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MASTER THESIS

Emotion Regulation in Childhood Anxiety Disorders

Student: Dragan (Drasko) Radovancevic

Mentor: Prof. Dr. Julian Schmitz

Summer term 2016/2017

Leipzig, Germany

Table of Content

I Anxiety Disorders – a General Introduction 4

II Theoretical Background 7
1.1 Anxiety disorders in children and adolescents 7
1.2 Risk Factors and Etiology 9
2. EMOTIONS AND EMOTION REGULATION 12
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2.1 Concept of emotions 12

2.2 Modal Model of Emotions 13
2.3 Process Model of Emotion Regulation 16
2.4 Socialization of Emotions: Teaching Mechanisms 19
Emotion regulation development 20
III Emotion Regulation in Children with Anxiety Disorders 22
3.1 Process Model of emotion regulation (Gross) in relation to anxiety disorders/symptoms 22
3.1 Role of ER in anxiety disorders 25
3.2 Empirical evidences 27
3.3 Psychosocial Consequences of AD 30
III Methods 32
3.1 Recruiting and Sample Description 32
3.2 Diagnostic Instruments 36
Kinder-Dips 36
3.1.2 Questionnaires 37
Emotion regulation Questionnaire (FEEL-KJ) 39
Habitual and situation-related Emotion Regulation 40
Ecological Momentary Assessment 40
Interview Guide for Acquisition of the situative ER 41
Data Analysis 43
IV Results 46
Hypothesis and Research Questions 47
Emotion Regulation Effectivity 62
ER Efficiency – Group comparison (HC, SP, AS) 64
V General Discussion 68
Discussion of the findings 68
STRENGTHS AND LIMITATIONS 74
IMPLICATIONS FOR THE RESEARCH AND THE CLINICAL PRAXIS 79
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I Anxiety Disorders – a General Introduction

Authors distinguish normal from pathological fear. Anxiety as a short-term, contemporary state is a
natural reaction to distressing events. It may be beneficial in many ways as a biological mechanism
that helps survival and by facilitating appropriate defensive responses and therewith reducing
danger or injury (e.g., escape and avoidance) ( Rosen, J. B., & Schulkin, J., 1998 ). Some fears are mild
and occur only contemporary, or simply as a part during some developmental phase. Such fears do
not demand any treatment and usually die down after child approaches into another developmental
phase. If fears exceed certain limits in intensity and duration, or if person experiences difficulty to
control them, along with the impairments in everyday functioning, then we regard them as disorder.
(Tina In-Albon, 2011)

Pathological anxiety is not just a temporary worry, or fear. The symptoms of anxiety often do not go
away and may even worsen over time. (Tina In-Albon, 2011)

Familial aggregation of certain mental disorders, including anxiety disorders, which implies the
risk that children of mentally ill parents get ill themselves, is a well-known phenomenon. However,
precise aetiological factors underlying it are not fully clear. Many studies, long-term and cross-
sectional, examined the nature of patterns and dysfunctional mechanisms within the families. The
analysis of genetic and environmental risk factors shed more light on the possible sociobiological
determinants.

● Prevalence, lifetime course and comorbidity of anxiety disorders

According to a comprehensive literature material, anxiety disorders are among the most prevalent
mental disorders in childhood and according to some authors they are at the top among all of mental
disorders in childhood (Costello, E. J., Mustillo, S., Erkanli, A., Keeler, G., & Angold, A. (2003; Merikangas, K. R.,

He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., & Swendsen, J. (2010 ). A review done in Germany
by Ihle and Esser (2002) estimates six months to lifetime median prevalence for anxiety disorders in
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German children as high as 10,4%, (counting only those who meet clinical criteria for mental
disorder). Most of existing studies that they analysed consent that 10% of children and adolescents
meet clinical criteria for anxiety disorders.

In many studies, anxiety disorders were present in range from 8 to 12% of children (Anderson et al.,
1987; Costello, 1989, Ihle & Esser, 2002). Lifetime prevalence of anxiety disorders in German
adolescents (12-17 years old) was estimated to be as high as 18,6% (Essau, Conradt & Petermann,
2000). Prevalence rise in higher age, affecting females more than males ( Essau, C. A., Conradt, J., &
Petermann, F., 2000).

Many others mental disorders are comorbid with anxiety disorders, among which the highest
rate exists between them and depression and other anxiety disorders (Schmidt-Traub & Lex,
2005; Seligman & Ollendick, 1998). Brady and Kendall (1992) estimate comorbidity range from
16% up to 62%. Renneberg, Heidenreich und Noyon (2009) estimate varies from 20 to 80%.
There are different explanations for their co-occurrence (Wittchen, Beesdo, Bittner & Goodwin,
2003). Possible common aetiological factors are genetics, or socialisation (Wittchen, Kessler,
Pfister & Lieb, 2000). Another possibility is that the presence of one disorder facilitate the
chance of the other (Groen & Petermann, 2011). Wittchen et al., 2000 hypothesize possible
causal relation between those two. Brady & Kendall, (1992) found that depression precedes
anxiety.

Epidemiological studies exhibit great variability in the prevalence rates estimation. These values
vary, depending on that, which criterion for mental illness researchers chose (i.e. the presence of
clinical impairment, or not), on the chosen procedure for data recording, as well as on that,
according to which diagnostic classification system a diagnosis was made (In-Albon, 2011).

Anxiety disorder may occur at any age, but they mostly develop between childhood and young
adulthood. Less than 1% of people develop an anxiety disorder for the first time after the age of 65
years. (Wolitzky‐Taylor, K. B., Castriotta, N., Lenze, E. J., Stanley, M. A., & Craske, M. G., 2010 )
Prevalence of different anxiety disorders varies substantially across the lifespan. The most common
anxiety disorder in preschool age is separation anxiety disorder (Cartwright-Hatton, S., McNicol,
K., & Doubleday, E. (2006; Costello, E. J., Egger, H., & Angold, A. (2005).; Pine, D. S., Cohen, P.,
Gurley, D., Brook, J., & Ma, Y. (1998). Panic disorder, present in less than 1% of the children, has
the lowest prevalence (Pine et al., 1998; Reed & Wittchen, 1998). The prevalence of social phobia
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and generalized anxiety disorder rises in adolescence (Fergusson, D. M., Horwood, L. J., &
Lynskey, M. T. (1993) ; Verhulst, F. C., & Van Der Ende, J. A. N. (1997).

Half of mental disorders in adulthood start very early, at 14 years of age (Kim-Cohen, J., Caspi, A.,
Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R., 2003; Kessler, R. C., Chiu, W. T.,
Demler, O., & Walters, E. E. (2005a). According to those studies, specific phobia and separation
anxiety have lowest median ages of onset (7 years) Kessler, R. C., Berglund, P., Demler, O., Jin, R.,
Merikangas, K. R. & Walters, E. E. (2005b).

Separation anxiety is normal in young children, until the age of 3–4 years ( Bagnell AL, 2011). According
to Kessler et al. (2005b) median age of onset for social phobia is 13 years, and for other anxiety
disorders between 19 and 31.

https://www.ncbi.nlm.nih.gov/books/NBK262334/

There is a consistent order in the appearance of fears during life. While young children mostly
experience fear of animals, darkness, fear of school and death , in some higher ages predominant
fears are social anxieties and fears related to their health (Ollendick, Matson & Helsen, 1985). Many of
those fears are transient in their nature, occurring as a part of developmental phases and dissolute
spontaneously. Sometimes they represent only normal reaction to the environmental challenges. But
even as a contemporary state within a developmental phases, if they persist for longer period of time and
impair children´s functioning in school and their social and emotional adaptation, these fears should be
regarded as a disorder. Authors also claim that shyness and social phobia may be qualitatively
different, and not only to vary in degree. (Beidel & Turner, 2007).

Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003) suggest that most adult
disorders should be regarded as extensions of juvenile disorders. Their study showed that over half
of individuals suffering from some mental illness at 26 years of age, received a diagnosis before 18
and even three quarters had a first diagnosis before 18. Some of disorders had homotypical
trajectory (eg, juvenile anxiety develops into adult anxiety), others heterotypical with non-
specific precedents.
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Some studies report stable course of mental disorders during life, from the childhood until the old
age (Essau, Conradt & Petermann, 2002; for review Weems, 2008). Ihle and Esser (2002) found that
almost half of the emotional disorders at 13 years of age are still present at the age of 18 and
continues that way into the higher age of 25 (Ihle, Esser, Schmidt & Blanz, 2002). Nevertheless,
finding are inconsistent. Another study delivered completely different conclusion (Züricher
Längsschnittstudie, Angst & Vollrath, 1991), which reports stabile course of the illness in only 4%
of individuals with generalized anxiety disorder and panic disorder during 15 years. Another study
(Merikangas, K. R., Avenevoli, S., Acharyya, S., Zhang, H., & Angst, J. (2002) indicated that none of the
participants had continual social phobia during the whole examination period in a 15-year prospective
longitudinal community study.

In the study Early Developmental Stages of Psychopathology Study follow up research found after
two-years only 19,7% of the initially present anxiety disorders still present (Wittchen, Lieb, Pfister
& Schuster, 2000). Among them panic disorder with 44% and specific phobia with 30,1% exerted
the highest stability. Agoraphobia with 13,4% and social phobia with 15,8% were disorders with the
least stable course of onset.

Some other researches show that anxiety disorders are often a precursor of many other mental
disorders, like affective disorders, substance abuse or somatoform disorders ( Brückl, T. M., Wittchen, H.
U., Höfler, M., Pfister, H., Schneider, S., & Lieb, R. (2007); Woodward & Fergusson, 2001).

Ihle and Esser (2002), Bittner et al., 2007; Woodward & Ferguson, 2001 provided evidences that
phobic and social anxiety disorders exert the highest diagnostic stability and homotypic continuity
across all ages.

In Laucht and Schmidt (1987) longitudinal study, three quarters of the children with emotional and
neurotic problems reported similar mental problems three years after the first examination . Anxiety
disorders are precursor to other anxiety disorders, to affective disorders and substance addiction
(Brückl et al., 2007; Woodward & Ferguson, 2001). Some Anxiety disorders have specific course,
like specific and social phobias in the childhood, which predict occurrence of the same disorders in
the adolescence. Separation anxiety is an indicator for panic disorder in the future. GAS has rather
unspecific course, being a predictor for various other mental disorders (Copeland et al., 2009;
Moffitt et al., 2007; Kaplow et al., 2001).
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Most of the studies on emotion regulation in anxious children examined the relationship between
emotional dysregulation on one side and disorder with separation anxiety, generalized anxiety disorder,
specific phobias and social phobias on the other (Suveg & Zeman, 2004; Tan et al. 2012). In the next
paragraph, we are now going to delineate closer these disorders.

II Theoretical Background

1.1 Anxiety disorders in children and adolescents

In separation anxiety disorder, separation from home or from trusted carer, major attachment person to
whom an individual has strong emotional attachment represents a feared situation. Child is afraid of an
unexpected event that could separate it from the loved ones. These worries may lead to resistance of
going to school, avoiding to sleep alone, or outside own home and to the behaviours like demanding
from their parents a detailed timeline of their daily activities. Otherwise child may experience intense
emotional disturbances along with physical symptoms like stomach aches and vomiting, as well as
nightmares. In infants and small children separation anxiety is a normal part of their development.
Contrary to that, in SAD fear and distress overreach the line, making fears a hindering factor for child
development, leading to intense worries - from anticipatory uneasiness to full-blown anxiety. Stability of
SAD is quite high. In about 46% of children this disorder lasts for over eight years ( Keller, M. B., Lavori,
P. W., Wunder, J., Beardslee, W. R., Schwartz, C. E., & Roth, J. (1992). ). This disorder is one of general risk
factors and one of the best non-specific predictors of many other mental disorders in the future (Kessler
et al., 2005).
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Specific phobia denotes intense fear or anxiety in relation to specific objects or situations (present, or
anticipated). It is a long lasting state and the fear is experienced in intense way, so that it compels person
to avoid the object or situation that causes fear. According to the types of feared stimuli, we recognize
five subtypes of phobia: animal, natural (thunder, storm), situational (airplane, closed space), blood-
injection-injury subtype and others. People usually develop more than the fear of one stimulus only
(APA, 2013). An individual avoids feared object or situation that causes fear, or endures them with
intense distress and anxiety.

Social anxiety disorder (in DSM-IV known as social phobia) involves fear in social interactions and
concerns about being embarrassed, scrutinized by others or being judged as boring and stupid. Fearing
social rejection causes excessive self-consciousness and uneasiness that goes beyond common shyness.
Common age of onset is 13 years of age (APA, 2013), but children in earlier stages may also suffer
from it. Clinical criteria for young children is that the fear arises in interaction with their peers also,
and not only with adults. Physical symptoms may involve intense sweating, blushing, trembling,
heart palpitations and nausea, along with stammering, or rapid speech. We recognize two types of
social anxiety disorder: performance type (like speaking in public, ordering in restaurants etc.) and
interactional, which includes social situations, even when a person is not in the spotlight.

Generalized anxiety disorder is a state in which a person experiences excessive, uncontrollable

irrational worry, often imagining the worst case scenario. Common feared topics include work,
family, health or money. In children, those topics are often school performance and sport activities,
punctuality and natural catastrophes. Important criteria for diagnosing GAD are that child’s anxiety
is beyond its control and that it is related to a number of different activities, that it causes significant
distress or impairment, and is present “for more days than not” for at least 6 months. In children
with GAD, these worries occur very often and in intensive way, causing significant impairments.

1.2 Risk Factors and Aetiology

Some authors achieved to explain by 30-40% of genetics influence in anxiety disorders ( Kendler, K.
S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992). ; Boer, F., Lindhout, I., Silverman, W. K., &
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Treffers, P. D. A. (2001).). Twin studies confirmed at least a small role of genetics and failed to find any
significant role of common environment. It is likely that anxiety is an outcome of interplay between
specific environment and genetic predisposition (Barlow, 2002; Gregory & Eley, 2007).

Precise mechanism of phenotype-genotype interaction remained unclear. Some authors (Rapee,

2001) analyzed the role of personality traits like trait-anxiety, neuroticism (positive/negative affect),
behavioural inhibition (see below) and higher arousal level and emotionality. Rapee assumes that
those traits, determined by genes themselves, mediate phenotype-genotype interaction. Their
presence determines whether psychopathological symptoms will occur and in which way.

Some evidences suggest that the same genetic risk factors may express themselves bidirectionally,
underlying both development of depression and of generalized anxiety disorder. Which of those two
disorders would develop, depends on environmental factors (Rapee, 2001).

Behavioral inhibition is another inherited dispositional characteristic, described as child´s

consistent tendency to react with fear and withdrawal in novel situations (Kagan, Reznick, Clarke,
Snidman & Garcia-Coll, 1984). Its presence (in about 15% of children) expresses itself as a
tendency to feel shame and anxiety, or to react with withdrawal (Kagan, Reznik & Snidman, 1988).
Previous studies already proven the association between behavioural inhibition and the
development of social phobia and panic disorders (Rosenbaum, Biederman, Hirshfeld, Bolduc &
Chaloff, 1991; for the critical reading s. Neal & Edelmann, 2003).

