Emotion Understanding in Clinically Anxious Children: A Preliminary Investigation

Abstract

Children’s understanding of the nature, origins and consequences of emotions has been intensively investigated over the last 30–40 years. However, few empirical studies have looked at the relation between emotion understanding and anxiety in children and their results are mixed. The aim of the present study was to perform a preliminary investigation of the relationships between emotion understanding, anxiety, emotion dysregulation, and attachment security in clinically anxious children. A sample of 16 clinically anxious children (age 8–12, eight girls/boys) was assessed for emotion understanding (Test of Emotion Comprehension), anxiety (Screening for Child Anxiety Related Emotional Disorders-Revised and Anxiety Disorder Interview Schedule), emotion dysregulation (Difficulties in Emotion Regulation Scale) and attachment security (Security Scale). Children who reported more overall anxiety also reported greater difficulties in regulating their emotions, and were less securely attached to their parents. The results also showed that more specific symptoms of anxiety (i.e., OCD and PTSD) correlated not only with emotion dysregulation and attachment insecurity but also with emotion understanding. Finally, there were interrelations among emotion understanding, attachment security, and emotion dysregulation. The present results provide the first comprehensive evidence for a socio-emotional framework and its relevance to childhood anxiety.

Full text

ORIGINAL RESEARCH
published: 18 December 2015
doi: 10.3389/fpsyg.2015.01916
Edited by:
Antonella Marchetti,
Università Cattolica del Sacro Cuore,
Italy
Reviewed by:
Daniela Bulgarelli,
University of Turin, Italy
Mirella Zanobini,
University of Genoa, Italy
*Correspondence:
Francisco Pons
francisco.pons@psykologi.uio.no
Specialty section:
This article was submitted to
Cognitive Science,
a section of the journal
Frontiers in Psychology
Received: 31 March 2015
Accepted: 27 November 2015
Published: 18 December 2015
Citation:
BenderPK,PonsF,HarrisPL,
Esbjørn BH and Reinholdt-Dunne ML
(2015) Emotion Understanding
in Clinically Anxious Children:
A Preliminary Investigation.
Front. Psychol. 6:1916.
doi: 10.3389/fpsyg.2015.01916
Emotion Understanding in Clinically
Anxious Children: A Preliminary
Investigation
Patrick K. Bender1, Francisco Pons2*,PaulL.Harris
3, Barbara H. Esbjørn1and
Marie L. Reinholdt-Dunne1
1Department of Psychology, University of Copenhagen, Copenhagen, Denmark, 2Department of Psychology, University of
Oslo, Oslo, Norway, 3Graduate School of Education, Harvard University, Cambridge, MA, USA
Children’s understanding of the nature, origins and consequences of emotions has been
intensively investigated over the last 30–40 years. However, few empirical studies have
looked at the relation between emotion understanding and anxiety in children and their
results are mixed. The aim of the present study was to perform a preliminary investigation
of the relationships between emotion understanding, anxiety, emotion dysregulation,
and attachment security in clinically anxious children. A sample of 16 clinically anxious
children (age 8–12, eight girls/boys) was assessed for emotion understanding (Test
of Emotion Comprehension), anxiety (Screening for Child Anxiety Related Emotional
Disorders-Revised and Anxiety Disorder Interview Schedule), emotion dysregulation
(Difficulties in Emotion Regulation Scale) and attachment security (Security Scale).
Children who reported more overall anxiety also reported greater difficulties in regulating
their emotions, and were less securely attached to their parents. The results also showed
that more specific symptoms of anxiety (i.e., OCD and PTSD) correlated not only with
emotion dysregulation and attachment insecurity but also with emotion understanding.
Finally, there were interrelations among emotion understanding, attachment security,
and emotion dysregulation. The present results provide the first comprehensive evidence
for a socio-emotional framework and its relevance to childhood anxiety.
Keywords: emotion understanding, anxiety, emotion regulation, attachment, children, clinical sample
INTRODUCTION
Emotion understanding can be considered as the affective side of Theory-of-Mind (Wellman, 2014)
and can be defined as the understanding of the nature, origins, consequences and regulation of
emotionintheselfandothers(Harris et al., in press). Emotion understanding has been intensively
investigated, especially in typically developing children, during the last 30–40 years. At least six
conclusions have emerged from this large corpus of empirical investigations. First, in accordance
with Piaget’s hypothesis about the development of consciousness “from the periphery to the
center” (Piaget, 1974a,b), children’s understanding of emotions develops from a peripheral and
superficial understanding of rather visible and non-reflective aspects of emotions (e.g., recognition
of basic emotions, understanding of the impact of external causes and desires on emotions) to a
more central and deeper understanding of the more invisible and reflective aspects of emotions
(e.g., understanding of mixed and moral emotions, understanding of the possibility of regulating
emotions by using cognitive strategies) via an intermediate “stage” where children understand the
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Bender et al. Emotion Understanding in Clinically Anxious Children
distinction between expressed and felt emotions, the impact
of beliefs and memories on emotions and the impact of
emotions on cognitions. Second, although some variation in
rate of development has been observed across cultures (often
related to socio-economic factors) this movement from the
periphery to the center seems to be universal. Third, stable
individual differences in children’s understanding of emotions
have been observed from early childhood to late adolescence.
