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Transdiagnostic Case Conceptualization o Emotional

Problems in Youth with ASD: An Emotion Regulation


Approach
Jonathan A. Weiss, York Universit
y

Youth with autism spectrum disorder often struggle to review, I view emotional and behavioral problems as
cope with co-occurring anxiety, depression, or anger, symptoms that lead to significant impairment above the
and having both internalizing and externalizing symp individual's baseline level of impairment related to his
toms is a common clinical presentation. A number of or her symptoms of ASD (i.e., above the impairment

authors have designed cognitive-behavioral interven associated with the core social, communication, and

tions to address transdiagnostic factors related to multi repetitive features of ASD; as in Leyfer et al., 2006).
Distinguishing core symptoms of ASD from comorbid
ple emotional problems, although none have applied
internalizing and externalizing symptoms is particularly
this focus to youth with ASD. The current review article
challenging, and a number of authors suggest that while
describes how a transdiagnostic emotion regulation
some symptoms may reflect distinct disorders with
framework may inform cognitive-behavioral interven
unique etiologies, other symptoms are likely "co-
tions for youth with ASD, which until now have focused
occurring" issues, related to the etiology of the ASD or
almost exclusively on anxiety. Research is needed to associated with symptoms of ASD (see also the com
empirically test how a transdiagnostic intervention can mentaries by Folstein & Carbajal, 2012; Kerns & Ken
address the processes of emotion regulation and assist dall, 2012; Ollendick & White, 2012; Scahill, 2012;
youth with ASD to cope with their emotional disorders. Wood & Gadow, 2010).
Key words: autism spectrum disorder, cognitive Rates of emotional and behavioral problems are
behavior therapy, emotion regulation, transdiagnostic. high in youth with ASD, either when viewed as co-
[Clin Psychol Scl Prac 21:331 350, 2014] morbid or as co-occurring. Using a population-based
cohort, Totsika, Hastings, Emerson, Berridge, and
Lancaster (2011) report that 59% of 5-year-olds with
I N T R O D U C T I ON ASD and no intellectual disability have clinically sig
Emotional and behavioral difficulties are a serious set of nificant levels of hyperactivity, 46% have clinically
associated issues for individuals with autism spectrum significant conduct problems, and 38% have clinically
disorder (ASD) who by definition of their diagnosis of significant emotional problems. Across 5- to 16-year-
ASD already struggle with pervasive impairments in so- olds with ASD and no intellectual disability, 85% are
ciocommunicative functioning and restricted or repeti noted to have clinically significant levels of hyperactiv
tive behaviors or interests. For the purposes of this ity, 74% with clinically significant levels of emotional
problems, and 64% with clinically significant conduct
problems (Totsika, Hastings, Emerson, Lancaster, &
Address correspondence to Jonathan A. Weiss, Department of Berridge, 2011; with similar rates for youth with ASD
Psychology, York University, 4700 Keele Street, Toronto, and intellectual disability). Using an adaptive psychiatric
ON M3J 1P3, Canada. E-mail: jonweiss@yorku.ca. interview that distinguished ASD symptoms from other

2014 The Author. Clinical Psychology: Science and Practice published by Wil ey Periodicals, Inc., on behalf of the American Psychological Association.
All rights reserved. For permissions, please email: permissionsi8wiley.com. 331
This is an open access article under the terms of the Creative Commons Attribution License, which permits use,
distribution and reproduction in any medium, provided the original wo rk is properly cited.

Axis I psychiatric symptoms, Simonoff et al. (2008)


anxiety disorders being the most common set of disor
estimate that 70% of 12- to 16-year-olds with ASD
ders, at 42%. Similarly, Leyfer et al. (2006) developed
meet criteria for at least one comorbid condition, with the Autism Comorbidity Interview to distinguish
between ASD-related social avoidance from social led many to suggest that there are limitations to a dis

