural Disaster Negative Cognitions • War Conflict • Low Perceived Control Behavioral • Terrorism • Negative Memories • Avoidance • Negative Schemas • Emotiona Physiological Arousal Cognitive • Increased Heart Rate • Experient • Cortisol Secretion • Ruminatio • Distractio Negative Affect • Attention • Fear/Anxiety • Anger Neurobiologic • Shame • Prefronta • Increased Activation • Cortisol R Figure 18.1  An Emotion Regulation Model of Traumatic Stress Exposure in You

73 Effortful Potential Negative Outcomes ulation Mechanisms Short-Term Outcomes • Internalizing Problems e/Escape • Externalizing Problems al Suppression • Interpersonal Problems • Poor Academic Achievement tial Avoidance • Biological Changes on on Long-Term Outcomes n to Threat • Affective Disorder Onset • Substance Use cal • Academic Failure al Cortex • Exaggerated or Blunted Parasympathetic HPA Axis Functioning n Reactivity Secondary Posttraumatic Stress Reactions Physiological/Emotional • Maintained or Increased Arousal • Emotional Numbing Cognitive Response • Attentional Bias • Cognitive Bias • Memory Bias uth and Potential Negative Outcomes

873 378 Children Exposed to Traumatic Stress Regulation Mechanisms in Figure 18.1; note that mechanisms on a continuum, such that a effort- ful process may become more automatic over time or typically automatic processes come under effortful control). Thus, the inability to effectively regulate their Immediate Posttraumatic Stress Reactions will give rise to Secondary Posttraumatic Stress Reactions, that include cognitive biases (sustained attention to threat, poor self-âe•‰ fficacy, or trauma memories), increased or maintained heightened emotional arousal, and prolonged negative affect. Finally, Secondary Posttraumatic Reactions may lead to further reliance of maladaptive or dysfunctional mechanisms via a negative feedback loop, thus maintaining the experience of negative emotional distress (subjectively and physiologically) and negative cognitions over time. A vicious cycle of heightened emotional reactivity and dysregulation, coupled with negative thought patterns, may result in short-╉and long-t╉erm negative sequelae (as aforementioned in the preceding Posttraumatic Stress Outcomes section). In the short-t╉ erm and as shown in past research, youth may begin to experience internalizing problems (e.g., anxiety, depression; Copeland et al., 2007), externalizing problems (e.g., aggression; Marsee, 2008; Scott, Lapré, Marsee, & Weems, 2014), interpersonal problems (e.g., peer bullying and victimization; Terranova et  al., 2009a), poor academic achievement (Scott et  al., 2014; Weems et  al., 2013)  or certain neurobiological changes across development (atypical maturation in amygdala volumes; Weems, Scott, Russell, Reiss, & Carrión, 2013). Long-t╉erm effects may become even more serious with affective disorder development (e.g., PTSD, Anxiety Disorders, and Major Depressive Disorder; Hoven et al., 2005; La Greca et al., 1996), substance use (Wagner et al., 2009), academic failure (Porche, Fortuna, Lin, & Alegria, 2011), and changes in neurobiological functioning (De Bellis, 2001; Weems & Carrión, 2007). The following sections further develop each facet of the model. Defining emotion and emotion regulation Although a standard definition of emotion has yet to be developed, most emotion theorists agree upon several key features (Campos et al., 2004; Cole, et al., 2004; Gross, 1998a; Gross & Thompson, 2007). In this chapter we adopt Gross and Thompson’s (2007) process model of emotion because it provides a comprehensive overview of emotion based on several emotion theories (Campos et al., 2004; Cole et al., 2004; Frijda, 1986; Gross, 1998a; James, 1884; Thompson, 1994) and thus allows for a solid foundation in establishing a working definition of emotion regulation. Gross and Thompson (2007) suggests that most emotion theories agree upon three core features of emotion, which are: an emotion 1) occurs when an individual attends to an internal or external event that pertains to achieving a personal and enduring goal (e.g., avoiding dangerous situation) or self-╉ efficacious and transient goal (e.g., passing a test), but the meaning of each goal will produce a specific emotion; 2) arises within a flexible, multi-s╉ ystem structure and involves independent but also interactive changes among cognitive (e.g., “I have no control over bad things happening to me”), behavioral (e.g., not returning to the physical site of trauma or similar settings), and affec- tive (subjective and physiological; “I feel scared” and faster heart rate, respectively); and 3) is mal- leable and may be modulated at any time or level of the individual and may vary across a number of situational domains. This third feature relates to the child’s ability to regulate emotion responses and how youth try to regulate such emotions. Again drawing from the framework of Gross and Thompson, emotion regulation is the automatic or effortful modulation (i.e., enhance, decline, or maintain) of both negative and positive emotions at multiple levels of the analysis (i.e., neurobiological, cognitive, and behavioral; Cole et al., 2004; Gross, 1998a; 1999; Thompson, 1994). Emotion regulation may occur at any given point of the emotional generative process and may involve modifications to the latency, intensity, rise time, magnitude, and duration of an emotion (Gross & Thompson, 2007).

973 Traumatic stress exposure and negative outcomes 379 Immediate posttraumatic stress reactions As shown in the Immediate Posttraumatic Stress Reaction box of Figure 18.1, exposure to mass trauma that involves life threat may result in posttraumatic stress reactions that are synonymous with symptoms outlined in the DSM-â5•‰ as part of the PTSD criterion (APA, 2013). First, trauma exposure may result in negative, intrusive cognitions, such as challenging one’s sense of control and self-âe•‰ fficacy in containing the actual or perceived threat (e.g., low perceived control) or the activation of emotion latent memories or schemas of past negative life events. Second, direct exposure to life threat may increase activity of the limbic-h╉ ypothalamic-âp•‰ ituitary-a╉ drenal (LHPA) axis and autonomic nervous system as part of a normative fight-âf•‰light reaction, thus inducing hyperarousal (Heim & Nemeroff, 2001; Porges, Doussard-R╉ oosevelt, & Maiti, 1994; Thayer and Lane, 2000). Research has shown that fear reactions are associated with elevations in the secretion of cortisol, a corticosteroid hormone produced by the adrenal cortex that can be assayed from blood, urine, or saliva samples (see Nader & Weems, 2011 for a review) and greater sympathetic activation can be assessed using heart rate and skin conductance measurement during stressful conditions (e.g., increased heart rate; Culbert, Kajander, & Reaney, 1996; De Young, Kenardy, & Spence, 2007; Weems et al., 2005). Third, trauma exposure may result in negative affect that may be difficult to regulate (e.g., anxiety, anger, or shame; Norris et al., 2002), further increasing the risk for the development of child psychopathology. As a whole, these posttraumatic stress reac- tions may occur simultaneously (thus covarying with one another), have some influence on each other, or even lead to the occurrence of the other. Emotion Regulation Mechanisms Immediate posttraumatic stress reactions may have a significant effect on the way that children regulate their emotions in the aftermath of a natural disaster or during wartime. For example, heightened arousal and hypervigilance to perceived or actual threat may promote the use of automatic or effortful mechanisms associated with emotion regulation to be activated within the child (e.g., avoidance, emotional suppression). Although these regulatory mechanisms respond in an adaptive manner, as to allow for the immediate reduction of intense arousal or to suppress negative cognitions, in the long run they may either serve as maladaptive mecha- nisms that could lead to greater arousal, more negative cognitions, and poor outcomes across emotional, behavioral, cognitive, and social domains. Moreover, these mechanisms will even- tually become the symptoms of the emotional and behavioral disorders (e.g., PTSD, anxiety disorders) that subsequently develop from their actions and also help maintain these disorders across development. Research has shown that mass trauma-âe•‰ xposed youth tend to use a greater number of emo- tion regulation strategies than non-e╉xposed youth (Russoniello et  al., 2002)  and high levels of PTSD, anxiety, depression symptoms and general mental health distress are related to greater fre- quency (or intensity) of emotion regulation use (Asarnow et al., 1999; Jeney-G╉ ammon et al., 1993; Kithakye et al., 2010; Punamäki et al., 2014; Russoniello et al., 2002). Thus, it appears that greater engagement in emotion regulation strategies does not necessarily protect youth from developing emotional and behavioral problems following a traumatic event, but that more likely, individual differences in the specific types (or patterns) of emotion regulation mechanisms utilized plays a larger role in post-t╉rauma functioning. Neurobiological mechanisms At the neurobiological level, theory and research suggest that emotional dysregulation may largely stem from structural changes in prefrontal cortices of trauma-âe•‰xposed youth,

083 380 Children Exposed to Traumatic Stress maladaptive parasympathetic-​mediated control over stress responses, and both diurnal cortisol release over time and cortisol reactivity to stress (Carrión et al., 2001; Carrión, Weems, & Reiss, 2007; Carrión, Weems, Richert, Hoffman, & Reiss, 2010; De Bellis, 2001; Feldman, Vengrober, Eidelman-​Rothman, & Zagoory-S​ haron, 2013; Lou et al., 2012; Richert, Carrión, Karchemskiy, & Reiss, 2006; Scheeringa, Zeanah, Myers, Putnam, 2004; Scott & Weems, 2014; Vigil, Geary, Granger, & Flinn, 2010; Weems & Carrión, 2007). However, it is important to note that, relative to other types of trauma, the study of neurobiological mechanisms among mass trauma-e​ xposed youth is quite limited. Nevertheless, we rely on these small, but consistent past research findings (e.g., Feldman et al., 2013; Luo et al., 2012 Scheeringa et al., 2004; Scott & Weems, 2014; Vigil et al., 2010; Yehuda et al., 1995; Yehuda, 2006), to illustrate how traumatic exposure may affect neurobiological mechanisms related to emotion regulation and, in turn, their relation to mental health problems. Neuroimaging research comparing prefrontal cortical regions, that are theoretically linked to cognitive emotion regulation (medial frontal cortex, orbital prefrontal cortex, dorsal prefrontal cortex), has shown differentiated brain development and functional impairment among trauma-​ exposed and non-e​ xposed youth (see Carrión and Wong, 2012 for in-d​ epth review). For exam- ple, Richert et al. (2006) found that 23 youth with PTSD had larger volumes of gray matter in the middle-​inferior and ventral regions of the prefrontal cortex as compared to 24 children with no PTSD and that decreased gray matter volume of the dorsal prefrontal cortex increased the functional impairment of those youth with PTSD. The authors suggested that the larger volume of the middle-i​nferior and ventral regions may reflect frequent prefrontal lobe activity aimed at inhibiting emotional posttraumatic stress responses (thus maintaining PTSD symptoms), while decreased dorsal volume may signify a predisposition towards difficulty engaging in cognitive emotion regulation strategies, such as reappraisal. In terms of functionality, Carrión, Garrett, Menon, Weems, and Reiss (2008) found that youth experiencing PTSD symptoms had reduced middle frontal cortex activity and increased medial frontal activity during memory and executive functioning tasks, as compared to an age and gender-​matched healthy control sample of youth. Together these findings suggest two possibilities: 1) youth may have predisposed deficits in reg- ulating emotion using higher-​order cognitive processing (Emotion Regulation Mechanisms in Figure 18.1), or 2) traumatic stress exposure and subsequent maladaptive reactivity and regula- tion may alter youths’ brain development and functionality in centers of the brain largely involved in emotion regulation (Short or Long-T​ erm Outcomes in Figure 8.1). Accumulating research also has shown that maladaptive patterns of parasympathetic-​mediated control over the heart (i.e., indexed by heart rate variability [HRV] or respiratory sinus arrhyth- mia [RSA]) is related to PTSD symptoms, anxiety, and aggression in preschoolers and adolescents with trauma exposure (Scheeringa et al., 2004; Scott & Weems, 2014). Parasympathetic-m​ ediated control involves controlled modulation of emotions via a negative feedback loop between several afferent and efferent neurobiological structures thought to be responsible for top-​down emotion regulation (e.g., nucleus ambiguus, medial prefrontal cortex) and the heart’s sinoartial (SA) node (i.e., pacemaker) along the vagus nerve (Beauchaine, 2001; Oschner & Gross, 2005; Porges et al., 1994; Thayer & Lane, 2000). Theoretically, the PNS’s function is to help youth maintain bodily homeostasis during times of rest with lower resting HRV indexing a deficit in PNS-​mediated control over the heart it serves as a proxy for general emotional dysregulation (Beauchaine, 2001; Porges, 2007; Thayer & Lane, 2000). Moreover, parasympathetic nervous system (PNS)-m​ ediated control allows youth to quickly and efficiently regulate the amount of time and degree of control the sympathetic nervous system (SNS) has over bodily sub-s​ystems (Porges et al., 1994; Thayer & Lane, 2000). Porges (2007) posits that greater parasympathetic suppression is a flexible, adap- tive response to stress, which in turn promotes functional behavior, while increased or blunted