Besides individual characteristics, many researches deal with the interaction between individuals’
initial vulnerability and stress exposure. Vulnerability denotes likelihood to develop a disorder after
being affected by distressing life events. The level of vulnerability is different for each person. The
factors that determine initial vulnerability may be intraindividual (like genes, biological features,
temperament, pre- and perinatal factors, as well as early childhood experience) and interindividual,
related to our environment (cultural and societal factors, socio-economic status, or education, as
well as social and familial networks). Vulnerability-stress hypothesis assumes that social phobia
originates from a combination of biological, psychological and social factors, through the interplay
between our biological predisposition and the exposure to life stressors.
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Classical two-factor theory, proposed by Mowrer (1951), is a conceptual model which explains the
development of phobia and explain how they maintain their presence. It combines principles of
classical conditioning and operant learning. Starting point in aetiology is coupling between a
neutral stimulus and fear reaction, which takes place through their spatial and/or temporal
association. After an anxious response to a stimulus was already developed, person tries to avoid
feared object/situation in future, as a coping strategy for prevention of existing anxious reaction. In
that way, person misses to confront itself with feared stimuli. Therewith a positive experience that
would dispute conditionally learned false harmfulness of the stimulus, cannot be experienced. This
mechanism in return strengthens anxiety disorder by (negative) operational reinforcement.

The cognitive model of anxiety disorders assumes that selective processing of external and internal
information plays a role in development of anxiety disorders (review by Alfano et al., 2002;
Daleiden & Vasey, 1997; Hadwin, J. A., Garner, M., & Perez-Olivas, G. (2006). ), Through biased processing
towards threatening stimuli, person believes that some information may predict the onset of
potentially uncontrollable and unpredictable danger. Children with AD highly interpret different
stimuli as dangerous and pay attention to them more than healthy children (Barrett, Rapee, Dadds &
Ryan, 1996; Higa & Daleiden, 2008). Attentional bias (vigilance-avoidance pattern) was
experimentally examined in children suffering from separation anxiety (In-Albon, Schneider; 2012),
in which the participants were presented two sorts of visual stimuli: separating photos (threat
pictures for AD children) and reuniting photos. Opposite to the control group, AD group showed
attentional bias towards threat pictures.

Anxiety sensitivity

Anxiety sensitivity is a personal belief that anxiety-related symptoms (such as a pounding heart,
breathlessness and nausea) lead to harmful consequences, which go beyond present physical
symptoms during anxious feeling and leave permanent negative consequences. Therefore person
believes that anxious experience must be avoided (Reiss and McNally, 1986). Up to now, the
correlation was found between anxiety sensitivity on one side and panic attacks, separation anxiety
and agoraphobia on the other, but not with other anxiety disorders (Federer M, Margraf J,
Schneider S., 2000; Schneider & Hensdiek, 2003).
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2. EMOTIONS AND EMOTION REGULATION

2.1 Concept of emotions

One of the basic scientific assumptions is, that all living species must solve fundamental adaptation
problems in order to survive (see Plutchik, 1980). For that purpose, they developed mechanisms
that provide nourishment, reproduction, and protection from threat (Lazarus, 1991). Emotions too
are one of those mechanisms, which arise in person-environment interaction as a response to the
harm or benefit aspects of the situation (e.g., Arnold, 1960; Lazarus, 1991). Individual’s antecedent
motivational and belief variables determine how a person performs in relation to environmental
demands, constraints, and resources in a particular situation. Different emotional reactions initiate
different action tendencies.

Authors assume that reflexes (like patellar) and physiological drives (like hunger, or thirst) are an
evolutionary precursor of the emotions, whereas prior have more limited degrees of freedom in
response to environmental demands and therefore are simpler and more rigid adaptation systems
(Ellsworth & Smith, 1988a, 1988b). Common denominator of these three mechanisms is that they
all stimulate organism in direction of survival and flourish (Lazarus, 1991).

2.2 Modal Model of Emotions

Gross adopted some of Lazarus ideas as fundamental assumptions for his Modal Model of
Emotions. According to the first assumption of this model, emotions arise when person attends to a
situation that is relevant for the person’s goals and by that holds some meaning for it (Lazarus,
1991). If the personal goals and meaning change in the course of time, its emotional reaction to the
situation also changes.
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Emotions are embodied and comprise conjoined changes in several domains. Our subjective
experience, behavior, and peripheral physiology are all involved in emotional response (Mauss, I. B.,
Levenson, R. W., McCarter, L., Wilhelm, F. H., & Gross, J. J. (2005) . In everyday life we often use the words
“feeling” and “emotion” interchangeably, referring by that to the experiential aspect of emotions.
Nevertheless, physiological and conative component of emotions are unavoidable part of emotional
experience. Sometimes our conscious experience of emotion and other two aspects of them may
contradict each other (e.g., Bonanno, Keltner, Holen, & Horowitz, 1995). Conative component of
emotions stimulates us to take action (e.g., to express our opinion, to laugh etc.), what we otherwise
would be less likely to do (Frijda, 1986). This second feature, multimodality, is relevant for the
Gross model of emotions.

Based on William James work (1884), emotions were described as malleable, susceptible to the
modulation. Given that our reactions comprise many other aspects besides emotional, we are not
simply led by them. Emotions may take control over the situation and our awareness in one moment
(Frijda, 1988), but there is still a space for their regulation. In some occasions we try to intensify
our emotional reaction (like showing happiness on the party), in others to down-regulate emotion
intensity (by intense anger, for example), so that our behavior meets cultural demands and standards
(Gross & Levenson, 1997), or even to suppress them in order to maintain our well-being (Gross &
Levenson, 1997). Malleability of emotion opens the space for emotion regulation and is the third
crucial assumption of the Gross model.

Modal-model of emotions (Gross and

Thompson, 2007), conceptualize arising
of emotions as a stepwise process. The
starting point in the sequential process of
emotion generation is a psychologically
relevant situation (real or imagined), usually an external stimuli, that initiate the whole process. In
the second step, we deploy our attention to the different aspects of the situation. That redirection of
attention within a given situation to any aspect of the emotion eliciting stimuli determines how we
observe the present situation and modulate ongoing process.

How we apprise the situation in the third step, depends on that, how we perceived the situation
previously. In this step, we may focus on situation itself, by assessing its familiarity, its valence and
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its relevance in our value system (Ellsworth & Scherer, 2003), and we may think about our capacity
to deal with the challenge we are faced with. This process in the third step influences the emotional
significance of the situation.

Our emotional response as a final act comprises experiential, behavioral and physiological
responses. Our reaction to the situation changes the situation itself, so we may say that the Modal
Model of Emotions comprise a feedback loop. Regarding this, the emotion generation is recursive,
ongoing, and dynamic process (Gross, J. J. & Thompson, R. A., 2007)

Emotion regulation modify the magnitude and/or type of emotional experience or the emotion-
eliciting event (Diamond & Aspinwall, 2003; Gross, 1998). According to Gross, by ER we
influence which emotions we experience, when we experience them, and how we experience and
express them.

Authors hold the assumption that none of emotion regulation strategies is necessarily good, or bad.
In contrast to stress coping strategies, in which we predefined defense mechanisms as maladaptive
and coping as adaptive (Parker & Endler, 1996), we claim that ER processes may be used to make
things either better or worse depending on the context in which they take place.

In some cases, suppression of negative emotions may be adaptive, like when parent feels no disgust
while cleaning baby’s excrements. But the same ER strategy may be very negative if, for instance,
we neutralize empathic emotions and distress when someone suffers.

ER may be conscious, like turning off a horror movie as an upsetting material if we experience
intense fear watching it. But ER may also be unconscious, like tending to hide our fear during job
interview, or our disappointment by the novelties about the job that we found out during the
interview.

According to the most of the authors, emotion regulation and emotion generation are two distinctive
processes (Diamond & Aspinwall, 2003; Gross, 1998). Some authors, nevertheless, hold the
opposite position, claiming that we speak of one and the same process (see Campos, Frankel, &
Camras, 2004).
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From the neurological perspective, authors distinct between subcortical emotion generators and
cortical control systems, in which each of them is in charge for different processes. But in the
appraisal zone of emotion generation, certain overlapping brain circuits act together, so that emotion
generation and emotion regulation are no longer clearly distinguishable (James J. Gross, Lisa
Feldman Barrett, 2011).

Emotions may be regulated intrinsically (regulation in self) and extrinsically (like when the parent
regulates the emotions of its child; regulation in other). Intrinsic regulation is in focus of adult
researches and extrinsic more in the developmental literature (Gross & Thompson, 2007). If a
parent regulates his/her child emotion (extrinsically), as to calm down his-/herself, then those two
processes are interrelated. Especially in the first years of life, child depends on the extrinsic
measures of emotion regulation. In the course of life, children acquire capability for self-regulation
(Kulik & Petermann, 2012). Generally speaking, ER aims to fulfill individual and social demands in
a socially acceptable way (Cole & al., 1994). Koole (2009) made a list of the functions of emotion
regulation. They comprise hedonic needs, supporting specific goal pursuits, and facilitating the
global personality system. ER can be executed consciously and under our control, or may happen
unconsciously and automatic (Barnow, 2012). Gross argues nevertheless about a continuum
between conscious and unconscious regulation, rather than poles (Gross, 1999).

2.3 Process Model of Emotion Regulation

Based upon the modal model of emotion generative process, the process model operationalize how
each of these four steps is involved in emotion regulation. Different emotion regulation processes
have the primary impact in different phases of emotion generative process.
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Researchers have defined five families of those processes: situation selection, situation
modification, attentional deployment, cognitive change, and response modulation. The first four
families may be seen as antecedent-focused, because they precede emotional response tendencies.
Response-focused emotion regulation take place after the responses are generated (Gross & Munoz,
1995).

We try to choose such situations that will bring us desirable emotional state, based upon our
prediction, which emotions we expect to experience in them. Nevertheless, our bounded rationality
has limited capacities for predictions and often comes across many hindrances.

Biases in our memory are one of them. Authors described difference in “experiencing self” and
“remembering self” (Kahneman, 2000), implying that the real-time and retrospective ratings of our
emotional experience often differ. Due to this discrepancy, our emotional experience and later
remembrance of it are often not reliable source for inferring our future feelings. Another problem is
that our short-term emotional goals (such as avoiding unpleasant feelings) are not always beneficial
for our long-term well-being. Such case we see in anxiety disorders, in which a person tends to
escape from the feared situation, preventing habituation to the feared stimuli.

We may actively try to influence and to change some situation, or some aspects of is. This is the
process called situation modification. We may attempt to modify external environment, or
alternatively our inner cognitive experience (using cognitive restructuring). By both of them, we
change emotional impact that the situation makes upon us. We may illustrate this by example in
child-parent interaction, when parent assists its child in its activities. By that „external action“,
parent restructures the situation. But parents’ emotional reaction to events may itself change
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emotional impact of the situation too. The same applies to any social situation, when individuals
impact each other by different reactions (Keltner & Kring, 1998).

We may alter the emotional impact of the situation, by diverting our attention from some aspects of
situation and deploying it to others. By that we perceive the external reality in a (partly) selective
way. From developmental perspective, this strategy is the earliest one that child develops and uses
as to modulate its emotional experience (Rothbart, Ziaie, & O’Boyle, 1992). Alternatively, we may
modulate internal focus of our emotional experience and concentrate ourselves on some isolated
aspect of it. If we repetitively and passively focus ourselves on our inner states after encountering
an emotional distress, resembling how unfavorable event influenced us and analyzing possible
causes and consequences of the symptoms that broke out, then we speak of rumination. Rumination
leads to a circulus vitiosus by keeping us fixated on the problems and depriving us from taking
action (Just & Alloy, 1997: Nolen-Hocksema, 1993). Authors examined how rumination may lead
to the development of the depression. Its impact was proved, even when statistically controlled for
neuroticism, pessimism, perfectionism, and several other negative cognitive styles (Flett et al.,
2002; Nolen-Hoeksema et al., 1994; Spasojevic & Alloy, 2001).
Finally, even after we experience emotionally relevant situation (in the first step) and attend to it (in
the second step), the emotion still does not have to arise. Experienced and attended situation must
be permeated by some meaning that we ascribe to it, as to produce certain emotional response. How
we apprise the situation determines which emotion we will experience in it (Scherer, Schorr, &
Johnstone, 2001). Cognitive change, the fourth process in the chain of emotion generation, may
include one or more of these appraisals that impact how we observe the situation itself, or how we
estimate ourselves and evaluate our capacities in that situation (Gross & Thompson, 2007).

2.4 Socialization of Emotions: Teaching Mechanisms

Learning process of expressing and regulating emotions takes place in social environment. Different
socializing strategies and parenting styles result in a different emotional development and emotional
awareness in children.
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If agents of socialization tend to speak about emotions and do that in a warm and empathic manner,
whole process will result in adaptive acquisition of those necessary skills, fostering children to react
onto emotional arousals and to express emotions spontaneously (Denham & Auerbach, 1995).
Conversation is an important agent in parental emotional scaffolding (Bretherton et al., 1986;
Brown & Dunn, 1992). Talking about emotions opens the possibility for the child to evaluate the
feelings and to reflect upon them outside the situation when those feelings were present. This makes
more space to reexamine possible causes of emotions and their consequences (Denham, Cook, &
Zoller, 1992; Denham & Grout, 1992; Eisenberg, N., Cumberland, A., & Spinrad, T. L. (1998). ; Gottman, J. M.,
Katz, L. F., & Hooven, C. (1997).; Zahn-Waxler, Radke-Yarrow, & King, 1979). Agents of socialization
may clarify emotions. They may teach and share their emotional experiences with child in the
process of emotion socialization. Such parenting style is distinctive from that of trying to change
child, or to criticize. Child´s emotional life develops different in those two cases (Denham &
Grout, 1992; Eisenberg et al., 1998).

Mothers’ emotion language determines preschoolers’ emotion knowledge independently from the
child's language abilities. There is high correlation between the time that mother invests in
emotional teaching during first years of life and the level of emotional understanding (Brown &
Dunn, 1996; Denham, Zoller & Couchoud, 1994), as well as their moral sensitivity in their children
too (Dunn, Brown & Maguire, 1995). The impact of emotion talk related to empathy, or describing
of parents own emotions, what caused them and what were the consequences of certain emotional
experience, showed to be an important tool for children and useful for emotional learning ( Blair, K.
A., Denham, S. A., Kochanoff, A., & Whipple, B. (2004). ; Garner, Jones, Gaddy, & Rennie, 1997). Children
coming from emotion-oriented family climate are more empathic with their peers (Denham &
Grout, 1992; Denham, Renwick-DeBardi et al., 1994; Denham, Zoller et al., 1994).

Dunn (1994) examined nonparental adults’ emotion coaching and how form and quality of the
emotional experience, and not only the content of emotional learning, influences child. It was also
found that in very early age, teachers frequently use physical stimuli to reinforce children negative
emotions and some years later, in preschool age, they rely more on verbal explanations (Ahn, 2005).
Verbal messages are more directed towards explanations of the causes of negative emotions. They
instruct how should children express such emotions. The same study showed that teachers of older
children often do not encourage expression of positive emotions, or even do not recognize them.
 18

Concerning negative emotions, teachers are not willing to validate them and verbally encourage
children to express positive emotions.

Emotion regulation development

Children emotional life has to be regulated from the very birth. As they grow up, children gain
increasing control over variety of emotional experiences, like frustration tolerance, anxiety
management and dealing with the people from their environment (Cole, P. M., Michel, M. K., &
Teti, L. O. D. (1994). That development accompanies neurobiological maturation and development
of cognitive abilities, like the control of attentional processes (Kulik & Petermann, 2012).