anxiety disorder and ASD-related agitation from gener order-specific approach to treating emotional problems
alized anxiety and found that 72% of their sample met in the general population (Dudley, Kuyken, & Pade-
criteria for at least one D S M - I V Axis I condition. sky, 2011). These issues may well extend to treating
These emotional and behavioral problems place a high emotional problems in people with ASD, given the
burden on the individual, his or her family caregivers, aforementioned rates. O n a practical level, the current
and service providers, and detract tremendously from disorder-specific approach to treatment limits our abil
individual and family quality of life. ity to address multiple comorbidities in a real-world
There is also substantial overlap of internalizing and context. Clinicians are often asked to provide treatment
to individuals with ASD who do not demonstrate
externalizing symptoms in people with ASD. Approxi
mately 4050% of youth with ASD will meet criteria for symptoms that map efficiently onto diagnostic catego
two or more psychiatric disorders when using psychiatric ries, yet who continue to struggle with stressors. A
interviews adapted to take into account ASD symptoms stress generation dynamic has been described to explain
the nature of anxiety disorders within the context of
(Leyfer et al., 2006; Simonoff et al., 2008). Individuals
with ASD who have high levels of depression or anxiety ASD and can be readily applied to explain other emo
also show increased levels of noncompliance, aggressive tional problems, such as depression or anger (Wood &

behavior, and irritability (Kim, Szatmari, Bryson, Strein- Gadow, 2010). In their model. Wood and Gadow
er, & Wilson, 2000; Matson & Nebel-Schwalm, 2007; (2010) suggest that ASD-related stressors (of social con
Tantum, 2000), and difficulties with anger, depression, fusion; peer rejections and victimization related to ASD
and anxiety are found to be correlated, both when using symptoms; prevention or punishment of preferred
behaviors or interests; and frequent aversive sensory
self-report (Quek, Sofronoff, Sheffield, White, & Kelly,
2012) and parent report data (Hurtig et al., 2009). experiences) lead to increased overall negative affectiv-
Numerous studies of children with ASD highlight corre ity, anxiety disorders (depending on the experiences,
lations within and between internalizing and externaliz social phobia, obsessive-compulsive disorder, general
ized anxiety, or separation anxiety), or depression. In
ing symptoms (Gadow, DeVincent, & Pomeroy, 2006;
Lecavalier, Gadow, DeVincent, & Edwards, 2008; turn, such negative affectivity contributes to more ASD
Leyfer et al., 2006; Weisbrot, Gadow, DeVincent, & symptoms, conduct problems, and personal distress,
which lead to even further ASD-related stressors, com
Pomeroy, 2005). This overlap is not surprising, given
that even in the general population, both anxious and pleting a negative cycle. Wood and Gadow's (2010)
model is not limited to one form of anxiety disorder or
depressed individuals are noted to have associated diffi
culties with sadness, anger, and anxiety (Rohde, 2012). even anxiety disorders more broadly. By explaining the
Such data have led authors to suggest that there may be a cycle of a broad range of stressors and emotion
shared mechanism underlying problems with emotions problems, the model highlights how transdiagnostic
mechanisms may be important contributors to psycho-
(Trosper, Buzzella, Bennett, & Ehrenreich, 2009). They
suggest that the various expressions of psychopathology pathology in youth with ASD.
are the manifestation of a broader syndrome, with
THE NEED FOR A TR A NSDI AGN OST IC C OGNIT IVE-BE HAVIOR AL
"shared psychosocial and biological diatheses" (Barlow,
APPROACH
Allen, & Choate, 2004, p. 210).
The fact that individuals with various psychiatric While there does exist an important and growing liter
ature on the efficacy of cognitive behavior therapy
diagnoses may share common underlying problems has
(CBT) for anxiety disorders in youth with ASD
(McNally Keehn, Lincoln, Brown, & Chavira, 2013;
Reaven, Blakeley-Smith, Culhane-Shelburne, & Hep
burn, 2012; Sofronoff, Attwood, & Hinton, 2005;
White, Ollendick, Scahill, Oswald, & Albano, 2009;
Wood et al., 2009), the majority of this treatment