183 Traumatic stress exposure and negative outcomes 381 parasympathetic activation is a rigid and maladaptive response that leads to poor physical and mental health outcomes. In a study with 80 adolescents (ages 11–â1•‰ 7  years) with whom most experienced Hurricane Katrina or the BP Oil Spill (n  =  76), we found that lower resting HRV was related to greater anxiety problems (Scott & Weems, 2014). We also found evidence to support Porges’s (2007) the- ory in that greater parasympathetic activation (i.e., increase in HRV from baseline to cognitive stress task) was observed among the adolescents with higher levels of anxiety and aggression. Schreeringa et al. (2004) found that among 144 preschool children (62 trauma-e╉ xposed and 62 non-âe•‰ xposed) those with high levels of PTSD had greater RSA withdrawal to a trauma reminder, but only for those youth whose parents exhibited low positive discipline during a clean-u╉ p task. Though a number of factors may explain these contradictory findings, developmentally younger children with PTSD may display a more normative strong sympathetic-âm•‰ ediated response to stressful situations (HRV or RSA withdrawal), but as youth continue to encounter repeated stress responses for longer periods of time they may develop a vulnerability for emotion dysregulation (low resting HRV) or engage in greater overcontrolling responses, such as the HRV attenuation stress response found in our study (Scott & Weems, 2014). Changes in neural mechanisms following stress (Carrión, Weems, & Reiss, 2007; Carrión et al., 2010)  and susceptibility to dysregulation in the normative stress response may also character- ize individual risk for mental health problems among mass trauma victims. The persistent and intense taxing of the stress response system over time may lead to a physiological dysregulation of the system. Research suggests that after a period of relative cortisol hypersecretion elevated levels may reverse in trauma exposed youth (De Bellis, 2001; Weems & Carrión, 2007) to relatively low levels of cortisol in diurnal patterns and/âo•‰ r blunted cortisol reactivity in response to stress (Feldman, Vengrober, Eidelman-âR•‰ othman, & Zagoory-âS•‰ haron, 2013; Yehuda, 2006). This low or blunted cortisol response may result from an enhanced negative feedback loop at the pituitary-╉ adrenal level of the axis (Yehuda et al., 1995). A proposed mechanism for this sensitization is an increased number of glucocorticoid receptors in the LHPA axis and, hence, facilitation of this negative feedback loop (Yehuda, 2006). Dysregulation in the stress response system has been associated with several mental health disorders among trauma-âe•‰ xposed youth, including PTSD, anxiety, and depression (Feldman et al., 2013; Gunnar, 2001; Vigil et al., 2010; Weems & Carrión, 2009; Yehuda, 2006). Cognitive mechanisms At the cognitive level, youth seem to have a relatively large number of emotion regulation strat- egies to use, though these higher-o╉ rder, top-d╉ own regulatory processes are taxing to the indi- vidual and more accessible to older children and adolescents (Gross, 1998b; Oschner & Gross, 2005; Richards & Gross, 2000). For example, some trauma-âe•‰xposed youth may rely on cogni- tive strategies that reduce emotional distress quickly (thus negatively reinforcing use), but at the expense of chronic efforts to control internal reactions (e.g., emotional suppression, experiential avoidance) and thus maintaining or increasing negative affect and physiological arousal over the course of development (Polusny et al., 2011; Richards & Gross, 2000). Additionally, the use or capability to use certain emotion regulation strategies may vary across development. Following the September 11th attacks, Wadsworth and colleagues (2004) found an increase in the use of emotion-âf•‰ocused coping and decreases in rumination and disengagement across adolescence to adulthood. Cardeña and colleagues (Cardeña, Dennis, Winkel, & Skitka, 2005) reported that ado- lescents were more likely to use distraction and disengagement than adults, who tended to use strategies such as planning and acceptance. Furthermore, younger children exposed to trauma may still be developing the cognitive skills to fully process the event or engage in higher-o╉ rder

283 382 Children Exposed to Traumatic Stress cognitive emotion regulation (Shiner, 1998), such as reappraisal, and may be more susceptible to engaging in temperamentally-d╉ riven emotional coping, such as using avoidance or withdrawal (e.g., becoming sick and staying home from school). A few studies have begun to examine the relation between specific cognitive emotion regu- lation stratigies and negative outcomes in mass trauma-âe•‰xposed youth. In one study, Polusny et al. (2011) found that experiential avoidance (i.e., attempts at controlling, escaping, or avoid- ing negative internal experiences) concurrently mediated the relation between disaster exposure and PTSD symptoms among 288 adolescents exposed to severe tornados. In two other studies, Prinstein, La Greca, Vernberg and Silverman (1996) and Noppe, Noppe and Bartell (2006) found that distraction was associated with more severe symptoms of PTSD among hurricane exposed youth and greater anxiety among youth remotely-e╉xposed to September 11th, respectively. Wadsworth et al. (2004) also found among 168 sixth to eight graders exposed to September 11th, greater use of secondary control (cognitive restructuring, positive thinking, or acceptance) and less use of involuntary engagement strategies (e.g., rumination) was related to fewer anxiety prob- lems among all youth. Behavioral mechanisms At the behavioral level, youth have access to strategies that are accessible from early childhood to regulate various emotions (e.g., fear or aggression; Buss & Goldsmith, 1998; Calkins & Johnson, 1998; Diener & Mangelsdord, 1999)  and involve such behaviors as avoidance or withdrawal, approach, suppression of emotional expression, problem solving and comfort or help seeking. Research has shown that some of these behavioral emotion regulation strategies may shift fol- lowing exposure to a traumatic event from typically adaptive to maladaptive strategies (Kennedy, Charlesworth, & Chen, 2004). For instance, Kennedy et al. (2004) found in a prospective study 1-╉ 2 months before and after the September 11th attacks that children remotely affected (i.e., watched media coverage and lived in San Francisco, California) reported using more active coping strate- gies (e.g., “think about it” and “talk to someone”) before September 11th, but after September 11th used more avoidant coping strategies (“draw, read, or write” or “play a game”), which they viewed as effective. Research has shown that avoidant coping is consistently associated with greater PTSD symp- toms (e.g., La Greca et al., 1996; Vernberg, Silverman, La Greca, & Prinstein, 1996), while active coping (e.g., problem-f╉ocused) is related to lower depression symptoms in youth hurricane sur- vivors (e.g., Jeney-âG•‰ ammon et al., 1993). Pina et al. (2008) found that avoidant coping behaviors (i.e., repression, avoidant actions) predicted post-K╉ atrina PTSD and anxiety symptoms, which is consistent with other research (Norris et al., 2002). Terranova, Boxer and Morris (2009b) exam- ined predictors of PTSD symptoms in a sample of 152 sixth grade school children from southeast Louisiana (neighboring Orleans parish) assessed at one-âa•‰ nd-a╉ -h╉ alf months and eight months after Katrina and found that negative coping (a combination of internalizing, externalizing and avoid- ant coping) was associated with PTSD at one-âa•‰ nd-a╉ -h╉ alf months. Peer victimization (i.e., being bullied) was predictive of change in PTSD (PTSD symptoms at Time 2 controlling for symptoms at Time 1) and results further indicated that negative coping interacted with level of hurricane exposure to predict change in PTSD, such that high negative coping and high exposure was asso- ciated with the highest PTSD symptoms at Time 2. Though avoidance or withdrawal strategies have a strong and consistent relation with youth problems post-ât•‰ rauma, other strategies have shown specific associations. For example, Wadsworth et  al., (2004) found that greater use of involuntary disengagement (e.g., emotional numbing, escape) strategies and less use of primary control strategies (e.g., problem solving) were associated with increased anxiety in girls exposed to September 11th. Furthermore, research also has shown

38 Traumatic stress exposure and negative outcomes 383 that comfort and help seeking is associated with overall better mental health in youth exposed to a natural disaster (i.e., 2008 Chinese Earthquake; Zhang et al., 2010) and the absence of PTSD diagnosis among preschool children (ages one-âa•‰ nd-a╉ -âh•‰ alf to five years) continuously exposed to war conflicts. Secondary traumatic stress reactions The engagement in maladaptive emotion regulation mechanisms or the inability of such mech- anisms to modulate emotion effectively, will likely result in further increased or maintained emotional arousal, negative affect, and the activation of more negative cognitive responses (i.e., attention bias towards threat, general cognitive biases, poor self-âe•‰ fficacy, memory bias for nega- tive and trauma-r╉ elated information; Moradi, Taghavi, Neshat-D╉ oost, Yule, & Dalgleish, 1999; Scott & Weems, 2014; Weems, Russell, Graham, Neill, & Banks, 2015). For example, unsuccess- ful attempts to reduce their negative emotions (or produce positive emotions) may diminish youths’ self-e╉ fficacy to handle frightening or stressful situations (external events) or to effec- tively manage their emotions (internal events). In turn, this low perceived control may lead to further use of maladaptive emotion regulation mechanisms via a negative feedback loop (as illustrated with arrow in Figure 18.1 from the Secondary Posttraumatic Reactions to Emotion Regulation Mechanisms) or to Potential Negative Outcomes (Chorpita & Barlow, 1998). Scott et al., (2014) recently found that poor anxiety control beliefs were associated with lower rest- ing heart rate variability (an objective measure related to emotion regulation) among disaster-╉ exposed youth. Weems et  al. (accepted) also found that poor anxiety control beliefs were associated with more PTSD and Generalizing Anxiety Disorder symptoms above and beyond trauma exposure among 1048 Hurricane Katrina-e╉ xposed third to 12th graders. However, this relation was moderated by youths’ age, such that it only remained significant for youth over 12 years of age. Weems et al. (2015) suggests findings are consistent with cognitive develop- mental theory in that younger children may tend to attribute outcomes out of their control to their own behavioral responses and as they mature control beliefs become more realistic and predictive of youths’ emotional problems. Vulnerability and moderating factors A number of individual and environmental factors may place children at risk or protect them from negative outcomes. For example, at the individual level, research has suggested that pre-╉ existing characteristics of the child can affect the impact of disaster exposure on mental health outcomes. In particular, previous research has documented that pre-âh•‰ urricane trait anxiety and negative affect levels (which may represent the emotional dysregulation these youth are expe- riencing) predict PTSD symptoms above and beyond trauma exposure (La Greca et  al., 1998; Weems, Pina, et al., 2007), while emotion regulation capabilities may protect youth from the ill effects of trauma exposure (e.g., Kithakye et al., 2010; Punamäki et al., 2014). In addition, youth with certain temperamental qualities related to emotion regulatory processes may be at greater risk for having emotional and behavioral problems following a traumatic event. For example, Lengua, Long, Smith, and Meltzoff (2005) found in a prospective study before and after the September 11th attacks that greater inhibitory control was marginally related to fewer post-a╉ ttack PTSD symptoms (after controlling for pre-a╉ ttack PTSD symptoms) in 142 children (ages nine to 13 years). In another longitudinal study with Hurricane Katrina youth victims, Terranova et al. (2009b) found that Time 1 effortful control moderated the relation between Time 1 hurricane exposure and Time 2 PTSD symptoms with a positive relation exhibited for those youth with low effortful control.

483 384 Children Exposed to Traumatic Stress Halberstadt, Thompson, Parker, and Dunsmore (2008) have demonstrated that specific parent- ing beliefs of youths’ emotions increases the odds of the child using a specific type of emotion-╉ related coping strategy among 51 youth remotely exposed to the September 11th terrorist attacks. That is, youth of parents who believed youth emotion was valuable was related to the child’s use of typically adaptive coping strategies (i.e., problem-s╉ olving, support-s╉ eeking, and emotion-âo•‰ riented coping), while their belief that their child’s emotions were dangerous was related to typically mal- adaptive coping strategies (i.e., avoidance and distraction). In a second study, Polusny et al. (2011) found that the concurrent mediated relation between adolescents’ disaster exposure and PTSD symptoms via experiential avoidance was stronger among those youth with parents experienc- ing greater PTSD-r╉elated distress. In a third study, Hendricks and Borstein (2007) found, that relations between PTSD arousal symptoms and both attentional control and cognitive avoidance among 97 adolescents directly exposed to the September 11th attacks, disappeared once distal contextual factors were statistically controlled for in the model (i.e., maternal personality charac- teristics and adolescent’s perceptions of parenting), suggesting that family factors may also play a large role in the development of PTSD symptoms beyond individual factors. Evidence-b╉ ased interventions for trauma-âe•‰ xposed children Helping children and their families effectively process traumatic experiences and cope with the deleterious impact of mass trauma exposure is a difficult, but much needed undertaking. Robust empirical evidence supporting the efficacy and/âo•‰ r effectiveness of interventions for mass trauma-╉ exposed youth is scant. As La Greca and Silverman (2009) note, there are several ethical and methodological challenges that have thwarted stringent tests of manualized interventions in the immediate aftermath or recovery phases (i.e., 1st year post-ât•‰rauma) of mass trauma. Examples of such roadblocks include the inability to ethically withhold treatment from exposed youth (i.e., lack of no-ât•‰reatment control), wide spread displacement of youth and their families from the community after exposure, breakdown of the community’s infrastructure, and limited immediate funds or mental health resources in affected areas. Despite these limitations, a few interventions have been developed and empirically tested during the recovery (within one year post-t╉rauma) and long-t╉erm recovery phases (one year or more following initial trauma exposure), such as cog- nitive behavioral therapy (CBT), school-âb•‰ ased interventions, and Eye Movement Desensitization and Reprocessing (EMDR). In this section, we focus on those interventions that meet criteria as a probably efficacious or well-âe•‰ stablished for reducing negative posttraumatic stress reactions and which target emotion regulation skill deficits in trauma-e╉ xposed youth. Cognitive behavioral therapy (CBT) Cognitive behavioral therapy (CBT) has long been a first-l╉ine intervention for anxiety and stress-╉ related disorders, such as PTSD, and is one of a few treatments with robust empirical support of efficacy and effectiveness in reducing negative post-t╉rauma reactions. Several variants of indi- vidualized, exposure-b╉ ased CBT interventions, that include common core features, have been examined among youth exposed to natural disasters, terrorism, and war (March et  al., 1998; Taylor & Weems, 2011). One of the more widely known and supported interventions for trauma-╉ exposed youth is trauma-âf•‰ocused cognitive behavioral therapy (TF-C╉ BT). Although TF-C╉ BT was initially designed for youth exposed to child sexual abuse, it has since been modified and widely adapted to help children exposed to other types of trauma (Cohen & Mannarino, 1996; 2008). TF-C╉ BT incorporates affective modulation training, trauma narratives to assist in cognitive pro- cessing of the events and emotional reactions, and guided cognitive and affective modification during in vivo exposure to traumatic cues into the traditional CBT format and relies heavily on