Fourth, many interrelated social, cognitive and emotional
factors such as children’s language, intelligence, executive
functions, and maternal attachment relationships (including
maternal sensitivity, as well as emotional responsiveness and
communication) contribute to these developmental changes and
individual differences. Fifth, children’s emotion understanding
is related, not only to the quality of their psychological well-
being (self-esteem, anger, behavioral problems, etc.) and their
social relationships with peers and adults (friendship, popularity,
cooperation, etc.) but also to their ability to resolve cognitive
problems alone or in a group. Sixth, it is possible to help typical
and challenged children to improve their emotion understanding
via, for example, cognitive-behavioral programs, language-based
interventions or philosophically based programs both in an
experimental setting and at school (e.g., Marchetti et al., 2006;
Gavazzi and Ornaghi, 2011;Nunez, 2011;Daniel and Gimenez-
Dasi, 2012;Albanese and Molina, 2013;Andrés-Roqueta et al.,
2013;Baron-Cohen et al., 2013;Molina et al., 2014;Harris et al.,
in press; Viana et al., submitted, for reviews and illustrations).
This corpus of investigations represents a substantial advance
in our comprehension of children’s understanding of emotions.
However, although several studies have looked at emotion
understanding in challenged children (e.g., autistic, deaf, with
specific language impairment), few have looked at the relation
between emotion understanding and anxiety in children. Anxiety
is an emotional disorder involving the experience of fear and
danger that is either irrational and/or disproportionate to the
perceived threat and has a negative impact on one or more
areas of children’s normal functioning and/or psychosocial
development (e.g., Fonseca and Perrin, 2011). Studies that
have investigated the relation between children’s understanding
of emotions and anxiety show mixed results. For example,
studies have shown that children suffering from social anxiety
have difficulties interpreting others’ facial (Simonian et al.,
2001)andvocal(McClure and Nowicki, 2001)emotionalcues.
It has also been demonstrated that socially anxious children
experience difficulties in understanding the relations between
emotions, intentions, and beliefs in social situations (Banerjee
and Henderson, 2001), and that a decreased ability to differentiate
between emotions relates to social anxiety in children and
adolescents (Rieffe et al., 2008). Sprung and Harris (2010)
found that, in hurricane Katrina-exposed children, there was
a positive correlation between their knowledge about thinking
(including emotions) and their capacity to report on their
negative intrusive thoughts. Southam-Gerow and Kendall (2000)
found that anxious children have a less developed understanding
of the possibility of hiding and changing emotions. A recent
meta-analysis found a small-to-medium, negative correlation
between general internalizing problems, such as anxiety and
depression, and children’s ability to understand emotional cues
(Trentacosta and Fine, 2010).
The relation between children’s understanding of emotions
and their ability to regulate those emotions also deserves
attention. The regulation of emotions is a complex and dynamic
process involving the ability to assess the context surrounding an
emotional experience, identifying and evaluating the emotional
experience, as well as modifying the expression of emotion in
accordance with personal goals and social demands (e.g., Jacob
et al., 2011). It has been suggested that children must possess
an understanding of emotions in order to be able to effectively
regulate their emotions (Suveg et al., 2009;Izard et al., 2011).
Indeed, in an intervention study, Izard et al. (2008) employed
an emotion-based prevention program developed for young
children, and showed that gains in emotion regulation were
mediated by gains in emotion understanding. Other research has
found that a better emotional understanding relates to improved
emotion regulation abilities in children (Cunningham et al.,
2009).
In a different line of research, the links between children’s
emotion understanding and parent–child attachment
relationships have been investigated. An attachment relationship
may be understood as the bond between child and caregiver,
which constitutes an emotional and behavioral system aimed at
establishing and maintaining caregiver proximity in threatening
situations (e.g., Manassis, 2011). According to Bowlby (1973,
1982), caregivers who respond sensitively and consistently to
their children’s attachment-related needs and behaviors lay
the foundation for the development of a secure attachment
relationship. Securely attached children come to think of
themselves as being able to elicit proximity and care from their
attachment figures in times of distress, which allows them to
explore their environment confident that they will be able to elicit
help should they need it. Research investigating this association
has shown that well-functioning attachment relations within
families play an important role in the development of children’s
emotional understanding (see e.g., de Rosnay and Harris, 2002;
Ontai and Thompson, 2002;de Rosnay et al., 2008). For example,
Steele et al. (1999) found that infant-mother attachment at 1 year
predicted children understanding of mixed emotions 5 years
later.