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N4, DE C E M B E R 2014 332

research does not account for youth who specifically far less evidence demonstrating ways of treating con
have co-occurring depression or anger problems, and duct problems, oppositionality, attentional problems, or
none have examined commensurate changes in these
depression in individuals with ASD, although some
other important emotional domains. Further, there is
promising initial pilot work is emerging in these areas (e.g., used in a uniform way to target social anxiety,
(Scarpa & Reyes, 2011; Singh et al., 2011; Sofronoff, generalized anxiety disorder, and specific phobia), was
found to be as efficacious as disorder-specific CBT for
Attwood, Hinton, & Levin, 2007; Spek, van Ham, &
these conditions (Norton & Barrera, 2012) and more
Nyklicek, 2013). Having co-occurring disorders is
known to be related to poor prognosis in and follow efficacious than a group relaxation training program

ing therapy for typically developing individuals (Ro- (Norton, 2012). This group transdiagnostic treatment
also appears to result in greater improvements in co-
hde, 2012), which may also explain why a significant
morbid mood disorders compared to diagnostic-specific
proportion of youth with ASD in treatment for an
CBT from previous studies (rates of 67% improvement
anxiety disorder continue to exhibit problems with
in the transdiagnostic group versus approximately 49%
anxiety following the disorder-specific intervention
in benchmarking studies; Norton et al., 2013). Other
(McNally Keehn et al., 2013; Reaven et al., 2012;
Wood et al., 2009). Relying solely on a diagnosis- research groups have demonstrated that transdiagnostic
driven approach may make it difficult to find interven CBT for adults with anxiety and depression is effica
tions to address the underlying factors that might lead cious compared to waitlist controls, using R C T designs
to any combination of anxiety, depression, or anger- (Farchione et al., 2012; Johnston, Titov, Andrews,
related problems, which, if addressed, could facilitate Spence, & Dear, 2011; Titov et al., 2013), and may
assist in long-term relapse prevention compared to
change across several presenting problems. At the same
treatment as usual for adults who received inpatient
time, Dudley et al. (2011) note that although disorder-
CBT (Ebert, Tarnowski, Gollwitzer, Sieland, & Ber-
specific models may emphasize differences in treatment
applicability, there are considerable similarities among king, 2013). The research on transdiagnostic CBT for
evidence-based manuals, which may in fact be helpful children or youth with anxiety and depression is less
to address multiple emotional problems. This exists developed, leaving many to call for more research
even within the very limited CBT literature for chil using R C T designs (Kendall, Settipani, & Cummings,
dren with ASD, with two randomized controlled trials 2012; Rohde, 2012). To date, most research on trans
(RCTs) using almost exactly the same "tool kit" for diagnostic CBT in youth is limited to case studies (e.g.,
anger and anxiety (Sofronoff et al., 2005, 2007). Ehrenreich-May & Bilek, 2012) or open trials (Bilek &
A number of cognitive-behavioral interventions Ehrenreich-May, 2012), although ongoing R C T stud
exist targeting transdiagnostic factors that are common ies appear promising (Ehrenreich-May, Queen, Bilek,
across presenting problems, in individuals without ASD Remmes, & Marciel, 2013).
Emotion regulation is often a core focus of these
(Boisseau, Farchione, Fairholme, Ellard, & Barlow,
2010; Ehrenreich, Goldstein, Wright, & Barlow, transdiagnostic models (McLaughlin, Hatzenbuehler,
2009). While a systematic review of the evidence for Mennin, & Nolen-Hoeksema, 2011), which has been
the effectiveness of transdiagnostic approaches for youth implicated in over half of DSM-IV Axis 1 and all of the
and adults is beyond the scope of this review, there are Axis II disorders (Chambers, Gullone, & Allen, 2009).
a number of findings that suggest that a transdiagnostic For example, the Unified Protocol for the Treatment of
Emotional Disorders is a transdiagnostic cognitive-
conceptualization can inform treatment planning. For
behavioral intervention for adults with anxiety or
instance, a recent R C T in adults with anxiety disorders
(without ASD) using group transdiagnostic CBT, depression (UP; Barlow et al., 2011; Farchione et al.,
designed to address multiple types of anxiety disorders 2012) that focuses on the internal emotional experience
and emotion regulation, employing commonly used
strategies of psychoeducation, reappraisal, and exposure
(for a discussion of its development and how it differs
from traditional CBT, see Ellard, Fairholme, Boisseau,
TRA NSDI AGN OST IC CASE CONCEPTUALIZATION W E IS S Farchione, & Barlow, 2010). The UP was recently
adapted for children and adolescents (UP-Y; Ehrenreich
et al., 2009; Trosper et al., 2009), with a focus on