583 Evidence-based interventions for trauma-exposed children 385 parental involvement. As a whole, TF-âC•‰ BT does meet criteria for a well-âe•‰ stablished treatment (see Silverman et al., 2008 for review) for reducing PTSD symptoms, depressive symptoms, shame, and other emotional and behavioral problems (e.g., Cohen & Mannarino, 1996; Cohen, Deblinger, Mannarino, & Steer, 2004; Deblinger & Heflin, 1996; Deblinger, Stauffer & Steer, 2001; Deblinger, Steer, & Lippman, 1999; March et al., 1998). School-‰b•â ased interventions Increased risk created by disasters and terrorism within the family environment can be offset by the presence of protective factors within other microsystems surrounding the child. For example, school-b╉ ased mental health interventions represent a protective factor within the school micro- system that can counterbalance the negative developmental outcomes associated with mass trauma exposure (Pynoos, Goenijian, & Steinberg, 1998). School-b╉ ased interventions also allow for the delivery of mental health services to a large group of youth and may serve youth whose parents are not able to or are reluctant to seek out services in the community, or live in an area that is struggling to meet the demand of services (i.e., reduction in mental health providers, but a greater number of youth in need of mental health services). One of the more promising school-b╉ ased interventions for traumatized youth is the Cognitive Behavioral Intervention for Trauma in Schools, which meets criteria for a “probably efficacious” treatment of reducing PTSD symptoms (CBITS; Stein et  al., 2003; Jaycox et  al., 2010; Kataoka et al., 2003). CBITS is composed of ten group sessions and one to three individual sessions and is intended for school-âa•‰ ged youth. The therapeutic goals and components of CBITS closely align with those of TF-C╉ BT, as they focus on psychoeducation, affective modulation skills training, cog- nitive processing, trauma narrative, in-âv•‰ ivo exposure, safety development, and include optional sessions with parents and teachers. In a randomized field trial, Jaycox et al. (2010) compared the efficacy of CBITS against TF-âC•‰ BT among 195 hurricane-e╉xposed youth at 15  months follow- ing Hurricane Katrina. They found that the CBITS program was just as effective in significantly reducing PTSD symptoms following treatment. Although the CBITS providers were limited in their ability to tailor the intervention for each child to their specific trauma histories, as typically is done in TF-C╉ BT, CBITS was more accessible to youth, as 98% (91% completed treatment) began the CBITS program as opposed to 23% in a community mental health clinic (15% completed). Thus, implementing a trauma-âf•‰ ocused CBT program in a naturalistic setting may bring services to a large group of youth in a community whose citizens and infrastructure is struggling to recover from a devastating natural disaster. Another promising school-âb•‰ ased treatment targeting mass trauma-âe•‰ xposed youth is the Grief and Trauma Intervention (GTI; Salloum, Garfield, Irwin, Anderson, & Francois, 2009, Salloum & Overstreet 2008; 2012). GTI is a 10-âw•‰ eek school-âb•‰ ased trauma and grief focused interven- tion that was specifically designed for elementary-âa•‰ ged children (seven to 12 years of age) who have experienced either trauma or grief associated with death, disaster, or violence. The primary treatment components of GTI directly parallel those emphasized in TF-âC•‰ BT (e.g., psychoeduca- tion, affective modulation training, trauma narrative), though the active role of parents in GTI is limited to one parent session and targets other post-ât•‰rauma reactions, such as traumatic grief and depression. Salloum and Overstreet (2008) first tested the effectiveness of delivering GTI among 56 youth (second to sixth graders) exposed to Hurricane Katina via after-âs•‰chool programs and in-s╉chool mental health services (The LAST Project) just four months post-K╉ atrina. Youth were randomly assigned to an individual or group modality. Findings showed that both treatment modalities led to fewer PTSD, depression, and traumatic grief symptoms at post-ât•‰reatment and at a 20-âd•‰ ay

683 386 Children Exposed to Traumatic Stress follow-âu•‰ p. In another study (Salloum & Overstreet, 2012), they randomly assigned 72 youth (sec- ond to sixth graders) exposed to Hurricane Katrina to receive either GTI with coping skills plus a trauma or loss narrative or GTI with coping skills only. Both treatment groups showed signifi- cant reductions of PTSD, depression, and traumatic grief symptoms, though the GTI group who received the trauma or loss narrative reported expressing their thoughts and feelings more, while the GTI group who received coping skills-âo•‰ nly training reported more ways of coping. Evidence for the efficacy of similar treatment programs among youth exposed to hurricanes and war/╉terrorism also has been demonstrated (earthquakes, Goenjian et al., 2005: war, Layne et al., 2001; 2008). For example, Layne and colleagues (Layne et al., 2001; 2008) found sup- port for implementing a trauma and grief group intervention (17 sessions vs. 10 sessions for GTI) in war torn communities. More specifically, Layne et al. (2008) found in a randomized control trial that reductions in PTSD, depressive, and maladaptive grief only occurred for the treatment group and not for an active control group (classroom-b╉ ased psychoeducational and skills training) among 127 war-e╉ xposed youth in central Bosnia. Altogether, findings suggest that GTI and similar treatment protocols are probably efficacious and it will be important for future trials to include a control group (e.g., wait-l╉ist, well-âe•‰ stablished treatment for PTSD, such as TF-C╉ BT). Weems et  al. (2009; 2014)  also demonstrated the efficacy of a school-âb•‰ ased intervention on reducing posttraumatic stress symptoms in the post-d╉ isaster environment, even when the inter- vention was not specifically focused on treating post-ât•‰raumatic reactions. In one study (Weems et al., 2009), a prospective intervention design was utilized with a sample of 94 ninth graders from New Orleans exposed to Hurricane Katrina and its aftermath. Thirty youth with elevated test anxiety completed a primarily behavioral and exposure-b╉ ased (e.g., relaxation training combined with gradual exposure to anxiety-âp•‰ rovoking test-âr•‰ elated stimuli) group administered, test anxiety reduction intervention. Findings suggested a statistically significant effect of the intervention on test anxiety levels and academic performance with evidence of positive secondary effects on post- traumatic stress symptoms (PTS). Moreover, change in test anxiety predicted change in PTS and there appeared to be no negative effects on natural PTS symptom decline. Eye movement desensitization and reprocessing Eye movement desensitization and reprocessing (EMDR) is an upcoming and promising treat- ment for PTSD symptoms among traumatized youth (Fernandez, 2007). EMDR is centered upon the adaptive information processing (AIP) model, which asserts that traumatic memories are stored without fully processing the information, which interferes with adaptive responses to abate related cognitive or emotional reactions, and thus, one continues to experience chronic and intense reactivity (e.g., fear or anxiety) to trauma cues (e.g., memories; Shapiro, 2007). Moreover, neural networks storing unprocessed trauma memories do not assimilate positive experiences and may even block positive information from being accessed or processed in other networks. EMDR involves eight phases aimed at providing children with self-âr•‰ egulation skills to manage post-ât•‰ rauma reactions, identify or build adaptive positive networks to link with negative networks; process negative memories through desensitization; reduce distress to negative mem- ories; integrate and strengthen positive cognitive connections; improve self-e╉ fficacy; and elimi- nate negative bodily sensations to the negative memories (Shapiro, 2007). Educational meetings are scheduled with the parents to help them understand the posttraumatic stress reactions their child is experiencing and how their child can adaptively manage their posttraumatic stress reac- tions. Parents are also encouraged to attend each child session to serve as a family support system and to help the child through the processing experience.

783 Trauma-focused cognitive behavioral therapy (TF-CBT) 387 Only a limited number of studies have examined the efficacy of EMDR in youth exposed to mass trauma. In one study, Fernandez (2007) showed significant reductions in PTSD symptoms and PTSD diagnosis (61% vs. 9% from pre-╉to post-ât•‰reatment) among 27 children (ages seven to 11 years) who survived a primary school building collapse (27 of 59 children died) during the 2002 Molise earthquake in Italy. However, the lack of a control group limits one’s ability to dis- cern whether reductions were due to the passage of time. In a more recent randomized trial, De Roos et al. (2011) compared the efficacy of EMDR to CBT in 52 youth (ages four to 18 years) who were exposed to a large fireworks factory explosion in the Netherlands. Youth in both interven- tions showed significant post-ât•‰ reatment reductions in PTSD, anxiety, depression, and behavioral problems and effects were maintained at three-âm•‰ onth follow up, though EMDR produced these results using fewer sessions. As with the Grief and Trauma Intervention, EMDR is a promising treatment option for mass trauma-e╉ xposed youth, but further research with a control group is needed to elucidate the efficacy and effectiveness of EMDR to ameliorate negative posttraumatic outcomes. Trauma-f╉ ocused cognitive behavioral therapy (TF-âC•‰ BT) TF-C╉ BT is an individualized, component-âb•‰ ased intervention (i.e., length of treatment may vary and movement forward is not dictated by completing a session) that helps youth and their parents learn to process and cope with various posttraumatic stress reactions, such as PTSD symptoms, anxiety, depression, and grief (Cohen & Mannarino, 2008). TF-âC•‰ BT is appropriate to treat trauma-âe•‰ xposed youth ranging in age from three to 18 years. The primary therapeutic goal of TF-âC•‰ BT is to assist trauma-âe•‰ xposed children and adolescents in progressively master- ing the skills to understand and manage the cognitive, affective, and behavioral reactions that occur post-ât•‰rauma. Moreover, TF-âC•‰ BT is aimed to guide children and their parents through the cognitive processing of the initial trauma exposure and secondary adversities (e.g., depleted finances, lost home) that often happen in the aftermath of such mass trauma events. As such, parents serve as an integral part of the TF-âC•‰ BT program, as they often co-e╉ xperience the trau- matic event (e.g., natural disaster) directly or indirectly via their child and may also experience negative reactions. Thus, helping parents learn to cope with their own post-t╉rauma reactions will not only lessen parental and familial distress, but also provides parents with an opportunity to model adaptive coping skills for their children and encourage them to practice between treat- ment sessions. Nevertheless, Cohen and Mannarino (2008) are quick to note that TF-âC•‰ BT is still a child-f╉ocused intervention. Parents’ with severe PTSD symptoms or other psychopathol- ogy should be referred for individual treatment as their symptoms may interfere with adaptive parenting practices. TF-âC•‰ BT treatment components The TF-C╉ BT program consists of multiple components that envelop more specific therapeutic goals and is aimed at helping youth to systematically develop skills and self-âe•‰ fficacy for dealing with the various types of post-ât•‰raumatic reactions they may experience. The component-b╉ ased method allows for individualization of treatment needs and progression. That is, some youth may need as few as 12 sessions to process the trauma or learn coping skills, while other youth may need as many as 20 sessions to accomplish the same goals. Several components have strong connection to emotion regulation. For example, relaxation skills training, where youth and their parents are then taught methods to reduce physiological stress reactions (e.g., focused breathing or mindful- ness) and encouraged to apply these skills when posttraumatic stress reactions are experienced between sessions.

83 388 Children Exposed to Traumatic Stress Another component “Affective Expression and Modulation” occurs when the therapist asks the child-âp•‰ arent dyad to share and talk about their feelings and to engage in written or verbal exer- cises (e.g., produce a list of feelings in three minutes) and games (e.g., Emotional Bingo, Mitlin, 1998) aimed at helping the child identify their feelings. The dyad also learns a number of affective modulation strategies (i.e., thought interruption, positive imagery, positive self-t╉alk, and problem solving through social skill building) to combat negative and intrusive cognitive-âa•‰ ffective states via guided instruction and in-âs•‰ession practice. In Cognitive Coping and Processing the child-╉ parent dyad is taught how to generate alternative thoughts that may aid them in changing the way they feel. Three studies have provided some support for the efficacy of TF-âC•‰ BT among youth exposed to mass trauma. In one study, Jaycox et al. (2010) showed that TF-âC•‰ BT was just as efficacious in reducing PTSD symptoms as the school-âb•‰ ased CBITS (Jaycox, 2003), though the effective- ness of such treatment in disaster settings is still debatable given the low frequency of youth beginning or completing TF-C╉ BT (23% and 15%, respectively). In a second study among 306 youth exposed to the September 11th World Trade Center terrorist attacks, researchers for the CATS Consortium (2010) compared the effects of TF-C╉ BT (12–â2•‰ 0 sessions; adolescents received the trauma and grief component therapy for adolescents [Layne et al., 2002], which has comparable components) to a brief CBT program that included a parent component (4 sessions) at six-m╉ onths post-ât•‰reatment. Though youth were not randomly assigned to the conditions given ethical and methodological issues cited by La Greca and Silverman (2009), the researchers did employ a regression discontinuity (needs-âb•‰ ased assignment), which allows for comparison of regression slopes and intercepts across treatment groups (instead of mean level comparisons). The results showed reductions in PTSD symptoms from pre-i╉ntervention to six-m╉ onth follow-âu•‰ p across both groups. However, youth assigned to the TF-C╉ BT group had greater trauma exposure and more environmental adversity (e.g., victimization) at baseline and showed more clinical improvement on average as they moved from probable PTSD criteria (as based upon the PTSD Reactions Index; Msypmre-p‰•âtrteoamtmecnrt i=te r3i6a.6fo1llvosw. Min6g-‰•âmtroenathtmfolelonwt-.‰•âupIn =a 1t7h.0ir3d; scale ranges from zero to 80) to mild PTSD study, Schreeringa et al. (2011) showed that TF-C╉ BT may even be a viable treatment option for younger children who experience traumatic events. Specifically, they found that PTSD symptoms significantly decreased from pre-╉to post-t╉reatment for those traumatized pre-╉ school children (three to six years of age) who received and completed treatment immediately upon entering the study, as compared to wait-âl•‰ist control children assessed during the same time frame. Conclusions In summary, mass trauma-e╉ xposed youth utilize a number of mechanisms or strategies that span across neurobiogical, cognitive, and behavioral domains in an effort to regulate their negative emotional responses following trauma exposure (Kennedy et al., 2011). Review of the findings presented in this chapter further suggests that negative outcomes of PTSD symptoms, anxiety, and depression are associated specifically with certain neurobiogical markers of poor emotion regulation, such as structural and functional changes in prefrontal cortical regions, low HRV at rest and blunted or increased HRV to stress, and lower cortisol responses over time. In addi- tion, PTSD has been associated with the frequent use of maladaptive cognitive strategies such as, experiential avoidance, distraction, and rumination; and behavioral emotion regulation strategies such as avoidance, escape, and emotional suppression (Feldman et al., 2013; Jeney-âG•‰ ammon et al.,