Extrinsic control processes, coordinated by attachment figure for long time, undergo transformation
with the time, becoming self-regulated, i.e. intrinsic (Friedlmeier, 1999). Thompson & Meyer
(2007) emphasized the importance of social processes that shape the growth of emotion regulation.
Among others, those are modell-learning, socialisation, gender roles and cultural expression forms.
(Cole et al., 1994’; Thompson & Meyer, 2007).

Toddlers are predominantly regulated extrinsically by attachment figure, their verbal consolation, or
distraction (Friedlmeier, 1999). Over the first years of life, their capacity to self-control emotions
grows. Until the school age, children develop certain repertoire of ER strategies, like eye gaze
diversion, physical acting out, vocalisation or avoidance (Kullik & Petermann, 2012), as well as
cognitive strategies like self-distraction and refocusing attention in emotional situations. During
school adolescents become more independent and flexible in emotion regulation . They use
suppression of emotional expression more intense. Among cognitive strategies, they develop
positive thinking and, if necessary, can seek for social regulators, asking for help from parents or
peers (Kullik & Petermann, 2012).

With increasing independence and regulation stability, emotion regulation style becomes persistent,
long-lasting management strategy. Negative emotional styles become chronic themselves in that
period too. (Cole et al., 1994). Child diverts from caregivers towards autonomous individual
regulation. Prerequisite for that is rise of cognitive capacities - increasingly complex information-
processing and differentiated problem analysis. Besides that, mental disorders, like depression,
 19

eating disorders and substance abuse increase in that developmental period too (Zimmermann,
1999).

III Emotion Regulation in Children with

Anxiety Disorders
Emotion regulation and psychopathology in general

Emotion regulation as everyday activity takes place in social environment. It consists of situational
requirements and personal dealing with emotions. Dealing with emotions may exhibit a
dysfunctional pattern, causing impairments in level of functioning and to lead into psychopathology,
or to be the symptom of it (Cole et al., 1994).

Gross (1999) defined ER as the attempts to influence which emotions we

have, when we have them or how these emotions are experienced or expressed.

Thompson (1994) expanded the definition by asserting that it is as extrinsic and intrinsic
monitoring, evaluation and modifying of emotional reactions which a person uses in order to
accomplish its goals. At the same time, he assumes that ER is one of the central developmental
tasks in young age, pointing out the consequences it has on socio-emotional functioning and mental
health (Bradley, 2003; Cicchetti, Ackerman & Izard, 1995; Eisenberg, Cumberland & Spinrad,
1998). Gross & Munoz (1995) claimed core role for the ER in mental illness. Difficulties in
emotion regulation are interconnected with many mental disorders (Berking & Whitley, 2014;
Gross, 1998b; Gross & Munoz, 1995). Diagnostic criteria of the most mental disorders in DSM-5
 20

contain lower ability for effective emotion regulation (APA, 2013; Barnow, 2012). Disorder
nonspecific examples for this are improper or reduced affect, chronic tension, mood swings or
persisting negative emotions (Cole et al., 1994). Therefore, improvement in emotion regulation is
an important goal of psychotherapy, both in children and adults (Cole et al., 1994).

If a person´s capacity for emotional self-regulation is lacking or the skills are dysfunctional, then we
speak of emotional dysregulation (Cole, Michel & Teti, 1994). This dysfunctioning relates to the
range of emotions a person experiences, flexible modulation of emotion intensity, their duration,
and transitions between them. Emotional events are being experienced chronically in a
dysfunctional way and such reactivity becomes trait-like aspect of personality (Malatesta & Wilson,
1988).

In their meta-analysis, Aldao et al. (2010) explored correlation between emotion regulation
impairments and symptoms of anxiety, depression, eating disorders and substance abuse. Altogether
114 studies with children and adults were analyzed. It was shown that internalized disorders
correlate higher with emotion dysregulation, than externalized. All disorders correlate positively
with strategies avoidance, suppression and rumination and negatively with reappraisal and problem
solving. Specifically for disorders: depression and anxiety are higher correlated with emotion
dysregulation than eating and substance abuse disorders.

Most of mental illness are characterized by certain deficits in emotion regulation (Bradley, 2003;
Cole et al., 1994). Over half of the non-substance related Axis I disorders and all of the Axis II
personality disorders co-occur with some form of emotional dysregulation (Gross & Levenson,
1997). Cole et al. (1994) showed the role which play both absence of downregulation of the
negative emotions, as well as lack in fostering of positive emotions.
 21

Zeman, Cassano, Perry-Parrish & Stegall (2006) showed how children with internalizing and
externalizing disorders exhibit different types of ER deficits. Compared with children without any
disorders, children with depression, anxiety, or bulimia nervosa (internalized disorders) mostly
show poor emotional awareness. They are less self-effective in their ability to regulate their
emotions. The most difficulties they encounter in expressing the anger and coping with it, as well as
expressing their sadness appropriately.

Intensive feeling of fear and anxiety is the core of anxiety disorders. The emotional response to real
or perceived imminent threat is named fear, and anticipation of future threat is called anxiety (APA,
2013). They arise in confrontation with the feared stimuli (real, or anticipated). A maladaptive
network of constraints to regulate negative emotional arousal is a special challenge for anxious
children (Thompson, 2001), whose interpretative biases, emotional construals, internal encoding
procedures and attentional processes are rigid. In some children their temperamental disposition
makes them additionally more vulnerable, so that their physiological threshold is lower, making
them prone for negative arousal.

ER incompetence to downregulate negative emotions and maladaptive attempts to regulate them

leads to emotion amplification, uncontrollability and chronification, which may result in anxiety
and mood disorders. (Campbell-Sills & Barlow, 2007, Gross & John 2003, Linehan 1993, Mennin
et al. 2005). From inability of attentional redeployment may develop negativity bias (Vasey &
Macleod, 2001). Using suppression and avoidance as usual strategies for downregulation also leads
to mental problems (Gross 1998, Hayes et al. 1996), and avoidance of feared situations leads to
unsuccessful management of arousal and inability to lower anxiety levels (Jacob, Thomassin,
Morelen & Suveg, 2011). Barlow (1988) noticed that the common core of each anxiety disorder is a
tendency to experience intense emotions. Taking those emotions as unwanted and threatening,
person makes efforts to avoid them or to diminish their intensity (Barlow, 1988, 2002). In the
aetiological model of pathogenesis and maintenance of anxiety disorders too, emotional
dysregulation plays the central role (Vasey & Dadds, 2001; Kulik & Petermann, 2012).

3.1 Emotion regulation (Gross) in relation to anxiety disorders/symptoms

 22

Many available evidences suggest that anxiety disorders and emotion regulation, difficulties are
strongly interconnected, in the way that in emotional regulatory impairment intensive negative
emotions may not be effectively reduced, or terminated (Mohr & Schneider, 2013).

Suveg and Zeman (2004) examined emotion regulation in children age 8 to 13 by comparing two
groups of: children suffering from separation anxiety, generalized anxiety disorder or specific
phobia (4th ed., American Psychiatric Association, 1994) with healthy peers. Both children and
their mothers filled in the questionnaires. They found that children with AD show more
dysregulated expression of worry, sadness and anger in comparison to healthy children, and
predominance of less constructive ways of managing their negative emotions, presumably due to
higher intensity of experienced emotions and the lack of confidence in their ability to regulate this
arousal. Faced with negative emotions, they reacted aggressive (such as, telling nasty things to other
people) and were less able to divert their attention and to calm down themselves.

Authors hypothesized that children with AD regularly suppress their emotions, what also their
healthy peers do, but they overdo that, until they start to “bottle up”. These findings converge with
maternal reports, who described their children with AD as more negative and labile than their
healthy peers are. Children with AD are both less flexible in emotion regulation and perform
narrower repertoire of emotion regulation strategies. It remained unclear which strategy exactly and
in which way impair children with AD.

That question was examined in Carthy, Horesh, Apter and Gross (2010) partly qualitative study
was. Their working hypothesis was, that the children with AD have difficulties in the ER because
they experience negative emotions more often and with higher intensity than the healthy peers.
Children were asked, what would they do to calm down themselves in difficult situations. Their
results show that children with AD use avoidance, suppression or seeking for help, rather than to
reappraise or to use problem-solving tactiques. The discussion suggests that in the presence of
intense and dysregulated negative emotions, AD children are not able to deploy reappraisal strategy
 23

due to its too high cognitive demands. After AD children were trained and instructed to use
reappraisal during experiment, anxious and non-anxious participants achieved similar decrements in
levels of negative emotions, although AD were still showing lower ability to reappraise. Reappraisal
showed to be adaptive strategies in the both groups.

Carthy, Horesh, Apter, Edge et al. (2010) assumed that AD children experience difficulties in
emotion regulation, because negative emotions occur more often and in more intensive way by
them. Participants were presented a set of images with the disturbing scenes, both anxious and non-
anxious children (10 to 17 years old). Afterwards they reported the level of emotional reactvity and
the usage of reappraisal in everyday situations. Results showed higher levels of reactivity in AD
children. Afterwards experimenters carried out a training for both AD and non-anxious group, in
which the concept of reappraisal was introduced and practiced. Children were asked to reappraise
once again and to rated the negative impact of the pictures for the second time. According to self-
report, AD children showed again higher reactivity, weaker cognitive regulation ability and
experienced more difficulties in applying newly acquired reappraisal strategy.

The focus in Lagerstee et al. (2010) and Carthy, Horesh, Apter, Edge und Gross (2010) studies were
cognitive strategies. Lagerstee et al. (2010) report that AD children scored less on positive
reappraisal and refocus on planning in comparison to their non-anxious peers. They also got higher
score on catastrophizing and rumination.

Tan et al. (2012) used Ecological Momentary Assessment (EMA) with higher ecological validity
for capturing data in real-time for five days in 14 phone-calls. In their sample (9 to 13 years old)
they found higher levels of average past-hour peak intensity of nervous, sad and upset emotions in
AD children than in control group, but similar levels during momentary reports of current emotion.
That means that AD children experience higher levels of reactivity in response to challenging
events, but do not differ from NAD in momentary negative emotions. They found that AD and non-
AD children do not significantly differ in usage of emotion regulation strategies after negative
events - contrary to previous studies (Carthy, Horesh, Apter, Edge et al., 2010; Carthy, Horesh,
Apter & Gross, 2010; Legerstee et al., 2010; Suveg & Zeman, 2004). The difference between the
groups was in their effectivity of strategy-deployment. Both maladaptive (avoidance and
rumination) and adaptive family of strategies (acceptance and reappraisal) were less effective in AD
children when applied to downregulate negative emotional states. In both AD and NAD group
 24

reappraisal and problem solving strategies showed as effective to reduce negative emotions.
Rumination had more detrimental effects on AD children and reappraisal showed as effective only
in non-anxious children.

Analyzing children at risk, who live in difficult families, Thompson & Calkins (1996) found that
emotion regulation may simultaneously foster both resiliency and vulnerability. Their anticipation
of fearful situations provide benefits in the short run, functioning as buffer against stress (like
avoiding a depressed parent), but in long-term perspective it makes them vulnerable to other risks
and demands, leading to development of psychopathology (Thompson & Calkins 1996).

All these studies provide support for the key argument that the children with anxiety disorders
regularly show difficulties in the emotion regulation, but they do not enable us to finally determine
is it the ER that is dysfunctional (less effective) in AD children, or is that the unfavorable selection
of the strategy that these children deploy. Besides that, most of these studies were carried out
retrospectively, by post-hoc questioning, or in the experimental environment. Only few of them had
higher ecological validity (Bylsma & Rottenberg, 2011; Tan et al., 2012) and that is one of their
main limitations.

3.1 Role of ER in anxiety disorders

3.2 Emotion Dysregulation - Etiology (Empirical evidences)

Reviewers notice that emotion regulation gained increased attention in the research field. It gave
new insights into anxiety disorders and possibilities for their explanation (Campbell-Sills, Ellard &
Barlow, 2013; Cisler, Olatunji, Feldner & Forsyth, 2010). There are significant linkages between
ER deficits and anxiety disorders (see Aldao, Nolen-Hoeksema & Schweizer, 2010; Amstadter,
2008). Aldao´s et al. (2010) meta-analytic study showed positive correlation between the presence
of anxiety disorders and usage of certain ER-strategies (avoidance, rumination and suppression)
 25

and, contrary to that, the negative association between them and reappraisal and problem-oriented
strategies.

Questioning the underlying mechanism responsible for higher anxiety, Cisler et al. (2010) different
cognitive styles and listed three forms of attentional biases that may give rise to it. Those are
facilitated attention directed towards threat detection (a highly automatic process); difficulty in
disengagement (mixture of automatic and strategic processing) presumably based on attentional
control; and attentional avoidance (a mostly strategic process) presumably based on the emotion
regulation goals.

Legerstee et al. (2009) examined three groups of anxiety-disordered children that received a
standardized stepped-care CBT. Along similar line, they found a significant association between
treatment success and selective attention tendency, so that the success in anxiety treatment leads to
less pronounced attention biases. CBT may be less successful if child attends to severe threat and
may not turn its attention away from it.

By this time there are less such kind of examinations in children, which prompts further research in
that area (Carthy, Horesh, Apter, Edge & Gross, 2010; Hughes, Gullone, Dudley & Tonge, 2010).
Drawing on Hannesdottir, D. K., & Ollendick, T. H. (2007) review, we know that children's emotion
regulation follows socialization process and consequently reflects dynamic interplay between parenting style,
parents emotion regulation and emotion regulation in children. Numerable analyzed studies confirmed that
anxiety disorders and emotional dysregulation go together.

Starting from the Lewis, Stanger, & Sullivan´s (1989) finding that children can “hide” their
emotion by changing their facial expression, which is the ability they gain at the age of 3,
Southam-Gerow, M. A., & Kendall, P. C. (2002) examined the difference between healthy and anxious
children aged seven to fourteen years (with at least one diagnosed anxiety disorder). Compared with
healthy youth, anxious children perform poorer understanding of hiding emotions (emotional “know
how”). Besides that, although change in emotions and emotion expressions become increasingly
controllable with maturation, anxious children performed lower efficacy in both of those two
abilities.

Further research in this area included examination of emotion socialization practices in families of
children who met criteria for AD diagnosis and of healthy children. In one experimental study,
 26

children and both of their parents had 5 minutes each to discuss occasions when the child felt
anxious, angry, and happy. Gathered data show that fathers of AD children used less problem
oriented cognitive and behavioural strategy, like explanatory discussion of emotion overall and
exhibited less positive and more negative affect, than those of NAD children. AD children also used
more maladaptive strategies, like avoidance and aggressive behaviour. (Suveg, Cynthia; Sood,
Erica; Barmish, Andrea; Tiwari, Shilpee; Hudson, Jennifer L.; Kendall, Philip C., 2008).