333

treating anxiety, depression, and anger. The eight-mod vention) and three optional modules (motivational
ule intervention consists of five mandatory modules
enhancement, crisis management, and parenting skills).
(emotion education, emotion awareness, cognitive flexi Youth remain in the module until they demonstrate
bility, exposure to distressing emotions, and relapse pre
mastery over the material (up to 21 sessions in total). problematic behavior. For instance, a child may have a
Preliminary research with adolescents demonstrates sig specific ritual that he or she likes to perform to reduce
nificant reduction in anxiety and depressive symptom test-taking anxiety (e.g., making sure his or her desk is
atology, and an increase in parent-reported child organized correctly and counting to five quietly before
emotion regulation (Bilek & Ehrenreich-May, 2012). starting). When put into practice, this ritual may be
Ehrenreich-May and colleagues' pioneering application adaptive if there are no negative consequences to it
of an emotion regulation framework (Gross & Thomp (i.e., it does not lead to social, personal, or other nega
tive outcomes) and if it does not interfere with test
son, 2007) stands to inform how we address emotional
problems in youth with ASD, who struggle in many taking. Instead, it helps the child control his or her
stress and focus on the task at hand. This same behav
respects to a greater degree with emotion regulation than
ior may be considered maladaptive if adherence to it
typically developing peers. The following article outlines
a developmental contextual emotion regulation frame qualifies as an obsession and interference with it leads
work to assist in the treatment planning for youth with to behavioral issues or problems with the ability to take
ASD who struggle with multiple emotional problems. the test. It may also be considered maladaptive if it
leads to additional negative outcomes, such as social
E MO T I ON REGULATION FORM UL AT ION
isolation.
Emotion regulation is defined as the process of effec A number of recent review articles suggest that

tively managing emotions in response to environmental problems with emotion regulation may explain many
demands and has been implicated in conceptualizations of the emotional and behavioral problems in individuals
of emotional disorders in children and adults (see with ASD. Mazefsky et al. (2013) outline the ways in
which emotion regulation impairments may be related
Aldao, Nolen-Hoeksema, & Schweizer, 2010, for a
to ASD. Given the high rates of psychiatric comorbidi
comprehensive review). Emotion regulation strategies
are typically initiated, either consciously (eflibrtful and ties, it may be that a comorbid psychiatric condition
controlled) or unconsciously (effortless and automatic), impacts emotion regulation skills in youth with ASD.
in response to emotion-eliciting stimuli, with the aim Conversely, it may be that individuals with ASD have
of altering the degree or type of a person's emotional core deficits in emotion regulation, which then
account for emotional and behavioral problems in this
experience or the stimuli (Aldao & Nolen-Hoeksema,
2010). Successful emotion regulation, through the use population, similar to the research on transdiagnostic
of adaptive and the disuse of maladaptive strategies, has factors associated with multiple psychiatric comorbidi
been implicated as an instrumental act for positive out ties in the typically developing population (e.g.,
comes in children (Garnefski, Rieffe, Jellesma, Ter- McLaughlin et al., 2011). It may also be that the same
emotion regulation impairments that are associated
wogt, & Kraaij, 2006). Whether an emotion regulation
with the onset of anxiety and mood disorders are
strategy is adaptive is determined by its outcome, as it
refers to processes that are successful in achieving the related to the presentation of symptoms of ASD, with
shared underlying clinical and biological mechanisms.
appropriate affect and do not have negative long-term
costs (Campbell-Sills & Barlow, 2007). This last point For instance, emotion regulation occurs in the prefron
is important, as it sets the stage for determining tal and ventromedial prefrontal cortex, including the
whether a particular emotion regulation behavior amygdala (Kross, Davidson, Weber, & Ochsner, 2009),
should be promoted to reduce distress or seen as a and these same areas have been implicated in the social
impairments found in individuals with ASD (Gallager
& Frith, 2003; see Mazefsky et al., 2013, for a detailed
review of the neurological basis of emotion regulation
deficits in individuals with ASD).
Ultimately, Mazefsky and colleagues suggest that
emotion regulation deficits in individuals with ASD are
related to interactions among many elements, including