983 Conclusions 389 1993; Kithakye et al., 2010; Noppe et al., 2006; Pina et al., 2008; Polusny et al., 2011; Prinstein et al. 1996; Punamäki et al., 2014; Russoniello et al., 2002; Scott & Weems, 2014; Terranova et al., 2009b;Vigil et al., 2010; Wadsworth et al., 2004). However, and as with many other psychological processes, emotion regulation likely does not occur in isolation and youth may attempt to use many strategies (either consciously or non-c​ onsciously) during a stressful situation. Conceptually, youth may automatically respond to a particular trauma reminder or stressful event at first, but if distress continues, may progressively move through more effortful emotion regulation strat- egies until emotional distress subsides. Thus, over time youth may develop certain sequential patterns of responding to both positive and negative emotional events. It would be beneficial for researchers to use mixed modeling approaches (e.g., latent growth models; see Gullone, Hughes, King, & Tonge, 2010 for example of using such methods to measure change in emotion regulation over time) to examine patterns of emotion regulation mechanisms and whether they are uniquely related to posttraumatic stress outcomes among trauma-e​ xposed youth. Additionally, emerging research has already begun to test the mediating processes of emo- tion regulation as proposed in our conceptual framework and has shown evidence for a link between mass trauma exposure and negative outcomes via emotion regulation (Polusny et  al., 2011; Marsee, 2008). However, it is still relatively early to draw definitive conclusions on causal inferences, as these two studies were cross-​sectional and focused on a single cognitive emotion regulation strategy and general emotional dysregulation. Furthermore, it seems that contextual factors, such as temperament and parenting behaviors, influence whether youth develop or con- tinue to have problems following trauma (Halberstadt et al., 2008; Hendricks and Borstein, 2007; Kithakye et al., 2010; Lengua et al., 2005; Punamäki et al., 2014; Polusny et al., 2011; Terranova et al., 2009b). Future research will need to address the mediating and moderating role of emotion regulation in the development and maintenance of youth outcomes using both prospective (i.e., pre-​and post-t​ rauma) and longitudinal designs that can capture time dependent changes in emo- tion regulation mechanisms and posttraumatic stress outcomes independently and in relation to one another. Researchers will also need to carefully consider developmental factors, as younger children may be more prone to using maladaptive strategies (e.g., avoidance) as their access to high-o​ rder cognitive abilities is limited. Most of the aforementioned studies also relied on broad coping measures to capture emotion regulation strategies, though the strategies measured may go beyond specifically changing or modulating an emotional response and tell us little about youths’ ability to modulate emotions in non-​stressful situations (Compas et al., 2014). For example, seeking social support or com- fort from parents, peers, or teachers during a stressful time may serve to ease worries about losing a house or a loved one following a natural disaster (regulation of negative cognitions) or blaming others may reduce stress (not necessarily related to an emotion) through migrat- ing responsibility on environmental factors. Researchers also need to take caution when using coping measures to predict child psychopathology symptoms or other negative posttraumatic stress reactions as there is considerable overlap in measure constructs and items (e.g., behav- ioral avoidance is a DSM-​5 defined symptom of PTSD) and thus increases the odds of relations being driven by shared method variance (Pfefferbaum, Noffsinger, Wind, & Allen, 2014). In closing, it is important to note that effective interventions that target emotion regulation skills are available to youth experiencing mental health difficulties following mass trauma expo- sure. However, little is known about whether change in emotion regulation (increase in efficacy or greater or lesser use of specific strategies) is the mechanism that leads to reductions in negative outcomes following treatment or whether these skills require booster sessions to solidify their flexible and adaptive usage.

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693 396 Children Exposed to Traumatic Stress Silverman, W. K., Pina, A. A., Viswesvaran, C. (2008). Evidence-​based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37, 105–​130. doi:10.1080/​15374410701817907 Stein, B. D., Jaycox, L. H., Kataoka, S. H., Wong, M., Tu, W., Elliot, M. N., & Fink, A. (2003). A mental health intervention for school children exposed to violence. The Journal of the American Medical Association, 290, 603–6​ 11. doi:10.1001/j​ ama.290.5.603 Taylor, L. K., & Weems, C. F. (2011). Cognitive-​behavior therapy for disaster-e​ xposed youth with posttraumatic stress: Results from a multiple-​baseline examination. Behavior Therapy, 42, 349–​363. doi:10.1016/​j.beth.2010.09.001 Tedeschi, R. G., & Calhoun R. G. (2004). Posttraumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 14, 1–1​ 8. doi:10.1207/​s15327965pli1501_0​ 1 Terranova, A. M., Boxer, P., & Morris, A. S. (2009a). Changes in children’s peer interactions following a natural disaster: How predisaster bullying and victimization rates changed following Hurricane Katrina. Psychology in the Schools, 46, 333–​347. doi:10.1002/p​ its.20379 Terranova, A. M., Boxer, P., & Morris, A. S. (2009b). Factors influencing the course of posttraumatic stress following a natural disaster: Children’s reactions to Hurricane Katrina. Journal of Applied Developmental Psychology, 30, 344–3​ 55. doi:10.1016/​j.appdev.2008.12.017 Thayer, J. F., & Lane, R. D. (2000). A model of neurovisceral integration in emotion regulation and dysregulation. Journal of Affective Disorders, 61, 201–​216. doi:10.1016/S​ 0165-0​ 327(00)00338-​4 Thompson, R. A. (1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59, 25–5​ 2. doi:10.1111/​j.1540-5​ 834.1994.tb01276.x Vernberg, E. M., Silverman, W. K., La Greca, A. M., & Prinstein, M. J. (1996). Prediction of posttraumatic stress symptoms in children after Hurricane Andrew. Journal of Abnormal Psychology, 105, 237–2​ 48. doi:10.1037/0​ 021-8​ 43X.105.2.237 Vigil, J. M., Geary, D. C., Granger, D. A., & Flinn, M. V. (2010). Sex differences in salivary cortisol, alpha‐amylase, and psychological functioning following Hurricane Katrina. Child Development, 81, 1228–​1240. doi:10.1111/​j.1467-​8624.2010.01464.x Wadsworth, M. E., Gudmundsen, G. R., Raviv, T., Ahlkvist, J. A., McIntosh, D. N., Kline, G.H., … & Burwell, R. A. (2004). Coping with terrorism: Age and gender differences in effortful and involuntary responses to September 11th. Applied Developmental Science, 8, 143–1​ 57. doi:10.1207/​ s1532480xads0803_4​ Wagner, K. D., Brief, D. J., Vielhauer, M. J., Sussman, S., Keane, T. M., & Malow, R. (2009). The Potential for PTSD, Substance Use, and HIV Risk Behavior among Adolescents Exposed to Hurricane Katrina. Substance Use & Misuse, 44, 1749–​1767. doi:10.3109/1​ 0826080902963472 Weems, C. F., & Carrión, V. G. (2009). Diurnal salivary cortisol in youth: Clarifying the nature of post traumatic stress dysregulation. Journal of Pediatric Psychology, 34, 389–3​ 95. doi:10.1093/​jpepsy/​jsn087 Weems, C. F., & Graham, R. A. (2014). Resilience and trajectories of posttraumatic stress among youth exposed to disaster. Journal of Child and Adolescent Psychopharmacology, 24(1), 2–​8. Weems, C. F. & Overstreet, S. (2008). Child and adolescent mental health research in the context of Hurricane Katrina: An ecological-​needs-​based perspective and introduction to the special section. Journal of Clinical Child and Adolescent Psychology, 37, 487–4​ 94. doi:10.1080/​15374410802148251 Weems, C. F., Russell, J.D., Graham, R. A., Neill, E. L. & Banks, D. M. (2015). Developmental differences in the linkages between anxiety control beliefs and post-​traumatic stress in youth. Depression & Anxiety, 32, 356–3​ 63. doi:10.1002/​da.22319 Weems, C. F., Scott, B. G., Graham, R. A., Banks, D. M. Russell, J.D. Taylor, L. K., Cannon, M. Varela, R. E., Scheeringa, M. S. Perry A. M. & Marino, R., C. (2014). Fitting anxious emotion focused intervention into the ecology of schools: Results from a test anxiety program evaluation. Prevention Science. doi:10.1007/s​ 11121-0​ 14-​0491-​1

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893 Chapter 19 Adolescents who Engage in Nonsuicidal Self-â•I‰ njury (NSSI) David Voon & Penelope Hasking Nonsuicidal self-injury Nonsuicidal self-i╉njury (NSSI) is the deliberate damage to the body in the absence of fatal intent (Nock, 2009). As well as being a symptom criterion for a diagnosis of Borderline Personality Disorder (BPD; American Psychiatric Association, APA, 2013), NSSI is uniquely associated with symptoms of depression, anxiety, substance abuse, and reduced well-b╉ eing (Dilberto & Nock, 2008; Giletta, Scholte, Engels, Ciairano, & Prinstein, 2012; Hankin & Abela, 2011; Hilt, Nock, Llloyd-âR•‰ ichardson, & Prinstein, 2008). NSSI is distinguishable from other self-h╉ arm behaviors, such as substance use, where the harmful consequences of the behavior are usually unintended, and from suicidal behavior where the consequences are intended to be fatal (Nock, 2012). Yet, although distinct from suicidal behavior, NSSI is a risk factor for later suicide (Klonsky, May, & Glenn, 2013; Whitlock et al., 2013). Highlighting the transdiagnostic nature of NSSI (for discussion see Bentley, Cassiello-R╉ obbins, Vittorio, Sauer-Z╉ avala, & Barlow, 2015), and the significant impact of the behavior on psychological health and well-b╉ eing, the APA recently included NSSI as a condition requiring further research in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5╉ ; APA, 2013). Theoretical perspectives on NSSI suggest poor emotion regulation is critical to the aetiology and maintenance of the behavior. Regulation of negative emotional states is frequently cited as the predominant motivation for engaging in the behavior (Klonsky, 2009; Martin et al., 2010; Nock & Prinstein, 2004; Nock, Prinstein, & Sterba, 2009), and evidence-âb•‰ ased interventions focus- ing on improving individuals’ skills and capacity for emotion regulation hold promise for the treatment of NSSI (e.g., Gratz & Tull, 2011). “Emotion regulation” in this context refers to a set of responses that contribute to initiating, maintaining and modifying the occurrence, intensity, duration and expression of emotion (Gross, 1998a, 1998b). These responses are both conscious and unconscious, and may be both effortful and automatic (Gross, 1998a, 1998b; Koole, 2009). Specific emotion regulation processes that have been implicated in NSSI, which will be focused on in this chapter, include rumination, cognitive reappraisal, and expressive suppression (Armey & Crowther, 2008; Hasking, Momeni, Swannell, & Chia, 2008; Hasking, Coric, Swannell, Martin, Thompson, & Frost, 2010; Hilt, Cha, & Nolen-âH•‰ oeksema, 2008; Martin et al., 2010). In the next sections, we describe the nature and extent of NSSI, differentiating it from suicidal behavior. We broadly discuss the role of emotion regulation in the development, expression, and maintenance of the behavior, and discuss specific emotion regulation processes and how they might be implicated in NSSI. Finally, we discuss intervention approaches for NSSI and the evidence related to their effectiveness. We conclude with the observation that although there are currently no treatments developed specifically for NSSI among adolescents, and that treatment approaches for self-h╉ arm (broadly defined) have inconclusive evidence regarding their effectiveness for this population, findings from both empirical and intervention research, provide promising leads.

93 THEORETICAL PERSPECTIVES ON NSSI 399 The nature and extent of NSSI Although NSSI can occur throughout the lifespan, typically it first occurs during adoles- cence, making this a prime developmental period for prevention and early intervention efforts (Hankin & Abela, 2011; Jacobson & Gould, 2007; Nock, 2009). International prevalence rates of NSSI among adolescents have been estimated at 12.5% to 23.6%, with rates decreasing to approximately 13% in young adults (Muehlenkamp, Claes & Plener, 2012; Swannell, Martin, Page, Hasking & St. John, 2014). Common forms of NSSI include skin cutting, scratching, self-╉ battery, biting, and burning; with boys/âm•‰ en more likely to engage in self-b╉ attery than girls. Much of the work describing NSSI observes no gender differences in the prevalence of the behavior; however, gender differences are reported in the preferred means of NSSI (Bjärehed, Wångby-L╉ undh, & Lundh, 2012; Sornberger, Heath, Toste, & McLouth, 2012; You, Leung, Fu & Lai, 2011). A recent meta-a╉ nalysis reported a slightly higher prevalence among women (Plener, Schumacher, Munz & Groschwitz, 2015), with this difference particularly apparent in clinical samples (Bresin & Schoenleber, 2015). In early work, researchers studied NSSI alongside suicidal behavior, arguing both are characterized by intentional self-âd•‰ irected harm. Terms such as “parasuicide” and “deliberate self-âh•‰ arm” have been used to describe NSSI, without differentiating behaviors which may be performed with or without conscious suicidal intent. Conflating the two behaviors however obscures their differences. Apart from the absence of fatal intent, several authors have noted that suicidal and non-âs•‰uicidal self-iâ•n‰ jurious behaviors differ in prevalence, frequency and methodologies (Hamza, Stewart & Willoughby, 2012; Klonsky et  al., 2013). Highlighting the contrast between NSSI and suicidal behavior, rates of suicidal behavior among adolescents are estimated at between 1.3% to 10.1% (Bridge, Goldstein & Brent, 2006). NSSI typically involves methods that are non-âl•‰ethal, while suicide attempts typically involve more lethal methods such as hanging, poisoning, and drug overdose (Bridge et al., 2006; McNamara, 2013). While both behaviors do occur in the context of intense negative emotional states, Walsh (2005) observed that “the intent of the self-âi•‰njuring person is not to terminate consciousness (as in suicide) but instead, to modify it” (p. 7). Although frequent NSSI increases risk of suicidal thoughts and behavior, it ought to be noted that individuals who attempt suicide and/o╉ r experience suicidal ideation are equally likely to report concurrent or future NSSI (Whitlock et al., 2013). In other words, examination of the tem- poral relationship between NSSI and suicidal thoughts and behaviors does not support a direct causal link. While NSSI may serve as a “gateway” to concurrent and/o╉ r future suicidal thoughts and behaviors, several psychological and social indicators including lack of social connectedness, less meaning in life, and poorer access to mental health services, can play a critical role in increas- ing suicide risk. Nonetheless, reducing the frequency of NSSI among individuals who engage in the behavior is likely to be protective. Theoretical perspectives on NSSI There are several perspectives on why individuals might engage in NSSI to regulate their emo- tional states. Nock (2009) postulates that there are distal, proximal and NSSI-s╉pecific vulnera- bilities which increase the likelihood of NSSI. Briefly, he identifies distal vulnerabilities such as a genetic predisposition to emotional reactivity and sensitivity, and invalidating childhood environ- ments; proximal vulnerabilities such as maladaptive coping and poor communication; and NSSI-╉ specific vulnerabilities, including social learning and the release of endogenous opioids associated with physical injury, which might explain why some individuals engage in the behavior while others do not. It is beyond the scope of this chapter to discuss these various vulnerabilities. In