*********************** prebaciti *******************

Hughes et al. (2010) compared commonly used ER-strategies in two groups of children and
adolescents (10 to 14 years old): one clinical group of school refusal children, who met criteria for
at least one anxiety disorder and another age- and sex-matched nonclinical sample, in regard to
reappraisal and suppression. Their data show that anxious children use less reappraisal and more
suppression strategy than NAD children. Carthy, T., Horesh, N., Apter, A., Edge, M. D. & Gross, J.
J. (2010) examined abnormalities in emotional reactivity and regulation (reappraisal ability, its
efficacy and frequency) in sample with primary diagnosis of generalized anxiety disorder, social
anxiety, or separation anxiety disorder, comparing them to the nonclinical participants. AD children
experienced greater negative emotional responses during experiment and were less successful at
applying reappraisals. Nevertheless, being instructed to use reappraisal as the regulation strategy,
they showed intact ability to downregulate negative emotions, although - according to their self-
report - they do that less frequently in everyday life. They also showed greater reactivity than NAD
children.

Esbjørn, B. H., Bender, P. K., Reinholdt-Dunne, M. L., Munck, L. A. & Ollendick´s, T. H. findings
(2012) indicate that children and adolescents with AD exhibit the emotion regulation difficulties in
the same areas like anxious adults, namely in emotional awareness and the strategies they use for
dealing with emotions, along with attentional and cognitive biases. --------------------- family
influence

The main limitation of all mentioned studies is their cross-sectional design, which does not allow
final conclusions about causal directionality between ER and anxiety disorders (Amstadter, A.,
 27

2008; Kullik & Petermann, 2012). Folk, J. B., Zeman, J. L., Poon, J. A. & Dallaire´s longitudinal
study (2014) showed that emotion dysregulation was a robust predictor of psychopathology,
including anxiety disorders (McLaughlin et al., 2011). It is now clear that difficulties in emotion
regulation play an important role in many mental disorders. Nevertheless, from a general overview
of present research field, we may conclude that few studies have been published on systematical
categorization of ER-strategies in AD children (Carthy, Horesh, Apter & Gross, 2010). Furthermore
emotional dysregulation in specific anxiety disorders in childhood and adolescence is still less
known (Mathews, Kerns & Ciesla, 2014).

3.3 Psychosocial Consequences of AD

Children who meet criteria for anxiety disorders report many debilitating effects accompanied to
those psychopathological states, affecting their functioning at home and in school, somatic distress,
depression, low self-esteem, and substance abuse.

lifetime course

Considering high stability of these disorders (homo- and heteroform), as we already

mentioned, these impairments have chronical negative effects on children's
adjustment (Birmaher et al., 1994). In their longitudinal study, three quarters of the
children with emotional and neurotic problems reported similar mental problems
three years after the first examination (Laucht and Schmidt, 1987). AD precedes
other anxiety disorders, affective disorders and substance addiction (Brückl et al.,
2007; Woodward & Ferguson, 2001). Some AD have specific course, like Specific
and social phobias in the childhood, which predict occurrence of the same disorders
in the adolescence. Separation anxiety is an indicator for the future panic disorder.
GAS has rather unspecific course, being a predictor for various other mental
disorders in the future (Copeland et al., 2009; Moffitt et al., 2007; Kaplow et al.,
2001). ___________ jos

As Wittchen et al. (1998) examined, simple phobia, generalized anxiety disorder, and panic disorder
cause severe impairment, especially during their hardest episodes. AD reflect on school and school-
 28

related social activities (Kessler et al., 1994; Last et al., 1992). According to Benjamin et al. (1990),
teachers reported that children with AD exhibit impairments in both of those areas. Their parents
reports were not in accordance with the teacher's assessment. Another study (Bowen, Offord, &
Boyle 1990, Messer & Beidel 1994 and Strauss et al. 1988) showed that anxious children
experience problems in their peer relationships (McGee et al., 1990 failed to replicate this finding)
and tend to assess themselves as less self-competent. Association of anxiety symptoms and low
achievement in reading and in mathematics was found in two different studies (Ialongo, Edelsohn,
Wertharmer-Larson, Crockett, & Kellam 1994 and Ialongo, Edelsohn, Wertharmer-Larson,
Crockett, & Kellam 1995). Especially the children with social phobia tend to leave school
prematurely (Van Ameringen et al., 2003; Durchesne et al., 2008) and anxious children in general
tend to experience truancy.

In Khan et al. (2002) study AD participants showed higher risk of suicide. A longitudinal study,
pursued by Boden et al. (2007) showed significant association between AD and suicide risk, as well
as suicide attempt in the course of 25 years. Camparini Righini et al. (2005) failed to replicate these
findings on the clinical sample.

Besides that, AD are highly comorbid. One third of the children who received treatment for their
AD in the study by Last, Hansen, and Franco (1997) experienced at least one other psychiatric
disorder. Low rates of appropriate medical care in these cases makes the situation more
complicated. 76% of anxious participants in the study by Keller et al. (1992) did not receive any
treatment and in Essau, C. A., Conradt, J., & Petermann, F. (2000). study, that rate was only slightly
better.
 29

III Methods

3.1 Recruiting and Sample Description

The project Kinderängste (Child Anxiety) included the children aged from 10 to 13 years. They
were clearly categorizable into one of the three groups of interest (SP, AS, HC). Inclusion criteria
for SP-group was the presence of social phobia as a primary diagnosis. For AS-group, that was the
presence of the separation anxiety, specific phobia or GAS. Comorbid mental disorders were
allowed in both of the clinical groups. For all included children, there had to be participation
consent from both parent side, as well as their own consent. In the nonclinical group, the exclusion
criteria was the absence of any mental disorder in the moment of data acquisition, or rather absence
of any chronic mental disorder. For all children there was a prerequisite that they never visited any
psychotherapy, never participated in any of the studies at the Institute for Psychology with the
similar content, as well as no presence of major depression, or dysthymic disorder, no autistic
disorder, no risk of suicide, and the minimal intelligence prerequisite was IQ as high as 80. Children
with mental disability were also excluded, as well as those with any chronic neurological disease,
color-blindness or medication that could produce any changed psychopathological parameter (like
taking Risperdal, or Ritalin).

The recruiting process took place at the schools on the area of the city of Freiburg and surroundings,
in the paediatric praxis and psychiatrists, as well as at psychotherapy praxis for children and
adolescents and the Freiburger Ausbildungsinstitut für Kinder und Jugendpsychotherapie Fakip, an
institution affiliated to the Institute for Psychology. PR activities and appearances on media helped
winning the new potential participants. Those who reached us in this way, used e-mail, or phone
contact with our responsible project personnel and therewith appointed their first visit to the
institute.
 30

For the exploration of the questions posed in this thesis, both groups SP and AS were merged into
one group labeled as “children with anxiety disorders” and as such compared to the control group
with no AD.

TABLE 2

Recruitment procedures for our study involved phone pre-screening with potential participants.
Screening data were collected to find out if the person meets basic eligibility requirements
presented below. Besides that, diagnostic analysis was used in order to classify participants into
corresponding groups.

We first reached one of the parents (usually mother) who was informed about the study content and
the main study goals. Central diagnostic criteria were investigated by that occasion. If the exclusion
criteria were already met by that, the participation was not possible. Upon request, we provided
information to the interested party on where to find the psychological counseling, or psychotherapy.

If the participants met the criteria for participation and the interest for the participation still existed,
the research material was sent to the family by the e-mail, which they processed on-line by the
software Unipark (unipark.de). The children filled the Sozialphobie- und Angstinventar für Kinder
(SPAIK; Melfsen, Florin & Warnke, 2001) and Phobiefragebogen für Kinder und Jugendliche
(PHOKI; Döpfner, Schnabel, Goletz & Ollendick, 2006). One of the parents filled the
Elternfragebogen über das Verhalten von Kindern und Jugendlichen (CBCL/4-18; Arbeitsgruppe
Deutsche Child Behavior Checklist, 1998). The questionnaires-data were processed and the
information from the telephone-screening were analysed in our team. If afterwards there were still
no criteria for exclusion, children and their parents were invited for a diagnostic appointment by the
phone to come to the Institute for Psychology of the University of Freiburg.

By that appointment, both children and their parents separately passed the interview Diagnostische
Interview bei psychischen Störungen im Kindes- und Jugendalter (Kinder-DIPS; Schneider,
 31

Unnewehr & Margraf, 2009). The interview was conducted by the trained personnel, which passed
the training for interview-implementation and evaluation. In order to provide satisfied quality, the
interviews with parents were voice recorded and the interviews with children were recorded in
video-form. If necessary, one psychologist experienced in implementing Kinder-DIPS was regularly
at disposal.

Following up the diagnostic interview, children and parents were answering another questionnaires,
either at the Institute for Psychology, or via Unipark online from their homes. Children filled-in
Social Anxiety Scale for Children - Revised - Deutsch (SASC-R-D; Melfsen & Florin, 1997),
Fragebogen zur Erhebung der ER bei Kindern und Jugendlichen (FEEL-KJ; Grob&Smolenski,
2005) and Depressionsinventar für Kinder und Jugendliche (DIKJ; Stiensmeier-Pelster, Schürmann
& Duda, 2000). One of the parents filled Brief Symptom Inventory - Deutsche Version (BSI;
Franke, 2000), the Fragebogen zur Erhebung der ER bei Erwachsenen (FEEL-E; Grob & Horowitz,
2014), the Fragebogen zur Sozialen Kommunikation - Autismus Screening (FSK; Bölte & Poustka,
2006) and the Elternversion der deutschen Fassung des SASC-R (Schreier & Heinrichs, 2008).

The results from the Kinder-DIPS and the questionnaires were presented and analyzed within the
weekly meetings by Ms. Keil. If these analysis made it possible to classify children in one of the
three study-groups, we additionally pursued eye tracking analysis in the first following meeting.
Afterwards the participants took part in the second study (EMA) and finally the appointment for the
third (EEG) study was made. At the end of the final meeting, debriefing with the children and their
parents took place, whereby the clinical groups by request ought to get detailed diagnostic
informations and were informed about the proper treatment possibilities in the affiliated care
facility. Besides that, as the thank-you for participating, children got voucher in the drugstore
“Müller” worth 70 Euro and their parents 30 Euro in cash.
 32

Study Design
Introduction Date Telephone interview Completion Date

Day 1 Day 2 Day 3

Instructions, conducting the T1 T3 T5 Return of the mobile phone,
interview, giving the mobile between 1PM and 3PM debriefing session
phone, appointment
T2 T4 T6
between 1PM and 6PM

ca. 30 minutes Each 5-10 minutes ca. 15 minutes

Table 1

3.2 Diagnostic Instruments

General Diagnostic

Kinder-Dips

Kinder-Dips (Schneider et al., 2009) was designed to provide data record of the symptoms for the
core disorder categories present in the DSM-IV used in the clinical praxis: anxiety disorders,
affective disorders, conduct disorders and eating disorders in children and adolescents aged 6 to 18.
There are children and parents version of the interview, ought to be implemented independently.
The interview is divided into the overview-part which compounds the screening of the background
problems in recent times, the special part for collecting data about specific mental disorders and the
third part, meant for psychiatric and familial anamnesis of mental disorders. It takes in average 60
to 90 minutes for the interview execution.
 33

The questions from the special part of the interview lean on the diagnosis criteria in the DSM-IV
and ICD-10 (Dilling, Mombour & Schmidt, 2006). The symptoms are being rated based on their
intensity and the frequency of occurrence. Making diagnosis is based separately on parents and
children interview. Subsequently, stand on these symptoms, one complex/composed diagnosis can
be made. In cases of mismatched diagnostic report between parents and children, more weight
should be given to behavior-oriented symptoms from the parents’ assessment, than to those related
to the children inner states. Retest reliability of the Kinder-Dips for the independent interviewers is
as high as over 87% for the child version and at least 89% for the parents’ version. The inter-rater
reliability of the particular category of disorders exhibit the rate from 92% to 100%.

3.1.2 Questionnaires

Anxiety. In this paragraph we briefly described the two Questionnaires relevant for anxiety data
acquisition, SPAIK and PHOKI, on which the group comparison was based. For making diagnosis
we used two additional Questionnaires, SASC-R-D and the CBCL/4-18.

SPAIK (Melfsen et al., 2001) is a questionnaire used to diagnose clinically relevant social anxiety in
children and adolescents, 8 to 16 years of age, based on the DSM-IV and ICD-10 criteria for mental
disorders. Children are asked to assess the frequency of fears that appear in interaction and in
performance situations, as well as to estimate their somatic and cognitive symptoms of social
phobia based on 26 items with 3-step rating scales. Total sum value is used for the evaluation.
Maximal possible score is 52 and minimal 0. In the standardization sample SPAIK exhibited high
intern consistency, as high as 0,92 and reliably differentiate between social anxious children and
those with other disorders. In the sample we have, intern consistency was also very high with the
value of 0,96.

The evaluation may be conducted emotional-specific, or generally. By summing up the values on the 5-
grades scale by the columns, i.e. 14 item-values for each emotion, we get the emotion-specific row values for
adaptive strategies. By summing up the values of 10 items of maladaptive strategies, we get the sum value
for them. Those raw values may be transformed into corresponding percent-ranks and T-values by consulting
the norm tables.
 34

The questionnaire PHOKI (Döpfner et al., 2006) acquisite the phobic fears in children and
adolescents aged 8 to 18. Iz contains 96 items with the 3step scale for assesing the frewuency of
each of the situations from the item. As the result, we get a total score, but also the scores for each f
the sub-scales: separation anxiety, fear from death, social fear, fear of unknown and threatening, fear
from animal, fear from medical interventions, school and school-performance fear. The value of the
intern consistency was between α = .72 to α = .89 between the sub-scales. In this study, Cronbachs
Alpha for the intern consistency was between α = .61 and α = .87.

Depression. Depressionsinventar für Kinder und Jugendliche (DIKJ; Stiensmeier-Pelster et al., 2000) is a
self-assesment questionnaire based on English version of Children’s Depression Inventory (CDI, Kovacs,
1985). It is used to asses depressive symptomatic in children and adolescents, ages 8 to 16, in the past two
weeks. It questions the main sympthoms based on DSM-IV classification of mental illness (on emotional,
cognitive and somatic level). It contains 26 questions along with the 3-steps scale. According to the manual,
a score from 18 is already striking. It takes 10 to 15 minutes for filling-in. Cronbah´s alpha measure for
Reability is fairly high (.91) in a clinical sample. In a healthy sample it varied from .82 to .85. Construct
validity was proven through the high correlation with the related constructs.Children from out sample filled-
in this questionnaire after Kinder-DIPS. Crombach alpha was about .74 and threwith under the values from
the norm sample, but still satisfying. DIKJ was used for separation of the children into two categories: those
with strong and weak depression.

Emotion regulation Questionnaire (FEEL-KJ)

The construction of the FEEL-KJ is based upon the classical test theory. The intern consistency for each of
15 ER-strategies may be seen as satisfying (Cronbachs Alpha from .69 and .91). The emotion-specific scales,
each consisting of only two items, exhibit significantly lower values. For anxiety that value is between .37 up
to .86. For both of the secondary scales those values were satisfying, ranging from .82 up to .93 for emotion-
nonspecific and between .59 and .88 for emotion specific values. The analysis run on our sample delivered
the value of intern consistency for adaptive strategies as high as .84 and for maladaptive .62. Retest
reliability over six weeks for 15 emotion independent strategies ranges between .62 and .81, and by that was
satisfying. Emotion-specific values were somewhat lower (under .50 for the emotion anxiety for four
strategies). For the secondary scale the retest reliability was .73 for adaptive and .81 for maladaptive
strategies. By that, they are to be seen as satisfying.
 35

Relative low intercorrelation between the strategies-scale and secondary-scale testifies in favour of
independence between those sub-scales and by that exhibits their discriminant validity. Emotion-specific-
strategies scale and secondary-scales exhibit moderate to high intercorrelation (average value for 15
strategies .44 for anxiety and anger, .51 for sadness and anger and .53 for sadness and anxiety) justify both
emotion-specific and emotion-independent analysis and interpretation (Grob & Smolenski, 2005).
Exploratory factor analysis confirmed the factor structure of the two secondary scales. By comparing
calibration sample and validation sample (among them clinical apparent sample of children and adolescents,
as well as those with chronic disease). Among all differences, the differences between maladaptive strategies
are the most prominent. Between the values of depression and well-being there are the highest correlations,
which testify in favour of criterion-validity. There are also evidences that FEEL-KJ is sensitive for the
changes in children in their preferably used ER-strategies (Grob & Smolenski, 2005).