In line with the research concerning children’s emotion
understanding, research focusing on childhood anxiety has
also directed its attention toward the relation between anxiety
disorders and insecure attachment relationships with parents
(e.g., Muris et al., 2000, 2001;Shamir-Essakow et al., 2005), as
well as difficulties in regulating emotions (e.g., Suveg and Zeman,
2004;Carthy et al., 2010;Neumann et al., 2010). Although several
authors have argued that emotion regulation abilities in children
may be related to attachment security (e.g., Cassidy, 1994;Sroufe,
1996), the vast majority of studies has investigated either the
association between anxiety and attachment security, or the
association between anxiety and emotion regulation abilities
(e.g., Esbjørn et al., 2012,forareview).Veryfewstudieshave
investigated the relation between emotion regulation, attachment
security, and anxiety within the same individuals (however, see
Bosquet and Egeland, 2006;Brumariu et al., 2012;Bender et al.,
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Bender et al. Emotion Understanding in Clinically Anxious Children
2015, for exceptions). Furthermore, many of these studies have
been conducted using community samples. Thus, an examination
of the associations among anxiety, emotion regulation, and
attachment security within clinical populations is called for in
order to see whether the interrelations found in community
samples correspond to those found in clinical populations
(Esbjørn et al., 2012).
In summary, to the best of our knowledge, no research
has simultaneously examined the relationships between emotion
understanding, anxiety, emotion regulation and attachment
security either within the same individuals or in clinically
anxious children. By investigating the relation among these four
variables, we should not only expand the field of research on the
development of emotion understanding among atypical children
(e.g., beyond autism) but also improve our understanding of
the interplay among these variables. It is also important to
combine these variables in the same study so as to expand
our knowledge about the role of socio-emotional factors in the
etiology and maintenance of anxiety disorders in childhood.
Although research has demonstrated that traditional cognitive-
behavioral therapy (CBT) is an effective tool in relation to
childhood anxiety (e.g., Barrett et al., 2001;Hirshfeld-Becker
et al., 2008), meta-analytical investigations have shown only
moderate effect sizes for the efficacy of CBT with children
and called for the improvement of traditional CBT treatment
(Reynolds et al., 2012). In order to develop treatment protocols
that target a greater range of the factors involved in the etiology
and maintenance of childhood anxiety, and thus, maximize
treatment outcome, a simultaneous investigation of the various
factors related to childhood anxiety disorders, such as emotion
understanding, emotion regulation and attachment, is called
for.
The goal of the present study was to conduct a preliminary
examination of the associations between children’s anxiety, their
understanding of emotions, their difficulties regulating emotions,
and the quality of parent–child attachment relationships in a
sample of children diagnosed with anxiety disorders. Because
many of the previous investigations have been conducted using
community samples, we asked whether we would find the same
associations among anxiety, emotion understanding, emotion
regulation, and attachment security, as other studies; namely
that more anxious children will show more limited emotion
understanding, greater difficulties regulating their emotions, and
report less attachment security than less anxious children (e.g.,
Brumariu et al., 2012;Bender et al., 2015). Additionally, we asked
whether a better emotional understanding in children would be
associated with less anxiety, fewer emotion regulation difficulties,
as well as more secure attachment relationships with parents, as
suggested, in theory, by the literature.
MATERIALS AND METHODS
Participants
Participants were 16 children (eight girls, eight boys) ranging
from 8 to 12 years (M=10.38, SD =1.54). Children had been
referred for anxiety treatment to the Copenhagen Child Anxiety
Project (CCAP) at the University of Copenhagen; they were a
sub-sample of children referred for participation in a randomized
trial, assessing the efficacy of two types of CBT intervention
for anxiety (Esbjørn et al., 2015). For intervention purposes, all
children had to have one of four anxiety disorders [generalized
anxiety disorder (GAD), separation anxiety disorder (SAD),
specific phobia (SP) and/or social phobia (SoP)] as their primary
diagnosis. Children were diagnosed using the ADIS-IV interview
assessment; only children scoring above the clinical cut-off for
at least one of the anxiety disorders were included. Because
studies have shown that children with cognitive developmental
delays exhibit poorer social skills and problem solving abilities
than typically developing children (Fenning et al., 2011;Wieland
et al., 2014), only children with a full-scale IQ of 85–115
were examined in the current study (mean IQ for the sample
was 105.13; SD =8.29). Also, because of previously found
gender differences with regard to childhood anxiety and emotion
regulation difficulties (e.g., Bender et al., 2012), we balanced
gender in the current study by including an equal number of
boys and girls. From the eligible sample of 21 children (13 girls,
8 boys), five girls were excluded (the eight girls included in
the current study were matched as closely as possible to boys
with respect to IQ and age). All children were Danish and
had provided valid answers to all measures of interest at pre-
treatment. See Table 1 for additional clinical and demographic
information.