04 400 Adolescents who Engage in Nonsuicidal Self-injury (NSSI) this section we present theories and perspectives which highlight emotion regulation as a critical factor in understanding NSSI. Invalidating childhood experiences and NSSI Linehan (1993) attempted to explain self-âh•‰ arm behaviors such as NSSI among individuals with BPD and theorized that the propensity to engage in NSSI to regulate negative affective states may be due to invalidating childhood experiences. According to Linehan, individual vulnerabili- ties such as sensitivity to emotional stimuli and emotional reactivity interact with invalidating childhood environments to contribute to emotion regulation deficits in later life. The child learns to control his/h╉ er emotional expressiveness and, over time, becomes more restricted in his/âh•‰ er capacity to appropriately identify and regulate emotional arousal, tolerate distress, and trust his/╉ her emotional responses. As a consequence, emotional expression becomes increasingly charac- terized by extreme inhibition or extreme disinhibition. Emotions are experienced as intense with limited ability to effectively regulate them except through self-âh•‰ arm behavior. Extending Linehan’s theory, Lang and Sharma-âP•‰ atel (2011) suggest that in invalidating child- hood environments, individuals’ emotions are rarely reflected, accepted or clarified; furthermore, they have limited models of effective emotion regulation and limited opportunities to practice these during childhood. These experiences also contribute to representations of the world as threatening, others as unreliable and the self as inept. Consequently, individuals develop a height- ened sense of danger and experience high levels of arousal when confronted with stressful situa- tions and life events. They may perceive that they have limited internal and external resources to cope with stressors and use NSSI to help alleviate the arousal associated with stressful situations. Empirical support for the contribution of invalidating childhood experiences to engagement in NSSI exists predominantly in studies on childhood abuse. There is evidence from cross-âs•‰ ectional studies that childhood physical and sexual abuse (Fliege, Lee, Grimm & Klapp, 2009; Gratz, 2003; Gratz & Chapman, 2007) and emotional neglect (Fliege et al., 2009; Gratz, 2003) are associated with NSSI. More pertinent to this discussion are research findings that highlight emotion dysreg- ulation as a distinguishing characteristic among individuals with abuse histories who engage in NSSI and individuals with similar histories who do not. Several studies report emotion dysregu- lation as a significant predictor of NSSI over and above the presence of childhood maltreatment (Gratz, 2006; Gratz & Chapman, 2007; Gratz & Roemer, 2008; Muehlenkamp, Kerr, Bradley & Larson, 2010). In this regard, emotion dysregulation refers to a constellation of factors including non-âa•‰ cceptance of emotional experience, difficulties with goal-âd•‰ irected behaviors and impulse control, lack of emotional awareness, limited number, and restricted access to emotion regula- tion strategies, and lack of emotional clarity. Sim, Adrian, Zeman, Cassano and Friedrich (2009) found that poor awareness of emotion and reluctance to express emotion were partial media- tors of the abuse-N╉ SSI relationship among female adolescents in a clinical setting. Swannell and colleagues (2012) reported difficulties with identifying and articulating emotion (alexithymia) partially mediated the relationships between physical abuse and neglect, and NSSI among females aged 18 years and over. Taken together, the empirical evidence suggests while invalidating child- hood experiences may contribute to the aetiology of NSSI, poor emotion regulation is the likely mechanism explaining this increased risk. As such, poor emotion regulation is likely to maintain NSSI for people raised in invalidating childhood environments. Maladaptive coping, experiential avoidance and NSSI Lang and Sharma-âP•‰ atel’s (2011) observation that individuals who self-âi•‰njure perceive that they have limited resources to cope with stressors suggests that lack of effective coping strategies or

104 Theoretical perspectives on NSSI 401 maladaptive coping styles play a role in NSSI. Indeed, Haines and Williams (1997) reported that people who self-âi•‰njure have difficulty coping with problems. Others have found that reliance on avoidant coping strategies is associated with the presence of NSSI among adolescents (Evans, Hawton, & Rodham, 2005), young adults (Andover, Pepper, & Gibb, 2007; Borrill, Fox, Flynn, & Roger, 2009; Brown, Williams, & Collins, 2007), and adult prisoners (Kirchner, Forns, & Mohino, 2008). These studies suggest individuals who engage in NSSI are less likely to use coping strategies aimed at resolving problems and are more likely to engage in avoidant behaviors which potentially maintain high levels of emotional arousal. It is unsurprising then that self-âi•‰njurers are also more likely to engage in emotion-f╉ocused cop- ing strategies (Borrill et al., 2009; Mikolajczak, Petrides & Hurry, 2009); perhaps in an attempt to cope with the resultant negative emotions arising from problem avoidance. Interestingly, Williams and Hasking (2010) reported that, when experiencing psychological distress, individuals who relied on avoidant coping strategies were more likely to have higher scores on a measure of NSSI which took into account the frequency, recency, severity and range of methods of self-i╉njury used. Further, the relationship between psychological distress and NSSI was positive among study par- ticipants who did not rely on emotion-âf•‰ocused coping strategies, suggesting that inability to cope effectively with distressing emotions is implicated in NSSI. The cross-s╉ ectional nature of the above studies preclude conclusions regarding causal relation- ships; however, they indicate that NSSI is associated with a constellation of behaviors aimed at avoiding problems which, in turn, maintain emotional turmoil occasioned by these problems. Lack of effective emotion-f╉ocused coping may leave individuals with no other recourse than to engage in NSSI to alleviate their negative emotional states. Such a dynamic is proposed in the Experiential Avoidance Model of NSSI (Chapman, Gratz, & Brown, 2006) which conceptual- izes self-âi•‰njury as a means of avoiding unwanted internal experiences such as bodily sensations, thoughts, memories and emotions, and the events and contexts that occasion them. The Experiential Avoidance Model of NSSI provides a theoretical framework that makes sense of the empirical findings in the coping literature and accounts for the initial motivation for prob- lem avoidance as a means to avoid or escape from unwanted thoughts, memories and emotions associated with stressful situations and life events. According to the model, limited access to effec- tive strategies to regulate emotional arousal is a key factor, as their absence leaves individuals to contend with their unwanted emotions which are often experienced as intense. Without effective strategies to modulate their emotional states, individuals use NSSI to further escape from them. Chapman and colleagues (2006) contend that the behavior is maintained through behavioral rein- forcement and may become rule governed through verbal rules which specify that NSSI is related to feeling better. Functional accounts of NSSI The observations by Chapman and colleagues echo Nock and Prinstein’s (2004) Functional Model of NSSI, which draws on commonly reported motivations for engaging in NSSI. According to this perspective, NSSI serves two general functions in the intra-╉and interpersonal domains respectively. In the intrapersonal domain, NSSI assists individuals to feel better. NSSI is negatively reinforced when it reduces or brings to an end a negative emotional state (automatic-‰ân• egative reinforcement); and is positively reinforced when it induces a desired emotional state (automatic-╉ positive reinforcement) such as feeling something rather than feeling numbed. In the interper- sonal domain, NSSI is behaviorally reinforced as it assists individuals to escape from others’ demands (social-‰•ânegative reinforcement) as well as to gain attention from others or to have access to resources as a consequence of their behavior (social-╉positive reinforcement). It ought to be noted

204 402 Adolescents who Engage in Nonsuicidal Self-injury (NSSI) that while Nock and Prinstein identified two functional domains for NSSI, they acknowledged that regulating emotional states (i.e., the intrapersonal domain) was more commonly reported by people who self-âi•‰njure. Accordingly, the authors observed that the social/âi•‰nterpersonal function of NSSI may be secondary to the intrapersonal function of feeling better. Rumination, emotional cascades and NSSI The theoretical perspectives and empirical findings discussed above suggest high emotional arousal, low distress tolerance and lack of effective emotion regulation strategies are implicated in NSSI. However, they provide little explanation for the intensity of negative emotional experience that is associated with the behavior. Distal factors such as a genetic predisposition for emotional reactivity and sensitivity might contribute somewhat to the experience of emotional turmoil (Nock, 2009). Proximal factors, such as the types of responses individuals engage to initiate, main- tain and modify the occurrence, intensity, duration and expression of emotion might also play a role in the underlying processes of NSSI. Selby and Joiner (2009) proposed one such response type in the Emotional Cascade Model for Dysregulated Behaviours. They suggest that the intense negative emotional states that precede or co-o╉ ccur with NSSI are “emotional cascades” which begin with minute negative emotional stimuli which become amplified and intensified by a vicious cycle of rumination. That is, by “a tendency to repetitively think about the causes, situational factors, and consequences of one’s negative emo- tional experience … continuously thinking about and focusing attention on emotionally relevant stimuli” (Selby & Joiner, 2009; p.  220). The contribution of rumination in amplifying negative emotional states has previously been reported for depression, anxiety, worry and anger (Calmes & Roberts, 2007; Harrington & Blakenship, 2002; Muris, Roelofs, Meesters & Boomsma, 2004; Nolen-H╉ oeksema, 2000; Peled & Moretti, 2007). Moreover, other studies show that ruminating on one’s sad mood increased distress regarding current concerns (Conway, Csank, Holm, & Blake, 2000), and that the tendency to ruminate about negative inferences following stressful events had a larger effect on the number, rate and duration of depressive episodes than ruminating on depressed mood alone (Robinson & Alloy, 2003). There is empirical support for the contribution of rumination to NSSI among adults and ado- lescents (Armey & Crowther, 2008; Bjärehed & Lundh, 2008; Borrill et al., 2009; Hilt, Cha, et al., 2008). In an early test of the Emotional Cascades Model, Selby, Connell, and Joiner (2010) found significant direct effects of rumination and painful and provocative life events on NSSI. Further, they reported that individuals who had experienced more painful and provocative life events and who had greater ruminative tendencies were more likely to engage in frequent NSSI than indi- viduals who had lower ruminative tendencies. In a more recent test of the model Selby, Franklin, Carson-âW•‰ ong, and Rizvi (2013) found that individuals who engaged in more frequent rumina- tion, and individuals who experienced greater changes in levels of negative emotion, reported more NSSI episodes. As would be expected from the model, the researchers also found that indi- viduals with greater fluctuation in both rumination and negative affect had more episodes of NSSI. However, fluctuations in rumination also predicted NSSI, even when levels of daily nega- tive emotion were stable. This contradicted the Emotional Cascade Model, as the former should only predict NSSI in the context of more frequent and greater fluctuations of negative emotion. Nonetheless, when taken together, there is some preliminary empirical support for the model. Gross’ process model and NSSI The process model of emotion regulation developed by John Gross (1998a; 1998b) is one of the most widely used frameworks in the emotion regulation field (Gullone, Hughes, King & Tonge,