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N4, DE C E M B E R 2014 334

the presence of neural circuitry that explains both


negative affectivity and hyperarousal, and of ASD-
psychiatric issues and ASD symptoms (e.g., abnormal related behavioral (e.g., lack of social motivation,
amygdala/prefrontal cortex function and connectivity), awareness of emotion) and cognitive features (e.g., per
of psychiatric conditions, of greater baseline levels of
severation, rigidity, poor problem solving, and infor predictable (and particularly nonsocial) rules, novel sit
mation processing). Given the many different potential uations that are social and unstructured decrease the
likelihood of an adaptive response (Baron-Cohen,
interactions, it is likely that multiple profiles of emo
tion regulation characterize individuals with ASD Ring, et al., 1999; Baron-Cohen, Wheelwright, Stone,
& Rutherford, 1999; Lawson, Baron-Cohen, &
(Mazefsky, Pelphrey, & Dahl, 2012), and a framework
with which to organize emotion regulation is impor Wheelwright, 2004; Minshew, Meyer, & Goldstein,
tant to understand individual differences and determine 2002). Such situations require tolerance for uncertainty,
specific ways of intervening (Mazefsky & White, 2014; learning new rules, flexibility, understanding of con
Sofronoff, Beaumont, & Weiss, 2014). text, and theory of mind, all demands that are often
Gross and Thompson (2007) describe five tempo challenging for individuals with ASD (Gomot &
rally linked domains of a personsituation interaction Wicker, 2012). The insistence on routine and ritual
where emotions can be regulated: situation selection, exhibited by many youth with ASD, which has been
situation modification, attentional deployment, cogni associated with emotional problems (Gotham et al.,
tive change, and response modulation. By employing a 2013), may lead to an increased likelihood of choosing
a limited number of pleasurable and familiar situations.
transdiagnostic case conceptualization that examines
each component, clinicians can foster a child's internal Adaptive situation selection also requires that children
skills to help him or her regulate emotions when con have opportunities to choose to experience a variety of
fronted with challenges. For instance, these five com situations, and many parents report issues around a lack
of goodness-of-fit between a child with ASD's needs
ponents serve as the framework of Ehrenreich-May's
UP-Y program, informing intervention design to and the available environmental supports, thereby lim
address emotion regulation problems in youth without iting situational options (Hodgetts, Nicolas, & Zwai-
ASD. Understanding how youth with ASD demon genbaum, 2013; Orsmond, Krauss, & Seltzer, 2004).
strate maladaptive and adaptive emotion regulation Maladaptive situation selection typically refers to
processes can greatly assist treatment planning. Figure 1 problematic avoidance of situations. Avoidance has
presents common adaptive and maladaptive aspects of long been implicated within cognitive and learning
each component, and how it can be examined with an models of emotional disorders, particularly as a mecha
ASD lens (described below). nism that maintains the association between the stimu
lus and emotional response, through negative
Situation Selection
reinforcement. It also prevents the process of extinction
Situation selection (Figure 1) involves the "purposeful and habituation from occurring (which would weaken
the conditioning). Avoidance is a common element of
approach toward situations believed to result in pleasant
emotions, and avoidance of situations believed to result anxiety disorders (Aldao et al., 2010; Rapee, 2002),
in undesirable emotions" (Trosper et al., 2009, p. 238). and depression, where individuals withdraw from plea
surable activities and social situations (Mash & Wolfe,
Staying away from a truly dangerous situation is an
example of adaptive situation selection. Successful situ 2002). It further compounds anger responses as well,
ation selection requires an understanding of context when there is a likelihood that the situation will arise
and an ability to estimate probable outcomes. While in the near future and is believed to be threatening.
When confronted with the possibility of negative emo
many individuals with ASD may have no trouble
understanding familiar situations that have concrete and tion-eliciting situations, children with ASD have been
shown to resort to avoidance more than typically
developing peers (Jahromi, Meek, & Ober-Reynolds,
2012) and may act in ways to avoid being exposed to
the situation, never building the skills or confidence
TRA NSDI AGN OST IC CASE CONCEPTUALIZATION W E IS S related to it. Youth with ASD are at increased risk of
avoiding novel situations as a result of insistence on
routine and ritual (Gotham et al., 2013), further failing