The standardisation was made on the sample of 780 children and adolescents with no evidenced disorders,
aged 10 to 19 attending different school-types, the classes from 3rd to 12th. There are specific norms in the
form of percent-range, T-values and T-values bands for 15 strategies for both emotion-specific and emotion-
indeprendent scales of adaptive and maladaptive strategies. FEEL-KJ questionnaire is mostly used in the
developmental and clinical diagnostic. It indicates not only the developmental pathology in ER (i.e.
inappropriate regulation of negative emotions) but also tells us about the resources and the psychosocial
competences.

Habitual and situation-related Emotion Regulation

Ecological Momentary Assessment

Emotions are normally elicit in social context and as such they should should be assessed as well, providing
by that ecological validity of gained research data. Ecological Momentary Assessment (EMA) is one of the
strategies that make it possible. It represents a variety of methods for repeated real-time data acquisition
about person´s behaviour and experiences in the natural life environment (Shiffman, Stone and Hufford,
2008). For that purpose self-reports from diaries are used, palmtop-computers, or mobile phones, as well as
the ambulance measuring of physiological parameters (Bylsma & Rottenberg, 2011).

Given that data acquisition under such circumstances takes place soon after the event happened, memory-
induced biases ware reduced to a minimal level (Shiffman et al., 2008). Contrary to the laboratory-research,
EMA-assessment is based on the situation-related emotional-regulation and therewith it takes into account
 36

the situational context, providing higher ecological validity (Silk et al., 2011). Emotional reactivity and
regulation were already successfully examined in the clinical (Silk et al., 2011; Tan et al., 2012) and non-
clinical setting (Silk et al., 2003).

In our research situation-related ER were assessed by the telephone interview. Children were called by the
mobile phone while they were in their natural every-day environment at a given time and asked to report
about their recently experience. Besides its ecological validity, this procedure has the advantage, that the
data-acquisition is good integrated into the children every-day activities and does not require additional
support from the parents (Hilbert, Rief, Tuschen-Caffier, de Zwaan & Czaja, 2009).

Interview Guide for Acquisition of the situative ER

In our study, we assessed situational-related ER in anxiety-laden context. For that purpose, we constructed
and applied our own interview guide. In the following text, we will closely depict these guides.

At the beginning the child was asked to assess its own current mental state on the scale rating from 0 (very
bad mood) to 10 (very good mood). Afterwards children were asked if they experienced one or more
situations on that day, in which they were observed, or estimated from others, or if they experienced the
presence of unknown people (children, or adults), which they do not know well. These two types of
questions follow APA (2013) criteria for social phobia. Besides that, the child was asked if it avoided one of
those types of the situation. For each of the explored situations the interviewer gives the examples, like
giving a presentation, doing hobby-activities as a part of a performance situation, going shopping with the
unknown adults, or group activities with unknown children for an unknown person. Furthermore, we asked
how many of such situations were encountered. After asking for such situations, we choose the most recent
oney, as to minimize the memory bias effect.

As to inquire the situational context closely, the first four questions from the first part of Post Event
Processing Record were posed (PEPR; Lundh & Sperling, 2002). By that we got to know what exactly
happened in that situation, when and where it took place and who was involved in it. The chosen social
situations were classified analogy to the expended version of the Post EVent Processing Questionnaire
(PEPR; Rachman, Grü- ter-Andrew & Shafran, 2000), the PEPQ-R-D by Fehm, Hoyer, Schneider,
Lindemann und Klusmann (2008), that allows the classification into the categories “Presentation in front of
the class”, “Conversation with / Being criticizes by peers”, or “Speaking to a unknown person”. After
exploring the situational context, children were asked the questions that we formulated on our own, and to
estimate, how much anxiety they experienced in each of tjhose situation on the scale from 0 (not at all) to 10
 37

(very strong), how annoied they were, how unpleasant this situation was for them, or if they thought, that
they turned to be stupid in front of the others, or that someone could have thought anything bad about them.

Situation-related ER was explored by examining the strategies avoidance (Items ER3, ER7 and ER8),
suppression (Items ER1, ER5 and ER9) and cognitive reappraisal (Items ER2, ER4, ER6). The meaning of
these terms comprises different point of views: the avoidance of the situation was meant by the avoidance-
strategy, suppression of the emotional expression for suppression strategy and by the cognitive reappraisal
we understand reappraisal of the situation. Our items were partly based on the FEEL-KJ (Grob & Smolenski,
2005), on the Cognitive Emotion Regulation Questionnaire – kids Version (CERQ-k; (Garnefski, Rieffe,
Jellesma, Terwogt & Kraaij, 2007), on the ERQ-CA (Gullone & Taffe, 2012) and the Revised Avoidance and
Fusion Questionnaire for Youth (AFQ-Y; Greco, Murrel & Coyne, 2005) Some parts were formulated on the
grounds of the theory and definition of ER in the literature (i.e. Gross, 1998b; Hayes, Wilson, Gifford,
Follette & Strosahl, 1996).

The children were asked to estimate these situations with regard to the applied strategies in the
corresponding social situations on the scale from 0 (“does not refer to me at all”) to 10 (“it does refer to
me”). After the children responded, that they used a certain strategy, they were asked to reply if their
anxiety/agitation was (1) stronger, (2) weaker, or (3) not changed at all.

The special attention was given to the children appropriate design of the questions, in a sense of the simple
formulation and the examples close to the life, as well as the good understandability of the items and their fit
to each of the strategies. The evaluation of the items with regard to this criteria was made by experts-rating.
The internal consistency for applied strategies measured between six time-points of measurement was
satisfying. For the supression it was (α = .69 – α = .85); for reapprisal those values were (α = .65 – α = .81);
for avoidance (α = .75 – α = .83), based on the analysis on three items.

Besides the situational ER, the Interview registered the so-called Post-Event Processing (PEP), which means
the repeated thoughtful dealing with the experienced social situation, focusing on its negative aspects
(Schmitz, Krämer, Blechert & Tuschen-Caffier, 2010). The PEP was examined based on the PEPQ-R-D
(Fehm et al., 2008). Nevertheless, the PEP construct was not relevant for this study.

Data Analysis
 38

Data management begun with the group comparison with regard to age and gender and how they
relate to the anxious and non-anxious children. We wanted to find out if these socio-demographic
variables may explain some of the differences. By comparison of sum values of SPAIK and PHOKI
we tried to find out if the two groups differ in the amount of anxiety values. If the following basic
preconditions were met, the appropriate measure for the group comparison would be MANOVA
(multivariate analysis of the variance; Hair, Black, Babin & Anderson, 2010). Nevertheless our data
did not meet the criteria for normal distribution of the dependent variables, neither did the
homogeneity of variance-covariance matrix. In the light of these circumstances, there is
considerable argumentation for applying univariate analysis.

For the categorical variable gender (categorical is a variable that can take on one of a limited, and
usually fixed, number of possible values), we applied Chi-Square Test. Interval variables age and
sum values of SPAIK and PHOKI required data management by individual t-test for independent
samples. We assumed the independence of these measured values for each of the participants.

Multivariate analysis of variance is a procedure used when there are two or moredependent
variables. It comparesmultivariate sample means. Significance tests involves individual dependent
variables separately.

As reminder, we will now compare some statistical procedures: t-test is used to assess the likelihood
that the means for two groups are sampled from the same sampling distribution of means. If the
question is whether the means for two or more groups are taken from the same sampling distribution,
the appropriate procedure is ANOVA. MANOVA, on the other hand, tests whether the vectors of
means for the two or more groups are sampled from the same sampling distribution.

It is used when there are several correlated dependent variables, and the researcher desires a single
measure of the influence of the factor (independent variable) on the multiple dependent variables.

As an overall test of the equality of mean vectors for several groups, MANOVA does not tell us
which groups differ from which other groups on their mean vectors. MANOVA will not tell you
which variables are responsible for the differences in mean vectors.
 39

With proper contrast coding for the dependent variables we may infer this answer. Therewith we
may conclude if the changes in the independent variable(s) have significant effects on the dependent
variables and also what are the relationships among the dependent variables?

Several assumptions must be met, as for MANOVA to be the adequate procedure:

 Observations from the population must be sampled randomly and independently
 Dependent variables must have an interval measurement
 Dependent variables have to be multivariate normally distributed within each group of the
independent variables. ID must be categorical.
 The population covariance matrices of each group must be equal (just like in the case of
homogeneity of variances demanded for univariate ANOVA).

When applying MANOVA, violation of multivariate normality may be tolerated in case when the
samples are sufficiently large and if there are no any (or at least many) outliers. Our data do not meet
the normality requirement, but we may still assume that the multivariate normality assumption holds,
because we have at least 20 elements for each dependent × independent variable combination (Eid,
Golwitzer & Schmidt, 2011)
There were no missing values for none of the variables. The value of the effect size was expressed
by Cohen´s d, whereas we adopted the recommendation that d=.20 value corresponds to small, .50
to middle and .80 to large effect (Cohen, 1988). Bonferroni-correction was made, as to rule out the
alpha-error-inflation, which resulted in the lowering of the alpha-value from 0.05 to 0.016. For all
other analysis, if not other specified, alpha value=.05 was implemented.

Our dependent variables, like emotion regulation, were collected by the phone interviews, through
the setting known as the experience sampling (ecological momentary assessment). The instruments
for ER-assessment we used contained rating scales, with the values ranging from 0 to 10. Those are
interval scales which fit the requirements of the analysis of variance. Still, the normal distribution
requirement was not met, neither the homogeneity of the variance.

For the effect size of subsequent paired comparison, we used r-coefficient. This value stems from
the standardized test statistics and the sample size (Field, 2013). According to Cohen (1988), r value
under 0.3 corresponds to small effect size, between 0.3 and 0.5 to middle and greater than .5 as
 40

strong effect. For the non-parametric data there are no methods to calculate those values. Therefore
we took up the values from the parametric procedures.

For the data analysis we used the programme IBM SPSS Statistics Version 20. The significance
level in all computations was alpha=.05. The groups were compared in relation to age, gender,
anxiety, depression symptoms and other psychopathologies.

As for the data collected in the phone interviews, if an interview did not take place, or the specific
situation was missing in the moment of interviewing, that fact was documented, but we did not
replace any value with the (statistically) corresponding one. Our data demonstrate high situational
dependence and contextual variability (Schmidt-Atzert & Amelang, 2012).

The data collected through the repeated measurement belong to the different time points that are
nested in the tested person. Multilevel analysis corresponds to this structure of the data, derived
from the hierarchical structure (Gibbons, Hedeker & DuToit, 2010). Neverthless, statistical analysis
of the preconditions for such data processing showed the lack of test units (Eid, Golwitzer &
Schmidt, 2011; Hox, 2010). In accordance to that we calculated the mean values for the ER-
strategies over all six gathering time-points.

The measures of ER-effectivity are categorical values. Children report if their anxiety and arousal
were weaker, stronger or remained the same. These standards were chosen following Tan et al.
(2012) recommendations, which ensure that the ER was possible and necessary due to sufficiently
high emotional activity. Afterwards we computed relative frequency of these data.

This procedure orients on the EMA-Study of emotional regulation by Heiy and Cheavens (2014),
who used similar response categories. For the inference analysis of the frequency, the Chi-Square-
Test was used. It tests if the empirically collected data distribution corresponds to the random
frequency distribution. The prerequisite for that is that the categories are mutually exclusive and
that each and every person belongs to one of the categories.
 41

IV Results

Hypothesis and Research Questions

In this thesis two questions were posed:

1. Which emotion regulation strategies use the children wit social anxiety, with other forms of
anxiety excluding social and healthy children in everyday socially challenging situations,
when they feel noticed, observed, or scrutinized, or when the are in a contact with an
unknown child or adult, (Gross, 1998a; Tan et al., 2012)? By that we took the strategies
reappraisal, avoidance, suppression of the emotion expression and repetitive thoughts into
consideration.
2. Can the unpleasant emotional states in everyday challenging social situations be
downregulated by using emotion regulation strategies? Hereby the children should indicate,
if the deployment of a certain strategy led to the reduction of the anxiety and arousal.
3. Do the children with anxiety disorder have more repetitive thoughts after the socially
unpleasant situation?
4. Do the children with anxiety disorder reappraise less than healthy children in the socially
unpleasant situation?

Hypothesis 1: reappraisal

H0(1a): there are no group differences in the usage of the reappraisal strategy in the social
challenging situations.
H1(1a): SP children use reappraisal less often than AS, and also less than the HC children.
H0(1b): The deployment of the reappraisal does not lead to the reduction of the anxiety and arousal.
H1(1b): The deployment of the reappraisal lead to the reduction of the anxiety and arousal.

Hypothesis 2: suppression
 42

H0(2a): there are no group differences in the usage of the suppression strategy in the social
challenging situations.
H1(2a): SP children use suppression less often than AS, and also less than the HC children.
H0(2b): The deployment of the suppression does not lead to the reduction of the anxiety and
arousal.
H1(2b): The deployment of the suppression lead to the reduction of the anxiety and arousal.

Hypothesis 3a: avoidance

H0(3a): there are no group differences in the usage of the avoidance strategy in the social
challenging situations.
H1(3a): SP children use avoidance less often than AS, and also less than the HC children.
H0(3b): The deployment of the avoidance does not lead to the reduction of the anxiety and arousal.
H1(3b): The deployment of the avoidance lead to the reduction of the anxiety and arousal.

Hypothesis 4: repetitive thoughts

H0(4): there are no group differences in the occurrence of the repetitive thoughts in/after the social
challenging situations.
H1(4): SP children report more repetitive thoughts than AS, and more than the HC children.

Hypothesis 5: reactivity
H5(0): higher reactivity leads to higher usage of reappraisal (controlled for child-age)
H5(1): higher reactivity does not lead to higher usage of reappraisal (controlled for child-age).

RESULTS ANALYSIS

MANOVA revealed that the main effect of group on frequency in strategy choice was significant.
We further run post-hoc analysis (Tukey test) as to find out exactly where is the difference located –
i.e. between which of the three groups lays the significant difference.
 43

From the existing researches we draw the hypothesis that anxious children experience greater
reactivity in the socially challenging situations.

REACTIVITY

Carthy, Horesh, Apter, Edge et al. (2010) examined the interrelation between negative emotional
hyper-reactivity and deficits in emotion regulation. Their first hypothesis was that AD children
would express greater intensity and greater frequency of emotional reactivity. Second, when the AD
children apply ER strategies, their efficacy would be lower in comparison to HC. Research results
showed that AD children experienced greater negative emotional responses during experiment and
that anxious participants were less likely to use reappraisal spontaneously without external cue.
Besides that, they were less effective at applying reappraisal when being externally instructed to do
so.