304 Theoretical perspectives on NSSI 403 2010; Webb, Miles, & Sheeran, 2012). It describes five emotion regulation processes that contrib- ute to how emotions might be experienced and expressed. The first of these emotion regulation responses is situation selection which describes the process whereby an individual chooses to enter into and engage in different types of situations which might evoke different emotions. Individuals might choose to engage in NSSI as an alternative to engaging in situations which they anticipate will cause distress (McKenzie & Gross, 2014). They may also engage in NSSI as a means to enter new and more desired situations (e.g,. going to hospital and receiving medical attention). The second is situation modification—âw•‰ here individuals might choose to alter the situation in which they find themselves so as to increase or decrease the likelihood of experiencing specific emotions. Consistent with Nock and Prinstein’s (2004) Functional Model of NSSI, individuals engage in NSSI to elicit alternative responses from others which in turn modifies the situations in which they find themselves (e.g., increased caregiving or reductions in external demands from others; McKenzie & Gross, 2014). Attentional deployment refers to the selective attention to different aspects of a situation. Therefore, an individual might choose to attend to aspects of a situation that are likely to evoke specific types of emotional responses or may choose to disregard or distract from these emo- tional cues. Importantly, Webb and colleagues (2012) observe that attentional deployment can be applied to internal experiences such as memories where the individual is re-âi•‰mmersed in the initial situation that gave rise to the emotion that is then re-âe•‰ xperienced. Although not conceptu- alized within Gross’ model of emotion regulation, Webb and colleagues (2012) classified rumina- tion as an example of attentional deployment which is consistent with its definition in Selby and Joiner’s (2009) Emotional Cascade Model for Dysregulated Behaviours as rumination continually focuses attention on emotionally relevant stimuli. Several of the theories described above suggest that NSSI is a form of attentional deployment, with the Experiential Avoidance Model of NSSI positing that it distracts from aversive internal experiences. A fourth emotional regulation response is cognitive change which refers to the interpretations and appraisals placed on emotionally relevant stimuli. McKenzie and Gross (2014) suggest NSSI might be a mechanism by which individuals change their self-âv•‰ iews: Transforming higher-o╉ rder self-âc•‰ onstruals that may be overwhelmed by responsibilities and external demands and, therefore, lead to negative emotional states, to lower-o╉ rder self-âc•‰ onstruals focusing on bodily experiences which may not evoke the same intensity of emotion. Alternatively, individuals may engage in cognitive change to reinterpret and ascribe different meanings to specific emotional stimuli so as to change their emotional experience. Finally, individuals can choose to limit the expression of the emotional response through response modulation and in doing so regulate the behavioral, experiential, and/âo•‰ r physiological expression of the emotion. Engaging in NSSI might be a form of response modulation as the subsequent release of endogenous opioids soothes the physiological arousal that accompanies negative emotional states (McKenzie & Gross, 2014). Cognitive reappraisal and expressive suppression Two emotional regulation strategies from Gross’ process model—âc•‰ ognitive reappraisal and expres- sive suppression—h╉ ave been explicitly applied to NSSI. Cognitive reappraisal is a process whereby the emotional salience of a situation is reduced through cognitive change. Expressive suppression, on the other hand, is a response modulation process which specifically aims to reduce emotion- ally expressive behavior. Among adults, cognitive reappraisal is related to a greater experience and expression of positive emotion but reduced experience and expression of negative emotion (Gross & John, 2003). Conversely, expressive suppression leads to reduced experience and expression of

40 404 Adolescents who Engage in Nonsuicidal Self-injury (NSSI) positive emotion; and increased experience of negative emotion and lower expression of negative emotion, which has been associated with negative health outcomes (Gross & John, 2003). Among adolescents, the reduced use of cognitive reappraisal in conjunction with a greater tendency to engage in expressive suppression is related to depressive symptomatology, school refusal and anx- iety (Betts, Gullone, & Allen, 2009; Hughes, Gullone & Watson, 2011; Hughes, Gullone, Dudley, & Tonge, 2010). These studies hint at the protective effect of reappraisal and suggest expressive suppression is associated with maladaptive outcomes in psychological health and reduced well-​ being among adolescents. Given the contribution of cognitive reappraisal and expressive suppression in the regulation of negative states, it may be speculated that the ability to effectively engage in reappraisal might reduce the likelihood of engaging in NSSI, as it is likely to reduce the intensity and duration of negative emotion. Expressive suppression, on the other hand, would therefore increase the likeli- hood of engaging in NSSI as it has the tendency to increase the experience of negative emotion. In support, among adolescents aged 13–​18 years (Hasking et al., 2010), and young adults aged 18–​30  years (Williams & Hasking, 2010), cognitive reappraisal was negatively correlated with NSSI; whereas, expressive suppression had a positive correlation. Comparisons between groups of 18–3​ 0 year olds who did not engage in NSSI, those who engaged in infrequent and low sever- ity NSSI, and those who engaged in frequent (at least once per month) NSSI which resulted in wounds requiring first aid, revealed significant group differences in mean scores for expressive suppression, but not for cognitive reappraisal (Hasking et al., 2008). The moderate/s​ evere group had the highest mean score for expressive suppression, while those who did not engage in NSSI had the lowest. In other work, while there were differences in the use of cognitive reappraisal between self-​injurers and non-s​ elf-i​njurers aged ten years and above, no differences were found for the use of expressive suppression (Martin et  al., 2010). In the latter study, individuals who self-​injured were 3.3 times more likely to report difficulty with using reappraisal to regulate their emotional states compared with those who did not self-​injure. The discrepant findings in the above studies may be due to different criterion variables under investigation. Hasking and colleagues (Hasking et al., 2008, 2010; Williams & Hasking, 2010) were interested in frequency, recency and severity of NSSI; whereas, Martin and colleagues (2010) focused on NSSI history. It might be that the two emotion regulation processes have differential contributions to the presence of NSSI (i.e,. whether and when individuals engage in the behavior), and to the severity of the behavior (i.e,. the extent to which they engaged in the behavior in regard to frequency, recency, severity etc.). Cognitive reappraisal may be more pertinent in the former case; while, expressive suppression may be related to the latter (see Voon, Hasking & Martin, 2014a). Such an observation is consistent with findings from earlier studies on a related construct of emotional inexpressivity. A personality trait which confers a tendency to restrict displays of emo- tions regardless of the valence of the emotion or the manner of expression, it is similar to expres- sive suppression. Research findings show that although emotional inexpressivity did not reliably distinguish undergraduates with and without a history of NSSI (Gratz, 2006; Gratz & Chapman, 2007), it was significantly associated with frequency of NSSI among women who engaged in NSSI (Gratz, 2006; Gratz & Roemer, 2008). A set of studies from a longitudinal dataset produced mixed findings. In two, neither cognitive reappraisal nor expressive suppression predicted first episode NSSI among adolescents (Andrews, Martin, Hasking & Page, 2014; Tatnell, Kelada, Hasking & Martin, 2014); although, findings by Voon, Hasking, and Martin (2014b) suggest reappraisal may protect against NSSI onset in younger cohorts. Further, Voon, Hasking, and Martin (2014c) suggest persistent and increasing use of cog- nitive reappraisal may have a slight protective effect in reducing medical severity of NSSI although

504 Intervention approaches for NSSI 405 it did not contribute to changes in frequency and duration of the behavior over a two-ây•‰ ear period. Use of expressive suppression, while differentiating youth who self-âi•‰njured from youth who did not, had no bearing on NSSI over the same two-y╉ ear period. Finally, Andrews, Hasking, Martin, and Page (2013) reported adolescents who continued to engage in NSSI 12-m╉ onths from baseline reported less tendency to engage in both cognitive reappraisal and expressive suppression com- pared with adolescents who stopped self-i╉njuring, which is consistent with the general consensus that NSSI is associated with deficits in emotion regulation. The above studies suggest cognitive reappraisal and expressive suppression are pertinent con- structs in the underlying processes of NSSI, although further research is required to clarify their roles. Given NSSI is used as a means of emotion regulation, with the assumption being that this strategy is used when other emotion regulation techniques are lacking, increased understanding of what kinds of emotion regulation processes among adolescents are most effective in modulat- ing the negative emotional states that precede or co-âo•‰ ccur with NSSI can be beneficial in refining interventions. Intervention approaches for NSSI Most interventions for NSSI have been developed within the context of addressing self-h╉ arm behaviors broadly which include self-i╉njury with fatal intent and non-d╉ irect methods of harm. Accordingly, in this section, the term “self-h╉ arm” is used to denote all self-âi•‰njurious behaviors regardless of intent and includes overdose, while NSSI is used to specifically refer to self-d╉ irected physical violence without fatal intent. There are few interventions that have been developed spe- cifically for NSSI, and of the interventions that have been evaluated, most have been with adult participants rather than adolescents. With these caveats in mind, current treatment interventions for self-âh•‰ arm draw on a range of psychotherapeutic approaches including Cognitive-B╉ ehavioral Therapy, Dialectical Behavior Therapy, and Mentalisation-âB•‰ ased Therapy (Brausch & Girresch, 2012; Kerr, Muehlenkamp & Turner, 2010; Ougrin et al., 2012; Stoffers, et al., 2012; Washburn et al., 2012). These interventions have, for the most part, favored a comprehensive approach which addresses cognitive and emotional triggers for NSSI. Evaluations indicate such an approach is likely to be promising, particularly where it also includes skills building in managing emotions. However, more rigorous evaluations of existing interventions are required before firm conclusions regarding efficacious treatments for adolescent NSSI can be made. Cognitive-•â‰behavioral therapy (CBT) CBT is a treatment approach that comprises both cognitive and behavioral components (Stoffers et al., 2012). One of the earliest interventions applied to self-h╉ arm behaviors is a form of CBT known as Problem Solving Therapy (Brausch & Girresch, 2012; Washburn et al., 2012). The inter- vention assists individuals to cope with and resolve problems and includes cognitive restructuring to engender a more positive orientation to problems, as well as skills training in coping and ratio- nal problem-s╉olving. Use of this intervention to address self-âi•‰njurious behaviors draws on early conceptualisations of such behaviors as a general deficit in coping skills. However, the strength of evidence for the intervention was weak (Brausch & Girresch, 2012; Washburn et al., 2012). While initial evaluations were promising (showing a trend towards reductions in self-h╉ arm behaviors), the intervention did not produce statistically significant differences compared to controls. The need for more comprehensive intervention approaches to self-h╉ arm behaviors led to the development of Manual Assisted Cognitive-B╉ ehavioral Therapy (MACT; Washburn et al., 2012). This intervention integrates CBT with solution-âf•‰ocused therapy and includes a bibliotherapy component aimed at improving emotion regulation, and coping with negative cognitions (Kerr et

604 406 Adolescents who Engage in Nonsuicidal Self-injury (NSSI) al., 2010). Conducted over six sessions, MACT includes a functional analysis of self-âh•‰ arm behav- iors, education on emotion regulation and problem-s╉olving strategies, management of negative thinking, management of substance use, and relapse prevention (Weinberg, Gunderson, Hennen, & Cutter, 2006). Two early evaluations of MACT showed reductions in frequency of self-h╉ arm and duration between self-âh•‰ arm episodes in the intervention group, but these outcomes were not significantly different from similar reductions in the control group (see Evans et al., 1999; Tyrer et al., 2003). Kerr and colleagues (2010) noted that the non-s╉ignificant results in these studies could be due to the heterogeneity in how the intervention was delivered. Following these trials, Weinberg and colleagues (2006) evaluated the efficacy of MACT in reducing NSSI and suicide attempts among women with BPD (aged 18–4╉ 0 years). Participants were randomly assigned to a MACT intervention or treatment-âa•‰ s-u╉ sual (TAU). The authors reported significant reductions in frequency of NSSI post-t╉reatment as well as at six-âm•‰ onth follow-âu•‰ p. Moreover, NSSI severity was significantly lower compared with TAU at follow-u╉ p. Further emphasising the utility of focussing on factors other than coping with and resolving problems, Slee, Garnefski, van der Leeden, Arensman, and Spinhoven (2008) developed and eval- uated a CBT intervention to address deliberate self-h╉ arm among 15-3╉ 5 year olds and reported significant reductions over nine months in the number of self-h╉ arm episodes among the interven- tion group compared with TAU. The intervention comprised 12 individual sessions focussing on identifying cognitive and emotional factors maintaining self-âh•‰ arm behaviors, and included the use of cognitive and behavioral strategies to address these maintaining factors. Strategies include addressing cognitive distortions, emotion regulation, and problem-âs•‰olving. A  follow-âu•‰ p study (Slee, Spinhoven, Garnefski & Arensman, 2008), showed that improved emotion regulation par- tially mediated reductions in self-h╉ arm following the intervention. More recently, Taylor and colleagues (2011) evaluated the efficacy of a similar intervention (Manualised Cognitive-B╉ehavioral Therapy) developed specifically for adolescents aged 12–╉ 18 years. This intervention comprised eight to 12 individual therapy sessions utilising a standard manual which included modules on identifying cognitive and emotional triggers for self-âh•‰ arm behavior, as well as modules teaching skills in managing cognitive distortions, mindfulness, problem-âs•‰ olving, and assertiveness. Preliminary findings were promising and showed reductions in frequency of deliberate self-h╉ arm post-ât•‰reatment and at three-âm•‰ onth follow-u╉ p. However, the study did not include a control group and, therefore, inferences regarding its efficacy cannot be made conclusively. Dialectical behavior therapy (DBT) Of all interventions addressing self-âh•‰ arm, DBT has received the most attention with treatment efficacy assessed via numerous evaluations including randomized controlled trials (Stoffers et al., 2012; Washburn et al., 2012). Developed by Marcia Linehan (1993) to treat BPD, it targets the main areas of dysregulation in BPD through validating individuals’ experiences and assist- ing them to increase their coping skills across a number of domains (interpersonal function- ing, cognitive functioning, behavioral functioning and sense of self). It comprises a combination of individual therapy, skills training, and brief telephone counselling/âc•‰oaching components. Together these aim to improve individuals’ capacity to accept the negative emotions that motivate them: to engage in self-âh•‰ arm; to tolerate aversive situations, thoughts and emotions; to identify, appraise, and modulate their emotional experiences; and to improve interpersonal relationships. Importantly, therapy progresses through a number of stages with the initial stage focussing pri- marily on reducing self-h╉ arm. In this regard, DBT has been described as a specific treatment for self-h╉ arm rather than treating it as a peripheral consequence of psychopathology (Feigenbaum, 2010; Lynch & Cozza, 2009).