335
Situation Situation Attentional Cognitive
selection
-> modification
deployment change
Maladaptive Maladaptive Maladaptive Maladaptive Maladaptive
o - Avoiding challenging - Insisting on - Rumination - Rigid thinking - High rates of
a - Attentional avoidance - All-or-nothing
o situations safety signals physiological arousal
- Choosing situations - Modifying a - Focusing on thinking - Over- or under-
that do not promote stressful information that - Catastrophic expression of
W)
oS-i situation through supports negative thinking emotional experience
long-tenn goal
a achievement behaviors that affect - Other cognitive - Escape-related and
o - Over- or under- lead to escape or distortions other emotion-driven
a protective parental lead to negative behaviors
M outcomes
guidance
Adaptive Adaptive
- Avoiding realistically Adaptive Adaptive Adaptive
- Altering a - Awareness and - Shifting how we - Relaxation
dangerous situations stressful situation attention to think about strategies
- "Facing" challenging
to control high emotional states, situations and - Socially
situations levels of anxiety both positive and
- Choosing situations that stimuli to acceptable
without leading to negative maintain realistic methods of
promote long-term goal - Attending to
escape and reach affect emotional
achievement - Positive realistic
- Parents supporting adaptive information that is expression
outcomes and is not thoughts to - Awareness of
children and providing
congruent with counter negative context
guidance on situation one's mood ones - Distress tolerance
selection

o
>
a>
J

Parents / caregivers
o
o> Authority figures
J Peers Response
modulation

Figure 1.
1
Tr an sd ia gnos t i c e m o t i o n r egulat ion mod el . T h e five p roc e s s e s of Gross a nd Thompson's (2 0 07 ) moda l mode l of e m o t i o n regulation, with e a c h
one le a di ng to t h e next, and r e s p on s e mo du l a t i on a ff e c t ing one's situation selection or other ER d o m a i n s (Level 2). Successful e m o t i o n r egulat ion, a t a n y
one d om a i n , is con si de r e d an individual- rela tiona l inte rac tion with p a r e n t s / c a r e g i v e r s , peers, and other a u th o r i t y figures (e.g., t e a ch e rs ; Level 1). Each

proce ss m a y b e " a d a p t i v e " o r " m a l a d a p t i v e , " depending on a n y given s t r a t e g y ' s s hor t - and l on g - t e r m o u t c o m e s .
dealing with novel situations, understanding, and pre
dictive skill (Ivey, Heflin, & Alberto, 2004). Further,
to experience opportunities for increased competence the application of priming as a means of exposure to
and confidence. Similarly, they are at greater risk of assist in transitions or to new situations (Schreibman,
avoiding or withdrawing from social situations as a Whalen, & Stahmer, 2000), and programming for the
result of impairments in sociocommunicative skill generalization of skills to new situations (Kleeberger &
(Dawson & Lewy, 1989; Jawaid et al., 2012), losing Mirenda, 2010), is viewed as an evidence-based strat
important opportunities for social skills growth and egy in applied behavior analysis for children with ASD.
social engagement (Orsmond et al., 2004). Facing
emotion-eliciting situations through graduated exposure Situa tion M o d i f i c a t io n

is a foundational element of cognitive behavior therapy Situation modification (Figure 1) involves altering situ
for children with and without ASD (Munoz-Solomando, ations to address emotional responses. Successful prob
Kendall, & Whittington, 2008; Reaven et al., 2012; lem solving, defined as the conscious act of modifying
Wood et al., 2009). The use of social stories is another
strategy often employed to address weaknesses in