Procedure
All data presented here constitute pre-treatment data. Children
were assessed at the University Clinic at the University of
Copenhagen prior to their participation in the CBT programs.
All testing was carried out on the same day by members of
the CCAP staff and students associated with CCAP. Prior to
inclusion in the project, parents had provided informed, written
consent to participate in the study. On the day of testing,
children and parents were informed that they could terminate
participation in the study at any time. Parents and children
were interviewed and assessed separately. For child questionnaire
measures, experimenters read aloud the various items and
children were asked to check the answers they felt were most
appropriate.
Measures
Anxiety Disorders Interview Schedule for DSM-IV:
Child and Parent Versions (ADIS-IV-C/P)
The ADIS-IV-C/P (Silverman and Albano, 1996)isasemi-
structured interview assessing anxiety disorders and other types
of psychopathology in children according to DSM-IV criteria
(American Psychiatric Association [APA], 1994). The instrument
consists of two separate interviews, one conducted with the
child, and one conducted with the child’s parents. Both children
and parents rate the severity of symptoms experienced by the
child on a scale from 0 to 8, where a rating of 4 or higher
indicates clinical levels of difficulties and leads to a diagnosis
of the disorder in question. Based on the separate child and
parent interviews, a combined diagnostic description of the child
is created, summarizing any number of diagnoses obtained via
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Bender et al. Emotion Understanding in Clinically Anxious Children
TABLE 1 | Sample clinical and demographic information.
n
Primary ADIS-IV diagnosis (n=16)
Generalized anxiety disorder 3
Separation anxiety disorder 7
Social phobia 1
Specific phobia 5
Number of ADIS-IV diagnoses (n=16)
One diagnosis 5
Two diagnoses 7
Three diagnoses 4
Family status (n=16)
Child lives with both parents 12
Parents a re divorced 4
Number of siblings (n =16)
Three siblings 3
Two siblings 2
One sibling 9
No siblings 2
Educational level mother (n=14)
Short 2
Medium (vocational; business, technical) 1
Medium (academic; BA) 3
Long (Master’s) 8
Educational level father (n=13)
Medium (vocational; business, technical) 3
Medium (academic; BA) 2
Long (Master’s) 8
Family income (n=13)
Below average 1
Average 1
Above average 3
High 8
See http://www.dst.dk /en/ Statistik/ emner/ indkomster /familieind komster for the
Danish average family income.
both child and parent severity ratings. In the current study, most
children presented with one or two anxiety disorders with a
maximum of three diagnoses recorded per child (see Table 1).
The ADIS-IV-C/P has been shown to be a reliable instrument
for deriving DSM-IV anxiety disorder diagnoses in children
(Silverman et al., 2001).
Screen for Child Anxiety Related Emotional
Disorders-Revised (SCARED-R)
The SCARED-R (Muris et al., 1998;Muris and Steerneman, 2001)
is a self-report questionnaire, assessing DSM-IV related anxiety
disorder symptoms in children. The SCARED-R consists of 66
items and nine subscales, which provide indices of the following
DSM-IV anxiety disorders: (1) separation anxiety disorder
(SAD), (2) panic disorder, (3) social phobia, (4) obsessive-
compulsive disorder (OCD), (5) post-traumatic stress disorder
(PTSD), (6) generalized anxiety disorder (GAD), and (7) specific
phobias. Items are rated on a 3-point Likert scale (0 =almost
never; 1 =sometimes, and 2 =often) and assess the frequency
with which children experience the symptoms described by the
various items. The total score of the SCARED-R is reported
as a sum score ranging from 0 to 132. The SCARED-R has
shown good internal consistency (Muris and Steerneman, 2001).
In this study, Cronbach’s αwas 0.93 for the SCARED-R total
score; subscale’s αranged from 0.62 to 0.90 (two items of the
OCD subscale had zero variance and were removed from the
Cronbach’s αcalculations).
Test of Emotion Comprehension (TEC)
The TEC (Pons and Harris, 2000) consists of a picture book
containing cartoon scenarios, which are accompanied by various
descriptions and stories designed to test children’s understanding
of emotions. Each scenario comes with four possible emotional
story outcomes, represented as the facial expressions of the
story protagonist, which are left blank in the scenario itself.