704 Intervention approaches for NSSI 407 Stage 1 DBT as developed by Linehan is designed to be completed over a 12-âm•‰ onth period with weekly one-âh•‰ our individual therapy sessions, and two-âa•‰ nd-a╉ -h╉ alf-âh•‰ our group skills training ses- sions covering the following topic areas over two rotations: 1. Mindfulness 2. Distress tolerance 3 . Emotion regulation 4 . Interpersonal effectiveness The explicit focus on emotion regulation not only underscores the importance of emotion regu- lation in dysregulated behaviors, but differentiates DBT from similar therapies. Similar to CBT-╉ based interventions described above, individual therapy sessions focus on the identification of cognitive, emotional and situational triggers for target self-âh•‰ arm behaviors, and counselling/╉ coaching on the use of appropriate cognitive and behavioral skills to cope with these triggers (Koerner & Dimeff, 2007). This is achieved through the use of chain analysis which proceeds with identifying antecedent factors leading up to the focal behavior (typically self-âh•‰ arming behaviors such as NSSI). These antecedent factors include situational, social, cognitive and emotional fac- tors. The aim of chain analysis is to identify points at which individuals may interrupt the chain of events leading up to the behavior. As such, unlike CBT-b╉ ased approaches, chain analysis does not just focus on temporally proximate antecedent triggers. For example, an individual may identify feeling angry as a precursor to NSSI. The negative emotional state may be preceded by a comment from a family member or friend. Negative cognitions arising from the comment may also be iden- tified, as well as general factors such as feeling physically unwell or stressed which can contribute to the individual’s overall vulnerability or sensitivity. Using chain analysis, the therapist will work with the client to recognize the vulnerabilities associated with feeling unwell/âs•‰tressed and nega- tive cognitions and to identify strategies to prevent future recurrence of the behavioral chain. Evaluations of DBT among adults with BPD have demonstrated reductions in self-h╉ arm among participants. Stoffers and colleagues (2012) reported that the pooled effect from three trials undertaken between 2001 and 2005 showed significant reductions compared with TAU. However, a more recent Australian trial (Carter, Wilcox, Lewin, Conrad & Bendit, 2010) did not find sig- nificantly different results between a modified DBT program and TAU. DBT has been adapted for adolescents (DBT-A╉ ) by decreasing duration of treatment to a 16-╉ week program, using age-a╉ ppropriate terminology and inclusion of family members in the skills training groups (Groves, Backer, van den Bosch, & Miller, 2012). However, these programs have not been subjected to randomized control trials and results are mixed (Brausch & Girresch, 2012; Kerr et al., 2010; Washburn et al., 2012). Non-âs•‰ignificant group differences were reported when comparing DBT-A╉ with TAU on suicide attempts (Rathus & Miller, 2002) and self-âh•‰ arm (Katz, Cox, Gunasekara & Miller, 2004). Two other studies reported significant post-t╉reatment reduc- tions in self-âh•‰ arm (James, Taylor, Winmill & Alfoadari, 2008) and NSSI (Fleischhaker et al., 2011); although the absence of a control group limits conclusions regarding the efficacy of these inter- ventions among adolescents. Mentalization-‰â•based therapy (MBT) MBT draws on psychodynamic theories (Kerr et  al., 2010; Stoffers et  al., 2012), and aims to “strengthen patients’ capacity to understand their own and others’ mental states in attachment contexts in order to address their difficulties with affect, impulse regulation, and interpersonal functioning which act as triggers for acts of suicide and self-h╉ arm” (Bateman & Fonagy, 2009, p. 1355). Thus, MBT assists with improved interpersonal function by building individuals’ capac- ity to mentalize and be aware of how thoughts and emotions influence their own and others’

804 408 Adolescents who Engage in Nonsuicidal Self-injury (NSSI) behaviors (Kerr et al., 2010). Stoffers and colleagues (2012) noted that, comparing the interven- tion with TAU, MBT achieved significant reductions in self-h╉ arm among adults in two trials undertaken in 1999 and 2009. More recently, Rossouw and Fonagy (2012) reported findings from a randomized control trial of MBT for adolescents. Significant group differences among adolescents randomly assigned to the MBT treatment group versus TAU controls were found. Those in the treatment group had lower scores on self-âh•‰ arm at the end of the 12-âm•‰ onth period, and showed greater reductions in self-âh•‰ arm over the course of treatment. Although results are promising, further replication is required. Emotion regulation group therapy Finally, following research on the impact of emotion dysregulation on NSSI, Gratz, and Gunderson (2006) developed a 14-âw•‰ eek emotion regulation group intervention specifically for NSSI. Drawing on a range of extant psychotherapeutic approaches including Acceptance and Commitment Therapy and DBT, the intervention focused on building emotional awareness and acceptance of emotions (versus emotional avoidance). Initial results among a group of women with BPD were positive and showed significant between-g╉ roup differences (i.e., intervention vs TAU) in reduc- tions in NSSI. Findings were replicated in a subsequent study extending the intervention to more diverse settings and groups of women with BPD (Gratz & Tull, 2011). Importantly, in a follow-u╉ p study, which analysed data collated from the above trials (Gratz, Levy & Tull, 2012), decreases in NSSI and emotion dysregulation were reported among the intervention groups (RCT and open trial completers)1 but not among controls. Moreover, a mediation analysis showed that emotion dysregulation mediated the relationship between intervention and outcome. Thus, the available evidence indicates that achieving reductions in emotion dysregulation is a worthwhile goal and that the intervention is promising (Gratz, Tull & Levy, 2014). However, it has not been applied to adolescents. Clinical guidance on the management and treatment The foregoing discussion shows that emotion regulation is a critical factor in understanding the aetiology, and more importantly, the maintenance of NSSI. Specific emotion regulation pro- cesses such as rumination and expressive suppression have emerged in the research as possible processes which can play a role in the escalation of negative emotional states that precede or co-âo•‰ ccur with the behavior, while engaging in cognitive reappraisal might be useful as a de-╉ escalation strategy. Assisting individuals in managing their propensity to engage in ruminative thinking and focusing attention on minute emotional stimuli may be useful; incorporating skills in distracting oneself from one’s emotional distress in intervention programs for NSSI may be warranted, as distraction has been shown to be a more adaptive response to distress than rumi- nation (see Nolen-âH•‰ oeksema, 1991). Mindfulness skills may also have some utility in this regard as both distraction and mindfulness have been reported to be effective (compared with problem-╉ solving) for reducing rumination among adolescents (Hilt & Pollak, 2012). Indeed, these specific skills are incorporated in DBT in the distress tolerance and mindfulness skills training modules (Linehan, 1993). Additionally, improving individuals’ effectiveness in the use of cognitive reap- praisal to reduce the emotional salience of stressful situations and life events might also be a 1 The intervention groups comprised of the “RCT” group in Gratz & Gunderson (2006) and the “open trial completers” in Gratz & Tull (2011). The control group were the TAUs in Gratz & Gunderson (2006).

904 Conclusion 409 useful component in interventions for NSSI. As described above, reappraisal features in several existing interventions, in the form of cognitive restructuring to address cognitive distortions and beliefs. Although specific interventions for NSSI in adolescence have yet to be developed, the above observations dovetail with available intervention approaches for self-h╉ arm behaviors generally. Emotion regulation skills that feature in these intervention approaches include: Cognitive restruc- turing to address cognitive distortions and negative thinking styles such as in CBT-âb•‰ ased inter- ventions; acceptance of emotions through mindfulness and use of distraction as featured in DBT; and awareness of emotion and their contribution to actions and behaviors as in DBT (see emotion regulation module) and MBT. The current state of intervention research for self-h╉ arm behaviors does not at present point to any single component which influences treatment outcome. It is likely that a combination of these skills is warranted as the research suggests comprehensive approaches which address cognitive and emotional triggers for NSSI have greater utility. Further examination of how specific emotion regulation processes contribute to or modulate the underlying emotional distress which precedes or accompanies NSSI is warranted to assist with identifying further areas for inclusion in treatment for the behavior. Glenn, Franklin, and Nock (2014) highlight that in addition to emotion regulation skills train- ing, effective interventions for self-h╉ arm also include:  1)  A  focus on improving interpersonal functioning, 2)  high intensity and frequent sessions, and 3)  incorporation of interventions to address other co-âo•‰ ccurring maladaptive behaviors or risk factors such as substance use. These may be applicable to treatment interventions for NSSI among adolescents. In the absence of empirically tested interventions for NSSI among adolescents, Washburn and colleagues (2012) distilled from the available literature additional elements to guide the man- agement and treatment of NSSI among this population group. They suggest that assessment for NSSI is important and should, at a minimum, aim to improve understanding of current and past behaviors including methods, locations, frequency, severity, urges and age of onset. Motivational enhancement (e.g., through motivational interviewing) may be necessary both prior to and dur- ing treatment. Additionally, cognitive and behavioral interventions can be useful to address self-╉ derogatory and distorted beliefs about NSSI (e.g., through Socratic questioning and thought monitoring), and include contingency management and behavioral activation. Dialectical strate- gies such as acceptance and tolerance of distress may also be useful to address the urge to engage in NSSI. More broadly, Washburn and colleagues suggest individuals may benefit from interpersonal approaches to understand and modify maladaptive interpersonal styles which may coincide with the negative emotional states that precede or accompany NSSI. Skills training is likely to be central and should focus on improving emotion regulation, problem-s╉ olving, interpersonal and commu- nication skills. In addition, treatment may need to focus on physical factors such as body image and physical self-âc•‰ are. Of particular importance is the need to address “social contagion” when working with groups (Washburn et al., 2012). It ought to be noted that some DBT skills training groups address this by expressly discouraging discussion of the types of self-âh•‰ arm behaviors participants engage in. Finally, “contracts for safety” or “no-âh•‰ arm agreements” can be either ineffective or harmful, and treatment should focus on contingency management and relapse prevention instead (Washburn et al., 2012). Conclusion NSSI is a behavior that typically begins during adolescence and adversely impacts on psychologi- cal health and well-âb•‰ eing. Frequency of NSSI during adolescence predicts its maintenance into

014 410 Adolescents who Engage in Nonsuicidal Self-injury (NSSI) adulthood, as well as increasing risk for suicide behavior. Consequently, prevention and early intervention addressing the behavior among adolescents is of critical importance. The general consensus is that NSSI is a behavior that functions to alleviate negative emo- tional states. While distal factors such as a genetic predisposition to emotional sensitivity and reactivity may interact with invalidating childhood environments to predispose individuals toward a vulnerability to engaging in NSSI, poor emotion regulation is likely to maintain the behavior. It is, therefore, unsurprising that interventions to address behaviors such as NSSI have focused on building individuals’ capacity for emotion regulation. While there are no spe- cific interventions that have been developed solely for NSSI among adolescents, the existing interventions for self-h╉ arm behaviors provide promising leads. Research findings on specific emotion regulation processes (e.g., cognitive reappraisal, expressive suppression, and rumi- nation) and how they may be implicated in increasing or decreasing the emotional arousal associated with NSSI provide further clues that can assist with developing better targeted interventions among adolescents. This is particularly important as the evidence for effective interventions for adolescents addressing self-h╉ arm behaviors such as NSSI remain inconclu- sive. Thus, replication and adaptations of existing intervention approaches accompanied by rigorous evaluation is therefore, warranted. References American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association. Andover, M. S., Pepper, C. M., & Gibb, B. E. (2007). Self-m╉ utilation and coping strategies in a college sample. Suicide & Life-T╉ hreatening Behaviour, 37, 238–2•‰â 43. Andrews, T., Martin, G., Hasking, P., & Page, A. (2013). Predictors of continuation and cessation of non-╉ suicidal self-╉injury. Journal of Adolescent Health, 53, 40–‰â4• 6. doi:10.1016/j╉ .jadohealth.2013.01.009 Andrews, T., Martin, G., Hasking, P., Page, A. (2014). Predictors of onset for non-s╉ uicidal self-âi•‰njury within a community-b╉ ased sample of adolescents. Prevention Science, 15, 850–8╉ 59. doi:10.1007/╉ s11121-•â‰013-â‰0• 412-‰â•8 Armey, M. F., & Crowther, J. H. (2008). A comparison of linear versus non-l╉inear models of aversive self-╉ awareness, dissociation, and non-s╉ uicidal self-âi•‰njury among young adults. Journal of Consulting and Clinical Psychology, 76, 9–•â1‰ 4. doi:10.1037/0‰•â 022-0‰•â 06X.76.1.9 Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-b╉ ased treatment versus structured clinical management for Borderline Personality Disorder. American Journal of Psychiatry, 166, 1355–1≕ 364. Bentley, K. H., Cassiello-R╉ obbins, C. F., Vittorio, L., Sauer-‰â•Zavala, S., & Barlow, D. H. (2015). The association between nonsuicidal self-âi•‰njury and the emotional disorders: A meta-a╉ nalytic review. Clinical Psychology Review, 37, 72–•â‰88. doi:10.1016/≕j.cpr.2015.02.006 Betts, J., Gullone, E., & Allen, J. S. (2009). An examination of emotion regulation, temperament, and parenting style as potential predictors of adolescent depression risk status: A correlational study. British Journal of Developmental Psychology, 27, 473–4╉ 85. doi:10.1348/•â0‰ 26151008X314900 Bjärehed, J., & Lundh, L. (2008). Deliberate self-âh•‰ arm in 14-ây•‰ ear-âo•‰ ld adolescents: How frequent is it, and how is it associated with psychopathology, relationship variables, and styles of emotional regulation? Cognitive Behaviour Therapy, 37, 26–•‰â37. Bjärehed, J., Wångby-L╉ undh, M., & Lundh, L. (2012). Nonsuicidal self-âi•‰njury in a community sample of adolescents: Subgroups, stability, and associations with psychological difficulties. Journal of Research on Adolescence, 22, 678–‰â6• 93. doi:10.1111/‰j•â .1532-â7•‰ 795.2012.00817.x Borrill, J., Fox, P., Flynn, M., & Roger, D. (2009). Students who self-âh•‰ arm: Coping style, rumination and alexithymia. Counselling Psychology Quarterly, 22, 361–3╉ 72.