Tan, P. Z., Forbes, E. E., Dahl, R. E., Ryan, N. D., Siegle, G. J., Ladouceur, C. D. et al. (2012)
examined emotional reactivity and regulation in real-world contexts in an EMA study using cell-
phone interviews. Their finding was that AD children are less effective at using some strategies to
down-regulate negative emotions, but they do not differ in how frequently they use them.
Given that the findings from those two studies were partly contradicting, in this MA-thesis the
reactivity and its relation to ER strategies was further examined.

Children’s reactivity was assessed with four items which question upon anxiety, arousal, unpleasant
feelings and thoughts related to a negative social judgment.

A partial correlation was run on the collected data to determine the relationship between participants
mean reactivity on one side and mean avoidance, mean suppression and mean reappraisal,
controlled for the children age.
 44

There was a moderate positive partial correlation between reactivity (2,21±1,91) and avoidance
(2,03±6,24) whilst controlling for age (11,79±0,97 years), which was statistically significant,
r(83)=,282, N=86, p=,004.

A partial correlation between reactivity (2,21±1,91) and suppression (1,51±1,94), whilst controlling
for age (11,79±0,97 years), was also statistically significant, even highly significant, r(83)=,837,
N=86, p<,001.
 45

A partial correlation between reactivity (2,21±1,91) and reappraisal (3,69±2,43), whilst controlling
for age (11,79±0,97 years), was moderatelly statistically significant, r(83)=,369, N=86, p<,001.

In relation to the referent literature, further analysis was run, as to analyse the relation between
reactivity and reappraisal in more details. We further run the analysis for HC, SP and AS separately.

A partial correlation between reactivity (2,21±1,91) and reappraisal (3,69±2,43) in HC, controlled
for age (11,79±0,97 years), did not reach statistical significance, although it was marginally
significant, r(28)=,287, N=_________, p=,062.

A partial correlation between reactivity (2,21±1,91) and reappraisal (3,69±2,43) in SP, whilst
controlling for age (11,79±0,97 years), was moderately statistically significant, r(25)=,375, N=____,
p=,027.
A partial correlation between reactivity (2,21±1,91) and reappraisal (3,69±2,43) in AS, whilst
controlling for age (11,79±0,97 years), did not reach statistical significance, r(24)=,24, N=_____,
p=,119.
 46

Emotion Regulation Strategies

The initially postulated hypotheses were statistically examined. We checked if the children from
HC, AS and SP groups differ in how often they use each of the emotion regulation strategies when
they face challenging situations, like the fear of the critique, speech in front of the classmates,
conversation with the authority figure etc. For each child we computed the mean-value of cognitive
reappraisal, suppression, avoidance and repetitive thoughts, which is the mean value across all six
time-points of data acquisition. This variable can take the value between 0 and 10. The higher score
indicated higher intensity of the strategy in the situation of interest.

Multivariante analysis of variance with the factor group (HC, SP and AS group) on one side and
the deployment of three emotion regulation strategies, repetitive thoughts and reactivity in the social
challenging situations as the dependent variables on the other, showed the differences in using
emotion regulation strategies across the groups. In the following paragraphs we will present and
comment the outcomes we got.

Afterwards we computed the correlations between reactivity and emotion regulation strategies,
statistically controlled for the child-age as covariate.
 47

Group Differences in Usage of the Emotion Regulation

Strategies

Which emotion regulation strategies do the AS, SP and HC children use in everyday challenging
social situations?
One-way MANOVA with the factor group (HC, SP, AS) on one side and the deployment of three
emotion regulation strategies, repetitive thoughts and reactivity in the social challenging situations
as the dependent variables on the other, determined a statistically significant difference between the
groups: (F(8,160) = 5,49, p <.001; partial η2=,216).

Hypothesis 1: reappraisal

In many studies, reappraisal was shown to be the strategy which effectively reduces negative
emotions in situations when a child feels noticed, observed, or scrutinized, or is exposed to a
contact with an unknown child or adult (Gross, 1998a; Tan et al., 2012). Some researches show on
the other hand that people with mental disorders use it less often, especially those individuals
suffering from anxiety and depression (Aldao et al., 2010; Carthy, Horesh, Apter, Edge et al., 2010;
Gross, 1998a; Gross et al., 2006; Legerstee et al., 2010). The study by Tan et al. (2012), applying
ecological momentary assessment, failed to find any difference in using this strategy between the
children with and without anxiety disorder, with the caution that this strategy was assessed with one
item only. What they found is that anxious children are less effective at using some strategies.
Therefore, we undertook a closer analysis of the relation between anxiety disorders and reappraisal,
with the focus on the children with social anxiety.

H0(1a): there are no group differences in the usage of the reappraisal strategy in the social
challenging situations.
H1(1a): SP children use reappraisal less intensive than AS, and also less than the HC children.
We run MANOVA with the factor group as the independent variable and ER strategies and
repetitive thoughts as the dependent.
Post-hoc Tukey test that compares each group with another did not find a significant difference for
the intensity in reappraisal between the groups in the socially challenging situations: F(2)=2,08,
p=,131, so that we do not reject our null-hypothesis for H1a.
 48

Our analysis delivered the same conclusions for reappraisal as Tan et al. (2012).

Graphic N. mean usage of reappraisal in the groups

Hypothesis 2: suppression
By suppression we understand the suppression of the behavioural expression of the emotion and not
the suppression of the inner experience of emotion (Ehring et al., 2010; Gross & Levenson, 1997;
Gross et al., 2006; Silk et al., 2003). This strategy was found to be interconnected with the
psychopathology and used especially frequently in people with anxiety and depression symptomatic
(Aldao et al., 2010; Campbell-Sills & Barlow, 2007; Carthy, Horesh, Apter & Gross, 2010; Gross et
al., 2006; Queen & Ehrenreich-May, 2014; Suveg & Zeman, 2004).

H0(2a): there are no group differences in the usage of the suppression strategy in the social
challenging situations.
H1(2a): SP children use suppression more often than AS, and also more than the HC children.

We run MANOVA with the factor group as the independent variable and ER strategies and
repetitive thoughts as the dependent.
Post-hoc Tukey test that compares each group with another did find a significant difference for the
intensity in supression between the groups in the socially challenging situations:
 49

F-value in between subject analysis was statistically significant: F(2,83)=23,23, p<,001, partial
η2=,359. Mean suppression was statistically significantly higher in the SP (p<.001) compared to the
HC, as well as in comparison with AS (p<.001). Therefore we reject our null-hypothesis for H2a.
Post-hoc Tukey test for the difference between HC and AS was not statistically significant.

Graphic N. mean usage of suppression in the groups

Hypothesis 3: avoidance

Avoidance is the ER strategy highly related with psychopathology too, particularly in individuals
with anxiety and depression symptomatic (Aldao et al., 2010; Campbell-Sills & Barlow, 2007;
Carthy, Horesh, Apter & Gross, 2010; Gross et al., 2006). Avoidance may adaptively reduce anxiety
and arousal by eliminating inner and outer unpleasant experience in the present moment (“here and
now”) (Campbell-Sills & Barlow, 2007; Tan et al., 2012). In a short run that has the consequence,
that negative experiences are avoided, which testifies in favour of the adaptivity of avoidance. But
in a long term perspective, avoiding to face negative emotions leads to reduction of the scope of
activity and maintains the presence of fear (Campbell-Sills & Barlow, 2007).

H0(3a): there are no group differences in the usage of the avoidance strategy in the social
challenging situations.
H1(3a): SP children use avoidance less often than AS, and also less than the HC children.
 50

We run MANOVA with the factor group as the independent variable and ER strategies and
repetitive thoughts as the dependent.
Post-hoc Tukey test that compares each group with another did find a significant difference for the
intensity in reappraisal between the groups in the socially challenging situations:
F-value for avoidance was significant: F(2)=12,96, p<0.01, partial η2=,238, so that we reject our
null-hypothesis for H3a. Mean avoidance was statistically significantly higher in SP (p<0.01)
compared to the HC, and also SP compared with AS (p=,042). In accordance to that, we reject our
null-hypothesis for the group differences. Post-hoc test for the difference between HC and AS was
not statistically significant.

Graphic N. mean usage of avoidance in the groups

Repetitive thoughts are significantly conjoined with anxiety and depression symptomatic (Broeren
et al., 2011; Ehring & Watkins, 2008; McEvoy et al., 2010; McLaughlin & Nolen-Hoeksema, 2011;
Silk et al., 2003). The hypothesis is, that the HC report less repetitive thoughts after a socially
challenging day, than the children from AS and SP groups.

H0(4): There is no difference between the groups in the appearance of the repetitive thoughts
in the socially challenging situations.
H1(4): SP and AS report more repetitive thoughts in socially challenging situations.
 51

We run MANOVA with the factor group as the independent variable and ER strategies and
repetitive thoughts as the dependent.
Post-hoc Tukey test that compares each group with another did find a significant difference for the
intensity in reappraisal between the groups in the socially challenging situations:
Between subject F-value for repetitive thoughts was significant: F(2,83)=6,88, p=0,002, partial
η2=,142, so that we reject our null-hypothesis for H4a.

Post hoc group comparison showed that the mean repetitive thoughts were statistically
significantly higher in the SP (p=0,005) in comparison with HC, as well as with the AS (p=0,006).
Therefore, we reject our null-hypothesis for H4. The difference between HC and AS did not reach
statistical significance.

Graphic N. mean repetitive thoughts in the groups

We run MANOVA with the factor group as the independent variable and the reactivity as the
dependent.
Post-hoc Tukey test that compares each group with another did find a significant difference for the
intensity in repetitive thoughts between the groups in the socially challenging situations:
 52

F-value for reactivity (anxiety, arousal) in between-subject analysis was statistically significant:
F(2,83)=23,25, p<0.01, partial η2=,359, so that we reject our null-hypothesis. Reactivity was
significantly higher in SP group (p<0.01) in comparison to HC and AS (p<0.01). The difference
between HC and AS was not statistically significant.

Emotion Regulation Effectivity

Can the unpleasant emotional states in everyday challenging situation, from the children's
perspective, be downregulated by using the emotion regulation strategies?
The table below shows the relative frequencies of the efficiency of the strategies reappraisal,
suppression and avoidance across all groups.
 53

Graphic N. Relative frequency in the effectivity of the strategies across all groups

General chi square analysis for reappraisal found a significant difference between response
categories (anxiety stronger/weaker/remains the same): χ2 (2, N = 790) =414,69, p<0,001.

Across all groups, in 38,5% reappraisal led to lower self-reported anxiety and arousal.
Nevertheless, this strategy showed no effectivity in 60% of cases and led to the worsening in 1,52%
of the cases. Post hoc group comparison between “anxiety stronger” and “anxiety lower” showed
statistically significant difference: χ2 (1, N = 316) =269,82, p<0,001. Between “remains the same”
and “anxiety stronger” showed statistically significant difference: χ 2 (1, N = 486) =439,18, p<0,001
(weaker: 12, the same: 474). Between “remains the same” and “anxiety weaker” showed
statistically significant difference: χ2 (1, N = 778) =37,15, p<0,001 (weaker: 304, the same: 474).

For Suppression, general chi square analysis found a significant difference between response
categories: χ2 (2, N = 436) =387,39, p<0,001.
Suppression was self-reported as ineffective in 77,8% of the cases across all groups. Post hoc group
comparison showed that the differences between 12,16% of adaptive and 10,1% of maladaptive
 54

outcomes of suppression did not reach statistical significance: χ2 (1, N = 97) =, 835, p=,361. The
difference between the categories “anxiety stronger” and “remains the same”: χ 2 (1, N = 392)
=208,66, p<0,001 (stronger: 53, the same: 339). JOS JEDNAAAAAAAAAAAAAAAAAAAA

General chi square analysis found a significant difference between three response categories in
avoidance: χ2 (2, N = 383) =253,82, p<0,001.
In 71,3% of the cases the avoidance led to no changes in the self-reported levels of anxiety and
arousal across all groups. In 9,4% of the cases it caused the intensifying of the emotions and in
19,3% of the cases reduction.
Post-hoc group comparison across all groups revealed a significant difference between the
categories “anxiety stronger” and “anxiety lower”: χ2 (1, N = 110) =13,13, p<0,001.
The difference between the categories “anxiety weaker” and “remains the same”: χ 2 (1, N = 347)
=114,12, p<0,001 (weaker: 74, the same: 273). The difference between the categories “anxiety
stronger” and “remains the same”: χ2 (1, N = 309) =181,78, p<0,001 (stronger: 36, the same: 273).
The items of the effectivity show the categorical level, so that we analyzed the frequencies of the
strategy usage and subjected those values to the Chi-Square analysis.

ER Efficiency – Group comparison (HC, SP, AS)

Suppression was comparatively the least effective strategy but still post-hoc group comparison for
the HC and SP groups revealed statistically significant differences in frequency between adaptive
and maladaptive outcomes after suppression.

For HC it was χ2 (1, N = 21) = 5,762, p=,016 (anxiety stronger = 5, weaker = 16), showing that this
strategy leads significantly more often to adaptive outcomes.
For HC this value was χ2 (1, N = 21) =5,76, statistically significant, p=,016.
The analysis for AS delivered no statistical significant difference between adaptive and
maladaptive outcomes: χ2 (1, N = 19) =2,58, p=,108. The differences in SP group were statistically
significant, χ2 (1, N = 19) =12,79, p<,001.
Individual comparison between the frequencies of response categories “anxiety weaker” and
“anxiety remains the same” delivered the following Chi-Square values:
 55

5. for HC χ2 (1, N = 90) =37,38, p<0,001 (the same: 74, weaker: 16)
6. for SP χ2 (1, N = 214) =150,2, p<0,001 (the same 199: 3, weaker: 15)
7. for AS χ2 (1, N = 79) =35,56, p<0,001 (the same 66: 3, weaker: 13)

Graphic N. Relative frequency in the effectivity of the strategy suppression

For reappraisal, Chi-Square analysis delivered a statistically significant value χ2 (2, N =

249)=156,31, p<.001, which means that the frequency of the cases within the categories of efficacy
(anxiety becomes higher/lower/remains the same) is statistically significantly different.