After children are introduced to the individual scenario and
the experimenter has read the accompanying story, children are
asked to attribute an emotion to the story protagonist(s) by
pointing at the most appropriate of the four possible emotional
outcomes. The TEC assesses nine different components of
emotion understanding: (1) recognition of facial expressions, (2)
understanding of external causes of emotions, (3) understanding
of desire-based emotions, (4) understanding of belief-based
emotions, (5) understanding of the influence of a reminder on
present emotional states, (6) understanding of the possibility to
regulate emotional states, (7) understanding of the possibility of
hiding emotional states, (8) understanding of mixed emotions,
and (9) understanding of moral emotions. The TEC yields a
total score from 0 to 9 based on children’s overall level of
emotion understanding. The TEC has been translated into 23
languages until now. It has shown good test–retest reliability, as
well as concurrent, criterion and construct validity. It has been
standardized in Italian and Portuguese (see e.g., Pons et al., 2014
for a recent review).
Difficulties in Emotion Regulation Scale (DERS)
The DERS (Gratz and Roemer, 2004) is a self-report
questionnaire, which consists of 36 items and measures
difficulties with regard to emotion regulation. Items are rated
on a 5-point Likert scale, ranging from 1 (almost never) to 5
(almost always) and assess the frequency with which respondents
experience emotion regulation difficulties. The DERS consists
of six subscales: (1) non-acceptance of negative emotional
responses, (2) difficulties engaging in goal-directed behavior
when experiencing negative emotions, (3) difficulties controlling
impulses when experiencing negative emotions, (4) lack of
awareness of emotional responses, (5) limited access to emotion
regulation strategies perceived as effective, and (6) lack of
clarity of emotional responses. The DERS has shown good
internal consistency (Neumann et al., 2010). However, it has
been suggested that the subscale assessing lack of awareness of
emotional responses be removed when interpreting the DERS
total score (Bardeen et al., 2012). In the current study, the lack of
awareness subscale was removed and the DERS index computed
based on the remaining five subscales, yielding a score from 1
to 5. Cronbach’s αfor the DERS total without the awareness
subscale (items n=30) was 0.92.
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Bender et al. Emotion Understanding in Clinically Anxious Children
Security Scale
The Security Scale (Kerns et al., 1996) is a self-report measure,
which assesses children’s perceptions of security in parent–child
relationships. The instrument consists of 15 items, which assess:
(1) the degree to which children perceive their parents as being
responsive and available, (2) children’s tendency to rely on their
parents in times of distress, and (3) children’s ease and interest
in communicating with their parents. Items are rated on a 4-
point scale using an opposing statements format (“Some kids...
Other kids...”). For example, “Some kids find it easy to trust their
mom BUT other kids are not sure if they can trust their mom.”
Children are asked to indicate which of the two statements is
more characteristic of them, and whether this statement is “really
true” or “sort of true” for them. The Security Scale yields an
overall score from 1 to 4, where higher scores indicate a more
secure attachment. In order to get a more comprehensive picture
of children’s attachment relationships, children were asked to fill
out the Security Scale for both their mothers and fathers. These
two scores were then added and divided by two to get an overall
parental attachment security score, ranging from 1 to 4. The
Security Scale has shown good internal consistency (Kerns et al.,
1996;Van Ryzin and Leve, 2012). In this study, Cronbach’s αwas
0.81 for mother, and 0.73 for father.
Cognitive Ability/IQ Index: Wechsler Intelligence
Scale for Children-III (WISC-III) Subtests
In the present study, an index of children’s IQ was obtained
using the WISC-III (Wechsler, 1991), which assesses children’s
verbal, performance, and full scale IQ. The subtests employed
in the current study included the verbal subtests Information,
Similarities, Vocabulary, and Arithmetic, as well as the
performance subtests Picture arrangement, Picture Completion,
Coding, and Block Design. Based on children’s scores on these
subtests, the full scale IQ was computed.
RESULTS
Data Analyses
In this study, we employed one-sample t-tests to test for
differences between the various measure mean scores obtained
here and mean scores found in other studies. One-sample t-tests
compare a sample mean to a known or hypothesized value
ofthemeaninthepopulation.Inthiscase,thehypothesized
population means for the individual measures were the weighted
overall means extracted from the literature (see Appendix A).
To test for associations among the various measures, we used
one-tailed, bivariate Pearson’s correlations, which measure the
strength and direction, as well as the significance of linear
relationships between pairs of variables. We chose to employone-
tailed correlations due to the small sample size of this preliminary
study, as well as the directional assumptions regarding the
correlation (i.e., positive versus negative) among the assessed
variables.