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714 Part IV Epilogue

814

914 Chapter 20 Transdiagnostic Approaches to Emotion Regulation: Basic Mechanisms and Treatment Research Brian C. Chu, Junwen Chen, Christina Mele, Andrea Temkin, & Justine Xue Transdiagnostic approaches The broad construct of emotion regulation refers to multiple and diverse processes that individu- als use to modulate emotional experience and involves neuro-âa•‰ natomical, neuro-c╉ hemical, physi- ological, behavioral, cognitive, and interpersonal systems, among others (Gross, 1998). Systems are divided into multiple domains for greater specificity (e.g., the cognitive system can be under- stood across adaptive and maladaptive cognitive strategies; automatic and conscious processes), and domains can be separated further into sub-âd•‰ omains (e.g., automatic cognitive processes can be broken down into particular strategies, such as suppression, distraction, and cognitive avoid- ance). Each of these regulatory processes can be defined, assessed, and conceptualized along con- tinuous or (likely arbitrarily defined) discrete dimensions. These multiple regulatory systems and domains operate in close coordination, as activation of one system typically calls for response (either activation or inhibition) of other systems (Werner & Gross, 2010). As an example, behavioral problem solving (generating and weighing options; choosing and acting on decisions) calls for the activation of multiple cognitive, physiological, and behavioral systems. It is no surprise that such coordinated emotion regulation processes have been implicated in the onset, maintenance, and amelioration of nearly every psychological disor- der or problem set (Kring & Sloan, 2010). Such a complex and influential system deserves an epistemological approach that honors the inter-âd•‰ ependent nature of emotion regulatory systems. An explicit transdiagnostic research agenda recognizes this complexity and inter-r╉elatedness amongst systems and has the potential to optimize research efforts across pathology groups and regulatory systems. The modern-d╉ ay transdiagnostic research agenda emerged from two parallel efforts (Ehrenreich-M╉ ay & Chu, 2013; Mansell et al., 2009). First, pathology researchers were interested in explaining the tremendous co-o╉ ccurrence (comorbidity) amongst related disorders and increasing understanding of what mechanisms accounted for commonalities in presentation, impairment, and development across disorders. Until the turn of the millennium, clinical research was frequently conducted in the context of single-âd•‰ isorder research agendas. Efforts by experts across diverse fields of clinical psy- chology (Barlow, Allen, & Choate, 2004; Fairburn, Cooper, & Shafran, 2003; Harvey, Watkins, Mansell, & Shafran, 2004)  attempted to summarize converging lines of evidence generated in isolation of each other. Transdiagnostic work signaled a desire to identify and integrate these con- verging lines of research that helped explain the commonalities and distinctions across disorders and problem sets.

024 420 Transdiagnostic Approaches to Emotion Regulation A second aim of transdiagnostic research sought to economize and enhance the effects of evidence-​based treatments for psychological disorders. Most evidence-b​ased intervention research has produced treatment protocols designed to treat a single disorder, resulting in literally hundreds of distinct treatment protocols to treat individual problem areas (Chorpita & Daleidan, 2009), despite the fact that the majority of protocols were primarily comprised of a highly over- lapping set of clinical practices (e.g., in vivo exposure, problem solving). Thus, a second goal of transdiagnostic research has been to consolidate evidence-​based interventions into a more effi- cient set of empirically-s​ upported practices. It has also been hypothesized that treatments might gain robustness to the degree that common practices targeted core underlying mechanisms that maintained the diverse classes of pathology. A transdiagnostic framework might be particularly relevant for children and adolescents. The high rates of comorbidity (the co-o​ ccurrence of two or more disorders) seen in adult popula- tions are even higher in children and adolescents, where both within-​class (e.g., multiple anxi- ety diagnoses), and across-c​lass comorbidity (e.g., diagnosis of anxiety and conduct disorder) make comorbidity the rule rather than the exception (Angold, Costello, & Erkanli, 1999; Garber & Weersing, 2010). The field has become increasingly aware of the importance of dimensional conceptualizations of distress and multiple-d​ omain outcomes (functional impairment, symptom; Achenbach, 2005). Dimensional models are particularly relevant where great symptom overlap exists across disorders, as they do in youth, and where rapid development leads to transitory symptoms across developmental stages. In addition, multiple informants (e.g., youth, parent, teacher, doctor, coach) add complexity to any diagnostic picture that may be best accommodated by dimensional and multi-d​ omain models. A transdiagnostic approach may also help explain divergent trajectories and multifinality (the case where a single risk factor leads to the subsequent expression of different disorders), key con- cepts in developmental pathology (Nolen-​Hoeksema & Watkins, 2011). As one example, longitu- dinal evidence suggests that many, but not all, teens and young adults who develop depression first display evidence of anxiety earlier in life. Which teens and adults ultimately develop depression, which retain their anxiety disorders, and which show remission from anxiety? Transdiagnostic research encourages simultaneous evaluations of multiple processes (risk factors, mediators, moderators) across disorders. Such an approach permits unique understanding of the relative impact of multiple processes that lead to unifying and distinctive outcomes. As implied in its name, transdiagnostic research aims to identify or change mechanistic pro- cesses that unify related disorders and problem sets. However, it is critical to note that the bound- aries of each disorder class (e.g., anxiety disorders) and specific disorder (e.g., generalized anxiety disorder) are respected even as researchers aim to identify commonalities (Ehrenreich-M​ ay & Chu, 2013). It would be an error to mistake transdiagnostic research with prior attempts to “lump” all of diagnostic categories into a single or limited set of general personality traits or distress fac- tors (Taylor & Clark, 2009). Transdiagnostic research acknowledges that traditional diagnostic categories, represented by classification systems, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-​5; American Psychiatric Association, 2013), still retain helpful organiz- ing heuristics. After all, individual anxiety disorders still share many more commonalities with each other than they do with conduct or schizophrenic disorders. Thus, transdiagnostic research encourages unifying frameworks while retaining the knowledge we have gained from the science of diagnosis. This framework is consistent with initiatives to identify the dimensional neurobiological under- pinnings of psychological disorders. The recently initiated National Institute for Mental Health’s (NIMH) Research Domain Criteria (RDoC) project (NIMH, 2011) aims to bring mental health research in line with other areas of medicine that base diagnostic systems on underlying biology

124 CROSS-S​ ECTIONAL RESEARCH WITH ADULTS 421 and not just clinical presentations of symptoms (Insel, 2013). RDoC emphasizes underlying bio- logical and behavioral mechanisms as the root units of understanding pathology. In this way, transdiagnostic research can provide a bridge between traditional classification-âo•‰ riented research and tomorrow’s dimensional, mechanism-âo•‰ riented conceptualization of emotional distress. The current chapter reviews the state of emotion regulation research from a transdiagnostic framework. The first half of the review focuses on experimental, survey, and neurobiological research that explores etiological and maintenance roles of emotion regulation across disorders. The second half of our review evaluates transdiagnostic psychological interventions that incor- porated emotion regulation techniques or assessed emotion regulation processes as outcomes. By taking a transdiagnostic approach to our review, we hoped to demonstrate how investigations that take a multi-d╉ isorder approach can help the field understand more about both the underlying process and the organizing disorders of multiple problems in a unifying framework. Experimental, survey, and neurobiological designs To complete a review of basic research on transdiagnostic emotion regulation processes, includ- ing cross-âs•‰ ectional and longitudinal designs, we identified empirical studies that (1) included par- ticipant samples identified with two or more diagnostic or problem-a╉ reas, and (2) assessed any emotional regulation process and evaluated that process across disorders. The goal of this review was to evaluate the strengths and weaknesses of the extant literature, to reflect on the current knowledge base of the emotion regulation processes that unify or distinguish diverse disorders, and to offer recommendations for future directions in transdiagnostic research. Studies that recruited children, adolescent, or adult samples were included in this review because of limited available research focused on emotion regulation across multiple disorders. Types of methodology included cross-s╉ ectional, longitudinal, clinical trial, and neuro-âb•‰ iological (e.g., imaging) studies. We focus our review on evaluating the approach used to define and com- pare disparate disorder groups, the assessment tools implemented, and the clarity of results in establishing common and unique emotion processes that affect pathology. Cross-s╉ ectional research with adults Most adult research involving multiple disorder classes or symptom profiles has taken advan- tage of cross-âs•‰ectional research designs. Table 20.1 details study design, participants, measures, and results for cross-s╉ ectional research. Most of this research has shown heterogeneity across the types of emotion regulation strategies examined. Cognitive emotion regulation strategies (e.g., rumination, reappraisal, worry) have been defined as cognitive responses to emotionally provok- ing events in which an individual attempts to modulate his/âh•‰ er emotional reaction (e.g., Aldao & Nolen-H╉ oeksema, 2010, Campbell-âS•‰ ills & Barlow, 2007). The literature has also labeled cer- tain emotion regulation strategies as “adaptive” or “maladaptive” based on their function across contexts. Adaptive emotion regulation strategies (e.g., acceptance, reappraisal, problem-s╉ olving) are defined as strategies that are negatively correlated with psychopathology severity. Conversely, maladaptive strategies (e.g., rumination, suppression) have been associated with the contribution to and maintenance of disorders (e.g., Aldao & Nolen-âH•‰ oeksema, 2010; Conklin et al., 2015). Cognitive emotion regulation strategies have been examined as a key mechanistic process across internalizing disorders. Aldao and Nolen-H╉ oeksema (2010) examined four cognitive emotion regulation strategies (rumination, thought suppression, reappraisal, and problem-s╉ olving) across two internalizing disorders (anxiety and depression) and a non-i╉nternalizing disorder (eating dis- orders) among 252 undergraduate students. The strategies were also categorized as either adaptive (reappraisal, problem-s╉ olving) or maladaptive (suppression, rumination [including brooding and

Table 20.1  Adult cross-s​ ectional Citation Sample Characteristics and ER Measures ER compone Design were assess Aldao & Nolen-​ COPE (Problem-​Solving Hoeksema (2010) N = 252; Undergraduate subscale), ERQ, RRS, Rumination, students with symptoms of WBSI suppression, depression, anxiety, and eating problem-​solv disorders Conklin et al., N = 81; Clinical trial patients Brief COPE Maladaptive (2015) with comorbid alcohol use adaptive stra and anxiety disorders: GAD DERS, ERQ, FFMQ, Desrosiers et al. (67.9%), social phobia PSWQ, RRS Rumination, (2013) (50.6%), panic disorder (9.9%) worry, and n Vine & Aldao N = 187; Mood and Anxiety Emotional cl (2014) Disorder Clinic patients, ages 17–8​ 1, with GAD (42.9%), Rumination, Gruber et al. MDD (20.1%), or social phobia negative aut (2008) (12.2%) N = 211; Undergraduate ATTC, DERS students, ages 18–​32, with seven symptom types: anhedonic depression, anxious arousal, social anxiety, borderline personality, binge eating, restrictive eating, and alcohol use. N = 60; Adults with euthymic CCL, GRS, PSWQ bipolar disorder (n = 21), insomnia (n = 19), and non-​ clinical control (n = 20)

24 ents (all that Processes found to be Processes found to be sed) universal disorder specific , thought None , reappraisal, and Rumination, suppression, and ving reappraisal were significantly Not analyzed related to anhedonic e strategies and depression (.44), anxious ategies arousal (.24), and eating disorders symptoms (.15) Not analyzed , reappraisal, Simple mediation Reappraisal linked to nonacceptance model: Rumination linked depression; Worry linked to to anxiety and depression; anxiety larity Multiple medation model: Rumination linked to Specific indirect , worry, and depression pathways: anhedonic tomatic thoughts depression and shifting Emotional clarity deficits attention; social anxiety and linked to anhedonic acceptance and strategies; depression, social anxiety, borderline personality borderline personality, binge symptoms and shifting and eating, and substance abuse strategies; alcohol use and symptoms impulse BP and INS significantly linked None to rumination and worry; finding not significant when analysis controlled for anxiety and depressive symptoms

Brockmeyer et al. N = 140; Women, ages 18-​ ER self-​report: DERS Experience a (2012) 65, with MDD (41), anorexia of emotions nervosa (39), healthy controls CBCL, CEMS, EESC, and modula Queen & (60) ERQ-​CA, PANAS Ehreneich-M​ ay Cognitive re (2014) N = 76; Youth, ages 12–1​ 8, emotion sup with comorbid anxiety and emotional a depression (57.9%) or a expressive re primary anxiety disorder emotional in (42.1%) affect, nega Garnefski et al. N = 271; Youth, ages 12–​18, CERQ Self and oth (2005) with Internalizing symptoms rumination, (8.9%), Externalizing putting into symptoms (8.9%), Comorbid positive refo internalizing and externalizing reappraisal, symptoms (4.8%), “No planning problems” (38%) Table Abbreviations ER self-​report: Attentional Control Scale = ATTC, Brief COPE, Child Behavior Checklist = CBCL, Childr Children’s Response Styles Questionnaire = CRSQ-​Rumination, Children’s Sadness Management Scale = COPE, Difficulties in Emotion Regulation Scale = DERS, Emotion Expression Scale for Children = EESC, E and Adolescents = ERQ-​CA, The Five Facet Mindfulness Questionnaire = FFMQ, Global Rumination Sca Schedule = PANAS, Penn State Worry Questionnaire = PSWQ, Ruminative Response Scale = RRS, White Symptom self-r​ eport: Anxiety Sensitivity Index = ASI, Bech-​Rafaelsen Mania Scale = BRMS, Beck Anxi Fear of Negative Evaluation = BFNE, Children’s Depression Inventory = CDI, Children’s Eating Attitudes Depression Anxiety and Stress Scale = DASS, The Eating Disorders Attitude Test = EAT-​26, Eating Disord V, Hamilton Anxiety Rating Scale = HAM-​A, Hamilton Rating Scale for Depression = HRSD, Inventory of Measure = LIM, McLean Screening Instrument for Borderline Personality Disorder = MSI-​BPD, Mood an form = MASQ-​SF, Obsessive Compulsive Drinking Scale = OCDS, Overall Anxiety Severity and Impairme Anxiety and Depression Scales = RCADS/​RCADS-​Parent version, Revised Peer Experiences Questionnair Interaction Anxiety Scale = SIAS, State-T​ rait Anxiety Inventory = STAI, Youth Self-​Report = YSR Semi-s​ tructured interviews: Anxiety Disorders Interview Schedule = ADIS-​IV, Anxiety Disorders Interv Schedule for Children = DISC, Duke Structural Interview for Sleep Disorders = DSISD, Insomnia Diagnos FMRI and Physiological Measures: High Frequency heart rate variability = HRV-H​ F, Functional Magne BioHarness[TM] device = wireless physiological monitoring system