Group specific analysis in response categories delivered following significant values:

HC Group: χ2 (1, N = 84) =68,76, p<0,001 (stronger: 4, weaker: 80)
SP: χ2 (1, N = 146) =126,68, p<0,001 (stronger: 5, weaker: 141) and
AS χ2 (1, N = 86) =74,42, p<0,001 (stronger: 3, weaker: 83)

Individual comparison between the frequencies of response categories “anxiety weaker” and
“anxiety remains the same” delivered the following Chi-Square values:
for HC χ2 (1, N = 245) =29,5, p<0,001 (the same 165: 3, weaker: 80)
 for SP χ2 (1, N = 306) =1,88 p=.17, not statistically significant (the same 165: 3, weaker:
141) → consequences for our discussion
 for AS χ2 (1, N = 227) =16,39, p<0,001 (the same 144: 3, weaker: 83)
 56

“Stronger” / “remains the same”

 for HC χ2 (1, N = 169) =153,38, p<0,001 (the same: 165, stronger: 4)

 for SP χ2 (1, N = 227) =150,59, p<0,001 (the same 165: 3, stronger: 5)
 for AS χ2 (1, N = 227) =135,25, p<0,001 (the same 144: 3, stroger: 3)

Graphic N. Relative frequency in the effectivity of the strategy reappraisal

 57

Avoidance

GROUP SPECIFIC analysis (HC, SP, AS):

For HC it was χ2 (1, N = 24) = 8,17, p=,004 (anxiety stronger = 5, weaker = 19)
For SP it was χ2 (1, N = 66) = 6,06, p=,014 partially significant (anxiety stronger = 23, weaker = 43)
For AS it was not significant χ2 (1, N = 66) = 6,8, p=,371 (anxiety stronger = 8, weaker = 12)

1-3: Group specific (HC, SP, AS) analysis: HC Group: χ2 (2, N = 110) =102,24, p<0,001
SP: χ2 (2, N = 199) =103,52, p<0,001 and AS χ2 (2, N = 74) =52,65, p<0,001
POST HOC

Individual comparison between the frequencies of response categories “anxiety weaker” and
“anxiety remains the same” delivered the following Chi-Square values:

 for HC χ2 (1, N = 105) =42,75, p<0,001 (the same 86: 3, weaker: 19)
 for SP χ2 (1, N = 176) =46,02, p<0,001 (the same 133: 3, weaker: 43)
 for AS χ2 (1, N = 66) =26,73, p<0,001 (the same 54: 3, weaker: 12)
 58

Graphic N. Relative frequency in the efficacy of the strategy avoidance

 59

V
General Discussion

The goal of this Master thesis was to shed more light on the emotion regulation of the children
suffering from social phobia and other anxiety disorders in everyday situations. Regarding limited
extent of the ecological valid evidences in this area to the present (Berking & Wupperman, 2012;
Heiy & Cheavens, 2014), this study was conducted in ecologically momentary setting. For that
purpose, multiple phone interviews were made, collecting the data regarding four emotion
regulation strategies that were in the focus of the study. Beside the frequency of using emotion
regulation strategies, the effectivity of those strategies was analysed too.

Starting from the existing findings (Carthy, Horesh, Apter, Edge et al., 2010; Gross, 1998a; Gross et
al., 2006; Legerstee et al., 2010), it was assumed in this thesis that the children with social phobias
and healthy children, as well as all those children suffering anxiety disorders other than social
anxiety, differ among each other in using emotion regulation strategies. It was expected that
reappraisal decreases along with the rise in intensity of psychopathological symptoms. Contrary to
that, we hypothesize that the strategies suppression, avoidance and more frequent appearance of
repetitive thoughts should accompany psychopathological symptoms. We further hypothesize that
suppression and avoidance are not as effective in the reduction of anxiety and arousal as reappraisal.
Our data suggest that strategy is effective in reduction of anxiety and arousal to a certain extent,
which reflects a dual nature of this strategy.

The presence of the same level of reactivity (anxiety and arousal) would be a prerequisite, which
would allow us to attribute the differences in emotion regulation strategies to the differences in the
groups (i.e. differences between mental disorders, or between disorders and the absence of them in
healthy group). But the presence of higher reactivity is a feature of those groups by their nature
(Ruscio et al., 2015; Silk et al., 2011; Tan et al., 2012). Expressed in methodological terms, this means
that these mental disorders and high reactivity levels are confounded variables. Therefore we
conducted an initial analysis of reactivity levels and found a positive partial correlation between
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reactivity and reappraisal (controlled for the children’s age). This correlation was especially high in
the social phobic group. An assumption is that:
● If social phobic children had had lesser reactivity level, they would not have used
reappraisal such frequent as they did;
● This research also showed, that the efficacy of the reappraisal in anxious and social anxious
children was not as effective as in healthy children. Therefore these children were forced to
use reappraisal over and over again in their attempt to reduce the anxiety. Due to their
unskilful usage of reappraisal, they are forced to multiply the application of this strategy.

In the following chapter we will summarize and discuss the findings for each of the proposed
hypothesis, followed with the analysis of the limitations and strengths of our study. Afterwards we
gave an overview of the implications for the research and the professional practice.

Discussion of the findings

The situations we explored were socially challenging for all of the children included in the study.
Nevertheless, only some of the children from our sample suffer from social phobia. We expect those
children to express a certain pattern of emotion regulation in accordance to their mental disorder.
We also take into consideration that the group with this disorder shows high reactivity, which was
already known from the previous laboratory and field research (Ruscio et al., 2015; Silk et al., 2011;
Tan et al., 2012).

Contrary to some previous studies which suggest that children with anxiety and depression use
reappraisal less frequently (Carthy, Horesh, Apter, Edge et al., 2010; Gross, 1998a; Gross et al.,
2006; Legerstee et al., 2010), our study failed to find any difference between the three groups. The
meta-analysis of Aldao et al. (2010) showed small to medium-sized correlations between
internalized disorders and reappraisal. Another field study (Tan et al., 2012) found no evidences for
the difference in reappraisal between children with and without anxiety disorders. A possible
explanation for this discrepancy may be the setting, which in one case was laboratory and in another
(just like in ours) it was ecological environment. We may summarize that both of the field studies
 61

found no group difference and put forward the possibility that the divergent findings may have
arisen due to the influence of the everyday context. The absence of the difference between the
groups is more likely to be attributed to the high application of this strategy by AS and SP children,
then the low usage by the healthy ones.

Aldao (2013) stresses the necessity of integration of the everyday context into the situation of
emotion regulation studies, so that we consider ideographically relevant situations. In that way, the
external validity of the study would also rise. Besides that, we question if the construct of the
“reappraisal” was properly represented through our items. It may be the case, that the concrete
examples were formulated too specifically: „Ich habe versucht, gut über die Situation zu denken.
Hast du z.B. gedacht, die Situation wird bestimmt ganz gut verlaufen?“. There is a possibility that
the children actually did reappraised the situation, but not in that way as we formulate it. Another
example, the item „Ich habe mir gesagt, dass ich aus der Situation etwas lernen kann“ is proper for
the performance situations, but less so for the situations which the child finds embarrassing, or in
the situations when two people disagree with each other. A reactivity in the telephone interviews
was another possible explanation for the outcome we got. As we already know, certain changes in
behaviour due to observation were already noticed in another EMA-studies (Walz et al., 2014).

Our participants learned a lot about our project through the reading of our info-material before
entering the testing-procedure. Besides that, already by launch date children participants were
taught/trained to use reappraisal, so that it was introduced into the repertoire of their emotion
regulation techniques. By that already, a higher occurrence of it was to be expected during ER-data
acquisition. It would be valuable to know if the group differences were present in anxious groups by
the first data acquisition, before the training. Another possible explanation for the difference would
be the social desirability of the answers. Among all measured strategies, reappraisal was the only
positive and optimistic one. This fact may have lead to the higher frequency in reporting. Once
again, the present study is on the same line with the findings of Tan et al. (2012), who put forward a
thesis, that the intensity of the comorbid depression symptoms does not affect the usage of
reappraisal. Therefore we need some more examination with reference to the spontaneous usage of
the reappraisal in everyday situations.

In regard of its effectivity, compared with all others strategies, reappraisal was the only one that led
to the reduction of the fear. In even half of the cases in which it was used, the reduction was
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noticeable. This finding holds the same position like the studies by Gross (1998a) and Tan et al.
(2012), which also identified reappraisal as effective strategy in the reduction of the negative
emotions. Nevertheless, in the other half of the cases, the emotions remained as they were, in spite
of reappraisal. According to the study of Carthy, Horesh, Apter, Edge et al. (2010) too, there were
no differences in the efficacy in reappraisal between the anxious and the healthy children. Another
study showed that the children from the healthy control group and the anxious children with less
severe comorbid depressive symptoms were more effective in reappraisal than the anxious children
severely depressed (Kim Lützenburger, 2016).

We found the difference in the frequency of suppression between the healthy and the socially
anxious group, as well as between the socially anxious and the group with other anxiety disorders.
Contrary to the healthy children and the children with other anxiety disorders, socially anxious
group uses this strategy the most. A number of authors have reported the same findings (Aldao et
al., 2010; Carthy, Horesh, Apter & Gross, 2010; Ehring et al., 2010; Queen & Ehrenreich-May,
2014; Suveg & Zeman, 2004). There is a large volume of published studies describing the role of
the rigid usage of the suppression, particularly the suppression of the negative emotions, claiming
its role in maintaining of mental disorders (Folk, Zeman, Poon & Dallaire, 2014). This is one of the
possible explanations for such a high correlation between this strategy and the social anxiety in
children.

From the aspect of its effectivity, it was known that the suppression does not lead to the reduction of
the anxiety and arousal, but rather to their increase. By this we mean the suppression of the
emotional expression, and not the suppression of the emotional experience (Gross et al., 2006).
Closer analysis showed that this strategy was efficient for the great part of the children without
mental diagnosis, as well as the tendency to be used lesser by healthy children. We may assume that
the healthy children use this strategy more flexible and accordingly to the situation, in everyday life
people regulate the majority of their positive emotions too (Heiy & Cheavens, 2014). Contrary to
that, chronic usage of this strategy may hinder our adaptive reactions (Gross & Levenson, 1997).

We found a significant difference in the implementation of the avoidance strategy between social
phobic participants on one side and healthy participants, as well as other anxiety participants on the
other side. There was nevertheless no any significant difference between the healthy participants
and the participants suffering anxiety disorders (other than social anxiety). This finding is in
 63

accordance with some previous findings (Aldao et al., 2010; Carthy, Horesh, Apter & Gross, 2010;
Silk et al., 2003). It is worth to notice that the statistical strength of the difference was not as
significant as for the reactivity, the suppression, or the repetitive thoughts (p-value between HC
and AS was 0,042). The possible reason for this fact may be the fact that our items for avoidance
strategy were vaguely formulated, expressing just a wish or an attempt to avoid the situation, and
not as unambiguous as in some other researches, where the situations were described directly and in
active way: „I will go to the bathroom so I’ll miss my turn to introduce myself“ (Carthy, Horesh,
Apter und Gross, 2010). Such vague formulation might have produced less clear consequences as
the reaction. Some future studies should deal with this problematic and possibly reexplore our
findings.

The avoidance strategy lead to no changes of the negative emotions in the majority of the
participants participated in our study. It was nevertheless effective in one quarter of the participants
who experienced its decrease. This notion may reflect a possible discrepant impact of this strategy.
In the short run it reduces, or even eliminates negative emotions. In the long-time perspective it
produces more negative emotions and leads to the limitations in the scope of action (Campbell-Sills
& Barlow, 2007). The action of avoidance, as we operationalized it here (as a wish, or an attempt to
avoid a situation, but not factually avoiding it), is not likely to produce the effect as intense as a real
action of avoidance. This may also influence the statistical significance of the relation between the
avoidance and the short-term reduction of the negative emotional experience.

A global overview of the repetitive thoughts shows that none of the groups reports much of those
thoughts in relation to the social situations. None of the groups overreached the mean score value
higher than 2 out of possible 10. The post-hoc individual group comparison Tukey test showed a
significant difference between the social phobic group and healthy group, as well as the difference
between the social phobic group and the phobic group other than social anxiety. The healthy group
and the anxiety group (other than social) were nearly the same in the frequency of the repetitive
thoughts, not reaching statistical significance in the differences. Many existing studies collect their
data retrospectively, so that their reports are based on the habitual use of this strategy. In our
ecological momentary assessment, the data collection takes place within the shortest period of time
after the situation happened. Given that repetitive thoughts need some time to develop and to gain
in their intensity, we may assume that the time necessary for their collection is greater than the time
needed for the rest of the strategies. The way we collected them did not make it possible to
 64

represent them fully. Nevertheless, some other clinical studies used the same time slot and gained to
find the connection between the depression and the repetitive thoughts. The difference between
those studies and our study is that they did not refer to some concrete situation (Silk et al., 2003)
and that they were dealing with the grown-ups (Ruscio et al., 2015). In that study, repetitive
thoughts occurred more often in adults with the comorbid depression and GAS, than if only one of
the mental problems was present. That means that the participant´s age may play the role in the
occurrence of the repetitive thoughts. There are generally a few studies of repetitive thoughts with
the mentally ill children. Further researches in this field are needed.

Our data are eligible for multiple interpretations, including the perspective based on the Clark &
Wells (1995) and Beck & Clark (1997) Model of social anxiety. According to this model we assume
that socially challenging situation elicit higher levels of reactivity. The explanation for this may be

a distinctive role of self-related schemata, which Clarck et al. (1995) and Beck et al. (1997) claim
plays a crucial role in anxiety disorders.

According to that social feared situations activate this global negative schemata and foster the
negative self-evaluations in a particular situation. Consequently, children use significantly more
suppression of negative emotions and avoidance of feared situations as a self-regulatory
mechanism. Lower self-efficacy in emotion regulation and higher arousal level are presumably
mediators, that give rise to the higher frequencies in applying these strategies.

Apart from that, each of emotion regulation strategies may have strategy-specific cognitive
schemata. In case of reappraisal, we speak of self-induced change of negative emotions, a strategy
which demands cognitive efforts and longer dealing with the feared situation (Carthy, Horesh,
Apter, Edge & Gross, 2010). Global negative self-beliefs, such as “I am hopples”, or “I cannot
change anything anyhow”, may be associated with this schemata and therewith play a great role in
it.

Suppression is more related to a certain specific unpleasant situation and the following emotional
reaction. In case of suppression, some general beliefs about emotions show off themselves, such as
a trait-like belief that certain emotions are aversive and unacceptable (Campbell-Sills et al., 2013).
 65

Campbell-Sills et al. (2013) already found in adults with anxiety disorders that lower acceptance of
some emotions mediates the intensity of correlation between intensity of emotions and their
spontaneous suppression.

Given the specificities of each individual schemata related to different ER strategies, future
researches should examine the specificities of certain everyday situations and specificities of an
examined individual on that, which strategy-appliance would take place and (Aldao & Nolen-
Hoeksema, 2012; Sheppes, 2013). Some of the relavent personal characteristics may be self-
efficacy belief in regart to emotion regulation (Carthy, Horesh, Apter & Gross, 2010), or the
emotion related beliefs (Campbell-Sills et al., 2006). Presumably relevant situational characteristics
would be the intensity of the emotion in a present moment (Sheppes et al., 2011), or the presence of
a certain relevant person (Zeman & Garber, 1996).

Reappraisal. Contrary to some previous studies (Carthy, Horesh, Apter & Gross, 2010; Sheppes,
Scheibe, Suri & Gross, 2011), our data shows that higher reactivity goes along with higher usage of
all three ER strategies and repetitive thoughts too, and not only with maladaptive strategies -
suppression and avoidance. This includes higher usage of reappraisal in highly reactive groups too.
Contrary to Carthy et al (2011) in the study by Tan et al. (2012) no differences in reappraisal
between anxious and non-anxious children were found.

A possible cause for these inconsistent findings may be an artefact arising from the way of
measuring the strategies. Namely, by the direct inquiry if reappraisal was deployed, or not, higher
values arises, than in the studies in which participants indicate the usage by free reporting. Given
that our study used the former, direct variant, then the higher values of suppression, that we found,
are partly explicable by that.