In order to see whether the current sample of clinically anxious
children differed from other samples of both non-clinical, as
well as clinically anxious children, we first compared the mean
scores obtained in this study to mean scores obtained from the
literature. Next, we examined the relations among the overall
measures of anxiety, emotion understanding, emotion regulation,
and attachment security, to see whether we would find the
associations that have been found in various, separate lines of
research in this sample of clinically anxious children. Finally,
we investigated the associations between the subscales of the
SCARED-R and the overall measures of emotion understanding,
emotion regulation, and attachment security, in order to see
which aspects of children’s anxiety symptoms explained the
relations among the overall measures. Table 2 shows the sample
means and correlations among the variables examined in this
study.
Comparison with Clinically Anxious and Non-clinical
Samples
In order to compare the mean scores obtained in this study to
overall mean scores from the literature, one-sample t-tests were
used (see Appendix A for a list of studies and values from the
literature). Results showed that children in this study did not
differ from community samples of children with regard to their
level of anxiety (M=27.31, SD =16.37) and scored significantly
lower than other samples of clinically anxious children from the
US [t(15) =−6.00, p<0.001]. However, results also showed
that children who reported higher levels of anxiety alsoreceived a
higher number of anxiety diagnoses (r=0.71, p=0.001). Results
further showed that children in this study did not differ from
community samples of children with regard to their emotion
understanding (M=7.81, SD =1.33), their emotion regulation
difficulties (M=2.27, SD =0.46), or their perceptions of parent–
child attachment security (M=3.29, SD =0.39).
Relation between Anxiety, Emotion Regulation,
Attachment and Emotion Understanding
One-tailed, bivariate Pearson’s correlations were used to
investigate the relations among the overall measures of anxiety,
emotion understanding, emotion regulation, and attachment
security (see Table 2). Results showed that children who reported
higher levels of anxiety had more difficulties regulating their
emotions (r=0.49, p=0.03) and thought of their attachment
relationships as less secure (r=−0.49, p=0.03). Although
negative, the relation between children’s overall level of anxiety
and their level of emotion understanding was not significant.
Correlation analyses also showed that children who had a more
developed understanding of emotions had fewer difficulties
regulating their emotions (r=−0.46, p=0.04), and thought of
their attachment relationships as more secure (r=0.42, p=0.05).
Finally, analyses showed that children who reported perceptions
of a more secure attachment relationship with their parents
also reported fewer difficulties in regulating their emotions
(r=−0.42, p=0.05).
To determine which subscales of the SCARED-R accounted
for the relations among the total SCARED-R scores and the
other measures, one-tailed, bivariate Pearson’s correlations were
conducted (see Table 2). The analyses showed that the association
between anxiety and emotion regulation was largely due to
an association between the OCD subscale and the DERS
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Bender et al. Emotion Understanding in Clinically Anxious Children
TABLE 2 | Sample means (SD) and correlations table.
1 234567891011
M(SD)
(1) TEC 7.81(1.33)1
(2) DERS 2.04(0.55)−0.46 ∗1
(3) SecScale 3.29(0.39)0.42 ∗−0.42∗1
(4) ADIS 1.94(0.77)−0.01 0.32 −0.20 1
(5) SCARED-R 27.31(16.37)−0.22 0.49∗−0.49∗0.71∗∗ 1
(6) SAD 0.48(0.28)0.17 0.33 −0.24 0.71∗∗ 0.72∗∗ 1
(7) Panic 0.29(0.28)−0.13 0.37 −0.46∗0.35 0.78∗∗ 0.30 1
(8) Soc. phobia 0.39(0.41)−0.16 0.26 −0.34 0.67∗∗ 0.83∗∗ 0.59∗∗ 0.48∗1
(9) OCD 0.31(0.26)−0.51∗0.62∗∗ −0.61∗∗ 0.40 0.79∗∗ 0.45∗0.62∗∗ 0.65∗∗ 1
(10) PTSD 0.44(0.51)−0.63 ∗∗ 0.41 −0.55∗0.54∗0.67∗∗ 0.36 0.46∗0.50∗0.78∗∗ 1
(11) GAD 0.44(0.49)−0.17 0.34 −0.34 0.80∗∗ 0.85∗∗ 0.67∗∗ 0.45∗0.78∗∗ 0.57∗0.62∗∗ 1
(12) Spec. phobia 0.51(0.25)−0.04 0.36 −0.24 0.36 0.76∗∗ 0.42∗0.79∗∗ 0.59∗∗ 0.46∗0.16 0.45∗
TEC, Test of Emotion Comprehension; DERS, Difficulties in Emotion Regulation Scale; SecScale, Security Scale (parents); ADIS, Anxiety Disorder Interview Schedule
(number of diagnoses); SCARED-R, Screen for Child Anxiety Related Emotional Disorders-Revised. SCARED-R subscales (reported as mean values, range: 0–2):
SAD, separation anxiety disorder; Panic, panic disorder; Soc. phobia, social phobia; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder; GAD,
generalized anxiety disorder; Spec. phobia, specific phobia. ∗p≤0.05; ∗∗p<0.01.
(r=0.62, p=0.005). The relation between anxiety and perceived
attachment security was due to associations between the Security
Scale and the Panic disorder subscale (r=−0.46, p=0.04),
the OCD subscale (r=−0.61, p=0.007), and the PTSD
subscale (r=−0.55, p=0.01), respectively. Although the
overall measures of anxiety and emotion understanding did
not correlate significantly with each other, the subscale analyses
showed significant associations between the TEC and the OCD
subscale (r=−0.51, p=0.02), as well as the PTSD subscale
(r=−0.63, p=0.004).
DISCUSSION
This was the first study to investigate the relations among anxiety,
emotion understanding, emotion regulation, and attachment
securityinthesamesampleofclinically anxious children. The
findings of the current study are in line with previous studies
showing that more anxious children have greater difficulties
in regulating their emotions (e.g., Carthy et al., 2010), and
experience attachment relationships with their parents as less
secure (e.g., Colonnesi et al., 2011). Also in line with previous
findings, this study shows that a better emotional understanding
in childhood is associated with higher attachment security (e.g.,
de Rosnay and Harris, 2002) and fewer emotion regulation
difficulties (e.g., Izard et al., 2008). Finally, this study shows that
children who report a more secure attachment also report fewer
difficulties regulating their emotions. Although previous research
has demonstrated these associations in separate studies, using
predominantly community samples, the current study combines
and extends these findings to children with anxiety disorders.
When investigating the relations between the subscales
of the SCARED-R and the overall measures of emotion
understanding, emotion regulation difficulties, and attachment
security, respectively, results showed that the OCD subscale
correlated positively with emotion dysregulation and negatively
with emotion understanding and attachment security. The PTSD
subscale correlated negatively with emotion understanding and
attachment security. And finally, the Panic disorder subscale
correlated negatively with attachment security. Although none
of the children in this study were specifically diagnosed with
OCD, PTSD, or Panic disorder, these subscales contain items
that may also be regarded as more generic indices of intrusive
anxiety problems (e.g., “I have thoughts that frighten me,” “I do
things to get less scared of my thoughts,” “When frightened, I
sweat a lot,” and “When frightened, my heart beats fast”). This
study replicates and extends the findings of previous research
on intrusive thoughts in hurricane-Katrina exposed children
(Sprung and Harris, 2010); a better understanding of emotion is
associated with less PTSD and OCD.
Although the present study cannot answer questions
regarding the causal pathways connecting anxiety, emotion
understanding, emotion dysregulation, and attachment security,
the results obtained here once again underline the relevance
of socio-emotional factors in relation to childhood anxiety.
Based on theoretical conceptions and previous research, as
well as the results obtained in this study, we can formulate
testable hypotheses regarding the interactions among these
factors. For example, research on the development of emotion
understanding has shown that parents who establish secure
attachment relationships with their children also tend to use
more mental state language in conversation with their children
(e.g., McQuaid et al., 2008). This is thought to not only provide
a safe environment for children to experience an adequate range
of their own emotions but also to teach children about emotions,
their antecedents and consequences, via discussions with their
parents (see Harris, 1999). Similarly, it has been argued that the
defining characteristic of a secure attachment relationship is the
effective parent-child co-regulation of children’s emotions in
times of distress (Sroufe, 1996). This is thought to help children
develop adequate strategies for handling their own emotional
arousal and lay the basis for later emotional self-regulatory
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Bender et al. Emotion Understanding in Clinically Anxious Children
abilities (see Sroufe, 2005). Thus, one hypothesis is that children’s
attachment relationships with parents may constitute the basis
on which developing emotional competencies are built.
Consistent with previous findings, this study found a relation
between children’s perceptions of attachment security and
reported levels of anxiety. However, recent studies (e.g., Brumariu
et al., 2012;Bender et al., 2015) raise questions regarding the
nature of this association; that is whether attachment security
relates directly to anxiety or whether the effect is mediated via
other factors. Although this could not be tested in the current
study, given the theoretical importance of attachment security
to child emotional functioning (e.g., Cassidy, 1994), as well
as the well-established link between emotional dysregulation
and childhood anxiety, another hypothesis is that attachment
security relates to anxiety via children’s emotional capacities,
including children’s emotion understanding and regulation.
Indeed, research suggests that the relation between attachment
security and childhood anxiety may be mediated by children’s
emotion regulation abilities (Brumariu et al., 2012;Bender et al.,
2015).