Another possibility points out the role of a higher necessity of reappraising, as a self-regulative
mechanism, in the cases when the reactivity is high. This may also hint the fact that highly aroused
children (SP) have more occasions to reappraise, and therewith to practice and to, master their
reappraisal capability, so that it automatizes itself and demand no longer so much cognitive
resources.
 66

We may not rule out neither the possibility that the self-reported values of reappraisal were self-
reported higher in the SP group as a socially desired answer, given that this strategy was the only
optimistic one. Having that in sight and the fact that SP individuals exert higher desire to impress
and present themselves in a positive way and to conform themselves to the expectations of others,
we put forward this explanation too.

Apart from that and in line with our hypothesis, reappraisal was the most effective/adaptive strategy
in all three groups.

Avoidance. Our data show that avoidance leads to the anxiety reduction to a certain degree. This
happens more often then anxiety intensification. The difference between reduction and
intensification is statistically significant in HC and SP groups, but not in AS group. We propose
several explanations for this.

It is well known that confrontation with the feared stimuli is a procedure for fear reduction. In social
phobia, nevertheless, exposition to phobic situations does not show a marked reduction in fear
(https://www.ncbi.nlm.nih.gov/pubmed/27816079/). As Wells et al. (2006???) proposed, socially
phobic individuals engage in safety behaviours, which prevents them from experiencing a
disputation of their fault believes. Expecting the worst-case scenario, even after it does not happen,
they misattribute this positive outcome to those safety behaviours, and not to the fact, that the
situation was not dangerous. As Rudaz et al. (2017) noticed, avoidance behavior may be more
subtle in social anxiety disorder than specific phobia. From this vary fact arises the difference in the
SP and AS groups and the explanation for their usage of avoidance.

SP group experiences more positive outcomes by confronting with the feared stimuli. In that way,
they overcome their fears and do not have to use avoidance that much as SP.

Misattribution of "positive" outcomes to the safety behaviours in SP may also convince socially
phobic person that avoidance was a good chice. Namely, when the situation turns to be safe, with no
catastrophic outcomes, instead of disputing their false beliefs, SP tend to attribute good outcomes to
avoidance. Therefore they report positive effect of avoidance significantly more, then the negative
effects.
 67

We found that avoidance is adaptive in HC too. Contrary to SP group, in their case avoidance may
be adaptive because they use it less frequently and if they use it, the appropriately, flexible and
according to the situation, merely to reduce stress "here and now", and not as a long-term solution.

STRENGTHS AND LIMITATIONS

One of the strengths of this study is that it detects the psychopathology by using the multimethod
diagnostic, as Esser (2008) suggested. Following this, Kinder-DIPS questionnaire was carried out
separately with the child and with one of the parents. The clinical assessment gained in that way
was supported by the various questionnaires. Besides that, in our sample two groups with certain
psychopathology were presented and one healthy group. Aldao (2013) put forward a request that we
must observe multiple psychopathological groups, as to be able to differentiate between disorder-
specific and transdiagnostic deficits. Two psychopathological groups in our study had either social
anxiety, or some other anxiety disorder excluding social anxiety. Some further analysis might
examine the combined effect of social anxiety along with some other anxiety form.

The external validity of this study is higher in comparison with the labour-studies (Bylsma &
Rottenberg, 2011). In the labour-studies, participants were regulating their emotions while watching
the movies, or some artificial scenario, which put them into a relative passive observer´s position. In
comparison to this, in their everyday situations people take more active role. That is unquestionable
a context in which the emotion regulation usually takes place. The research which deals with such
material therefore delivers more valid data (Aldao, 2013). That is why we collected the data mainly
from the children's everyday situations. We took into consideration socially challenging situations,
which took place individually and different for each of the child in our research. This implies
idiographic approach, the one that heads back to Windelband (1894) and Allport (1937). This aspect
represents one more strength of our research. Through the EMA data acquisition, thoughts,
behaviours and emotions of the child may be collected on the individual level. Contrary to the
studies using the nomothetic approach, the children we explored did not pass through one
standardized situation. They were asked about one unique and personally relevant situation in their
natural environment. Besides that, EMA approach makes it possible, to observe the behaviour and
experiences relatively soon after they took place. In that way, memory biases are reduced to the
lowest possible degree (Walz et al., 2014).
 68

EMA-approach showed itself as very suitable and practical for collecting the data dealing with the
emotion regulation. Children were regularly approachable by the mobile phones throughout the day
and the questioning was good integrated into their everyday activities. In case of any uncertainties
and dilemmas, testers were also reachable by the phone for the participant's questions. The
compliance was very high in comparison with other studies (Csikszentmihalyi & Larson, 1987).
The most of the questionings took place according to the plan and the children were regularly able
to dedicate enough time and to find a quiet place for the interviews. Above all, they were able to
report of their everyday challenging social situations.

In respect of the clinical picture, the psychopathological group consisted of the individuals suffering
from different anxiety disorders. Given that the various anxiety disorders often occur comorbid
(Schmidt-Traub & Lex, 2005) and that they cause similar coping strategies (Legerstee et al., 2010),
they were analysed together in this study. All three groups were presented in the nearly same
number within the complete sample. We plausible assume that the social challenging situations we
analysed were especially eliciting for the socially anxious children. This assumption was justified
with the outcomes of the analysis we applied.

Field studies are largely based on the ecological valid data, with the high external validity, which
confronts us with trade-offs in internal validity. All these unstandardised situations, reported by the
children in our study and all interference factors were hardly controllable (Eid et al., 2011). There is
still room for improvement in the quality of measurement. Besides the factors we included in our
research, we should further inquire on the people accompanying child in the moment of the data
acquisition. We may also specify the time-window between the situation and the testing moment, as
well as the intensity of the emotion that was elicited by the situation. It is worth to notice that the
testing took place within the three days only, so that the occurrence of a certain social challenges
might have led to the overestimation, or to the underestimation of some other effects. As a
countermeasure, phone interviews should take place under similar circumstances: only on school-
days, and preferably on those school-days when the child has some out of school activities besides
that, so that both of the social situations would be involved.

EMA setting provides a lot of advantages. It is still worth to notice that the data collection at noon
and in the evening only, with those time points preset before the testing took place, has also
drawbacks. First of all, the time elapsed between the questioning and the situation of interest is not
 69

constant. It may vary from a several minutes up to several hours after the situation took place.
Different regulation strategies also demand different chronological order: while reappraisal,
suppression and avoidance demand the shortest possible time interval in order to reduce the
memory biases, the acquisition of the repetitive thoughts demands a longer interval. Even the
shortest retrospective remembrance relies on the reconstruction of the experience and may not
present the full memory of it. No remembrance may be as reliable as a direct experience itself.

In the present study we investigated four emotion regulation strategies, those that were empirically
best explored and theoretically good elaborated. Besides them, individuals use many other
regulation strategies. It can therefore be assumed that all those strategies were deployed in many of
the situations from our study. Due to our methodology, they remained not acquired by our testing.
As Aldao and Dixon-Gordon (2014) showed, so called overt emotion regulation strategies (like
drinking alcohol, seeking advice) are even more often used than so called covert strategies, those
that we measured, like reappraisal, or suppression. Simply expressed, people seek help from others,
they quarrel, or simply move away from a situation – they do that more often than they reappraise.
In the mentioned study strong evidences were found for the correlation between psychopathology
and overt strategies. For the age presented in our study, we assume the occurrence of the strategies
such as seeking the presence of relevant others, speaking to their peers, distraction, like playing
video-games, or using smartphones, or acting out through aggressive or defiant behaviour (Kulik &
Petermann, 2012). Such kind of strategies and their effectivity was not analysed in our research.
Furthermore, some of the children reported that they simply did not do anything to regulate their
emotions. This seems to be a common response, which leads us to the question to which extent are
the children motivated to regulate their emotions. “Wait-and-see” strategy, as well as the
acceptance were probably also existing means that we did not take into consideration.

Another key point is that the present study relies on self-report, implying the necessity of
introspection. It is questionable for the children from our study, in how far they developed
introspection capability (Papaleontiou-Louca & Thoma, 2014). Besides that, emotion regulation
may take place automatically, with no conscious decision, or even without paying attention to it,
especially if children find themselves in a complex situation with many uncontrollable elements
(Mauss, Bunge and Gross, 2007). Therefore we paid attention that the children remember the
situation very well, so that these automatic processes may be ruled out.
 70

We also have to analyse the quality criteria of the phone interviews. The guidelines for the interview
were established for the project based on the validated and reliable questionnaire for the emotion
regulation for adults and children. The items for the strategies reappraisal, suppression and
avoidance were validated through the experts. The items regarding repetitive thoughts were taken
from the questionnaire for adults, PEPQ, and reformulated for the children. The items were
validated on the huge sample and the factor analysis for the examination of the items subscales must
be implemented. (had to be, ili tek treba da se desi???)

We further took into account a possibility of the reactivity, as a result of the interview situation.
That implies changes in behaviour due to the testing situation. Many EMA-studies already showed
that the attention and the behavior may be redirected through the questioning process, so that the
symptoms may be presented in a biased way (Walz et al., 2014). Already after the initial interview
children knew that the topic of the interviews are the social challenging situations so that they paid
additional attention to them. Putting emotion regulation strategies into a focus may foster the usage
of the strategies itself. We may not rule out also that the collected variables in the present study
were not influenced through the interview repetition.

Finally, the presence of the socially desirable responses and the fact that the study is not investigator
blinded were additional sources of unwanted influences, affecting negatively intern validity of the
study.

As we listed above, this study exhibits many strengths. Our conclusions are nevertheless largely
based on very limited data, failing to gain optimal effect-size and power through the optimal
number of participants. As an a-priori PowerAnalyse (done by the programme G*Power) delivered,
than a minimal amount of as much as 159 person would only reach an effect-size of f = .25, α = .05,
and Power =.8. This fact made our parametric MANOVA analysis less reliable and more susceptible
to biases. It also does not allow us a multilevel analysis. Computing the mean values over the six
test intervals lead to the loss of intraindividual variability initially presented in the data. Something
of a pitfall is the fact that the context factors were dismissed too (Walz et al., 2014).

IMPLICATIONS FOR THE RESEARCH

AND THE CLINICAL PRAXIS
 71

Most of the previous studies in the field of emotion regulation in relation to the anxiety symptoms
were labor-studies and retrospective questioning. Our study is a field study, which was aiming to
collect the data in the ecological everyday environment and observing emotions as they naturally
arise in everyday situations. Apart from the analysis of the anxiety, we additionally segmented our
sample by dividing anxious individuals into two groups: socially anxious group and anxious group
suffering from anxiety disorders excluding social anxiety. By that we increased the homogeneity of
our sample in the sense of the similarity of their psychopathology.

The present master thesis deals with the question, which relation bear anxiety disorders to the
emotion regulation. We may not provide some complete answer at this point, so that the further
analysis on a huger sample are still needed. Additional increase in homogeneity of the sample
would also be valuable. For instance, the samples might be subdivided into smaller groups based on
the severity of their symptoms. The survey period should also be longer, so that it better represents
children´s everyday life.

It is also recommendable to collect other emotion regulation strategies and not only those that we
foresaw by our research plan. Many children reported that they used some other strategies then the
three which were took into consideration. If we aim to cover the full spectrum of the strategies that
helps the children to regulate their emotional life (regardless if the children have, or have no
symptoms), we would have to keep the response options opened. For instance, Carthy, Horesh,
Apter und Gross (2010) did that by asking children “What would you do to calm yourself down in
this situation?”. This option would be applicable in EMA-setting too, not excluding the combination
of the open response options and limited options format. Some future study should also include the
answer “not doing anything”, or acceptance as some of the possible strategies. This strategy was
often used by the children from the study of Tan et al. (2012), showing high effectivity in the non-
anxious children. Acceptance might also play the role in therapy of childhood depression, as well as
in diagnosing anxiety disorders.

In order to gain some further insights about the emotion regulation in everyday life, we may analyse
short-term and long-term effects of certain strategies. The strategy avoidance has besides its short-
term positive effects many negative effects too, like the maintenance of the symptoms of fear in
case of phobias and the limited scope of action (Campbell-Sills & Barlow, 2007). A meta-analysis
 72

of the repetitive thoughts showed that these thoughts lead to depression in a long run (Roelofs et al.,
2009). This finding should be extensively examined in children with anxiety symptoms.

In relation to this, automatic emotion regulation should also be taken into account. Mauss et al.
(2007) concluded in their review that automatic emotion regulation is correlated with the
maladaptive strategies. This might especially be related to learning from models in childhood.
Above all in the complex situations, where a lot of challenges are simultaneously imposed onto an
individual, it may come to the automatic emotion regulation.

An analysis of positive emotions could obtain some interesting knowledge too. There are
indications that the anxiety and depression are related to the dysfunctional regulation of the positive
emotions (Carl, Soskin, Kerns & Barlow, 2013). This phenomenon is especially poorly explored in
the early childhood age.

We also should not ignore the advantages of the labour-studies. Especially if we deal with the less
explored topics like emotion regulation, the possibility of a higher control is a great advantage.
After exploring a phenomenon in such setting, we may re-examine its nature in a field study.
Especially for the reappraisal strategy, which plays role in many therapeutic concepts, it would have
to be reassessed if the finding from the labour setting and from the field setting are congruent. In the
laboratory-setting, physiological measures, like heart-rate, or skin-galvanic reflex would have to be
measured as a marker of the effectivity of an applied regulatory strategy, given that the emotion
regulation has it effects in this area too (Gross, 2002).

Specific emotion regulation training is also recommendable. It is known that symptoms of

depression in combination with anxiety additionally influence emotion regulation. Within the
training, a person would be thought to use emotion regulation strategies more flexible and in
accordance with the personal goals and with the context in which it finds itself. That would
contribute to the healthy and balanced emotional life. Given that strategies like suppression and
avoidance, just like occurrence of repetitive thoughts, impair mental balance and hinder satisfaction
of our needs and reduction of unwanted emotional states. The goal would be to minimize those
strategies. Comorbid clinical picture additionally complicates the processing of unwanted emotions.
 73

EMA-setting is also combinable with such training interventions. Such training conduct along with
EMA-study would enable treatment procedure and therapy achievement to be better analysed (Walz
et al., 2014). On the other hand, directing attention itself by questioning a participant, along with the
higher level of self-observation might foster the changes on its own. Within that process, a person
starts to focus its attention on its behaviours and experiences (Runyan & Steinke, 2015). This
phenomenon is especially well explored in the substance and behaviour addictions and showed very
good results in that field. In the area of anxiety and depression additional improvements are needed.

If anxious children, as studies show, exert higher levels of anxiety in everyday life, some
intervention should direct at higher acceptance of those negative emotions and better understanding
of them (Ehrenreich, Fairholme, Buzzella, Ellard & Barlow, 2007). Mastering the techniques of
relaxation and social-skills training would also contribute to higher stability in unpleasant situations
(Hannesdottir & Ollendick, 2007). Therapeutical procedure addressing client´s self-efficacy
believes in regard to emotion regulation, or his dysfunctional cognitive-schemata, would modify the
factors that foster the usage of maladaptive emotion regulation strategies. Children should also get
acquainted with short-term and long-term consequences of suppression and avoidance and acquire
knowledge about alternative reaction possibilities.

The present study clearly shows that many further explorations dealing with these disorders are
needed, as to make it possible to pull some clearer conclusions in direction to the clinical praxis.
Nevertheless we may surely claim that the presence of anxiety disorders determines the choice of
the emotion regulation strategies in everyday situations.
 74

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