Although some studies have found an association between
children’s understanding of emotions and anxiety, there was
no significant relation between the overall measures of these
two factors in the current study (the only significant relation
was between emotion understanding and the specific measures
of PTSD and OCD). Children in this study were relatively old
and scored high on emotion understanding. It is possible that
emotion understanding is more strongly related to anxiety in
younger children who have a less developed understanding
of emotions. In any case, emotional understanding appears
to be a part of the socio-emotional framework surrounding
child anxiety via its links to attachment security and emotion
dysregulation. However, whereas the association between
emotion understanding and attachment security seems to be
relatively clear, the relation between children’s understanding
of emotions and their ability to regulate their own emotions is
less clear. Although it is plausible that some understanding of
emotions is necessary for an effective regulation of emotional
states to take place, emotional regulation often precedes an
explicit knowledge of emotions (Southam-Gerow and Kendall,
2002). More research is needed to study the relation between
emotion understanding and emotion regulation in children
with anxiety disorders. Meantime, we hypothesize a dynamic
relationship between the two factors based on the assumption
that the affective experiences that children collect via their
emotion regulation efforts will influence the cognitive structures
and processes related to the regulated emotional states, and vice
versa (Rieffe et al., 2005;Pons et al., 2010).
Taken together, the findings presented here and other findings
and concepts found in the literature point to a series of testable
hypotheses regarding the socio-emotional framework relevant to
childhood anxiety (see Figure 1). The proposed framework is
to be regarded as the beginnings of a conceptualization of the
relevant socio-emotional factors and their relation to each other,
as well as to child anxiety. Future research will need to refine
and revise the hypotheses laid out here. Also, a number of other
factors, such as behavioral inhibition (e.g., Shamir-Essakow et al.,
2005), peer relations (e.g., Bosquet and Egeland, 2006), cognitive
biases (see Hadwin et al., 2006), cognitive development (e.g.,
Fenning et al., 2011), and gender (e.g., Bender et al., 2012), are
likely to be related to this framework, and future investigations
need to examine how the various factors are associated with
each other. It is our hope that the revision and development
of the socio-emotional framework proposed here will lead to a
better understanding of the etiology and maintenance of anxiety
disorders in childhood, which in turn will help develop more
effective prevention and treatment protocols for child anxiety.
An unexpected finding of the current study was that children
showed lower levels of anxiety than clinically anxious children
in other studies and did not differ from community samples of
children with regard to their level of anxiety. However, previous
research has found that Danish children tend to score lower
on self-report measures assessing anxiety and worry than, for
example, US children (e.g., Reinholdt-Dunne et al., 2012;Esbjørn
et al., 2013), and that Danish individuals tend to overrate their
own health in self-report measures (Jürges, 2007). Further, we
have to keep in mind that community samples also include
children who experience clinical levels of anxiety, and thus,
FIGURE 1 | Testable hypotheses regarding the socio-emotional framework of child anxiety.
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Bender et al. Emotion Understanding in Clinically Anxious Children
anxiety levels found in community samples are not synonymous
with the expected levels of anxiety found in positively non-
anxious children. While we cannot definitely identify the
reason for this finding, the high correlation (0.71) between
children’s anxiety symptoms as assessed by the SCARED and
the number of children’s ADIS-IV anxiety diagnoses indicates
that we successfully assessed differentiating levels of anxiety in
the current sample of Danish children diagnosed with anxiety
disorders.
The present results cannot in themselves answer questions
regarding causal pathways among the various factors.
Furthermore, the findings presented here are preliminary and
based on a small sample of clinically anxious children and should
therefore be interpreted with caution. However, in an effort to
control for possible confounding influences, the sample was
carefully selected with respect to gender, age, as well as cognitive
abilities. In sum, the results underline the links between anxiety,
emotion understanding, emotion dysregulation, and attachment
security, and highlight the importance of combining the various
lines of research concerned with these factors. Although studies
separately examining the individual associations have identified
the factors of interest in relation to childhood anxiety, it is now
time to develop a comprehensive picture of the interrelations
among these factors, and future research should investigate these
using larger samples, as well as longitudinal and experimental
research designs. Based on this, as well as other studies and
theoretical concepts, a socio-emotional framework was proposed,
outlining hypotheses regarding the pathways connecting the
various socio-emotional factors to each other, as well as anxiety
in children.
FUNDING
This study was supported by grants from the Egmont Foundation
to the Copenhagen Child Anxiety Project (CCAP), at the
Department of Psychology, University of Copenhagen.
ACKNOWLEDGMENTS
We want to thank all participating children and their parents for
their contribution to this project. We also want to thank all the
staff and students at the CCAP lab, who were involved in this
project.
SUPPLEMENTARY MATERIAL
The Supplementary Material for this article can be found
online at: http://journal.frontiersin.org/article/10.3389/fpsyg.
2015.01916
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Conflict of Interest Statement: The authors declare that the research was
conducted in the absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
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Frontiers in Psychology | www.frontiersin.org 10 December 2015 | Volume 6 | Article 1916