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N4, DE C E M B E R 2014 336

the emotion-eliciting situation or its consequences man, Heap, Crawford, & Rios, 2001), which can lead
(Snyder, 2010; Spering, Wagener, & Funke, 2005), them to act in inappropriate ways or serve to make the
represents adaptive situation modification. Individuals problem situation worse. For example, if faced with a
with ASD are known to have difficulties with social stressful situation at school, an effective solution may
and "real-world" problem solving (Channon, Char-
be to speak to the teacher, and by doing so, could of which can result in a host of emotionally driven
serve to modify the situation in an appropriate way. responses (Barnhill, 2007; Dominick, Davis, Lainhart,
An ineffective solution might be to lose control over Tager-Flusberg, & Folstein, 2007). It is also clear that
one's anger and act aggressively in class. Both options behavioral rigidities in ASD serve a host of functions in
"solve" the problem by modifying the environment, addition to those that connote safety, such as sensory
reinforcement or producing adult attention, and that
yet one is clearly more adaptive than the other. Help
ing children with ASD to problem-solve effectively is understanding this function is instrumental for develop
ing effective behavioral interventions (Kennedy,
thought to be an important part of improving their
adaptive emotion regulation (Magyar & Pandolfi, Meyer, Knowles, & Shukla, 2000).
When we do not have an opportunity to choose or
2012).
A more subtle maladaptive modification would be modify our situations, we continue to regulate our
to overly rely on "safety signals" to indicate that an emotions via our attentional deployment (Figure 1),
aversive stimulus will not occur in a situation (Camp which involves how we choose to focus or distance
bell-Sills & Barlow, 2007). Safety signals "can be inani our attention on the situation. Three aspects of atten
mate objects (e.g., a certain room in the home), tional deployment are considered here: (a) emotional
behaviors (e.g., sitting at a desk close to an exit), or awareness, (b) mood-congruent attentional bias, and (c)
other people (e.g., a parent)" (Trosper et al., 2009, rumination. Emotional awareness is defined "as an
attentional process that serves to monitor and differen
p. 238). An overreliance on safety signals teaches an
individual to depend on the external world for control tiate emotions, locate their antecedents, but ignore the
and safety and leads to a dependence on the external physical arousal that is part of the emotion experience"
signal for temporary emotional relief, instead of learn (Rieffe et al., 2011, p. 656) and has been implicated as
a prerequisite process to successful attentional deploy
ing that he or she can manage successfully in the emo
ment. Children with ASD have difficulties with emo
tion-eliciting situation. The behavioral rigidities found
in ASD may serve as safety signal behaviors, by persev- tional awareness of themselves and others (Tanaka
et al., 2012; Williams & Happe, 2010), including diffi
erating on those cues that maintain emotional relief
culties assessing and labeling their own emotions (i.e.,
(Howlin, 2004). For instance, a child who must keep
his or her desk in a specific way to avoid feeling alexithymia; Fitzgerald & Bellgrove, 2006; Hill, Ber-
uncomfortable in class is relying on that rule for regula thoz, & Frith, 2004; Szatniari et al., 2008). Poor emo
tion. When children are able to identify and distance tion awareness has been linked to internalizing
themselves from an overreliance on safety signals, they symptoms in children with and without ASD (Rieffe
et al., 2011) and is a barrier to constructive help seek
develop a positive internal locus of control, which is
related to reduced anxiety, depression, and anger ing and problem solving (Zenian, Shipman, & Suveg,
(Clark, Olympia, Jensen, Heathfield, & Jenson, 2004). 2002). Helping children to learn about emotional sig
Finally, youth with ASD who exhibit an intense adher nals, and how emotions are related to their thoughts
ence to routine and ritual may demonstrate maladaptive and actions, can improve the ability to control emo
situation modification by attempting to ensure that tions (Friedberg & McClure, 2002; Scarpa & Reyes,
their environments remain exactly the same, a violation 2011). In fact, teaching about emotions is a common
aspect of well-known behavioral early intervention
programs for children with ASD (Smith, 2006).
When individuals struggle with emotions, they often
show an attention bias on information that is related to
TRA NSDI ACNO ST IC CASE CONCEPTUALIZATION W E IS S the problem emotion, confirming its validity by being
more likely to notice situational signals that are in line
with the emotion and less able to see the signals that
are not. Regardless of whether the bias is toward
threat-related cues (common in anxiety and anger;

337

Bogels & Zigterman, 2000; Koster, Verschuere, Crom- (common in depression; Williams et al., 1996; Yovel &
bez, & Van Damme, 2005; Mineka, Rafaeli, & Yovel,
Mineka, 2005), children benefit from seeing the posi
2003; Williams, Mathews, & MacLeod, 1996; Yovel & tive and neutral elements of their situations (Groden,
Mineka, 2005) or hopeless and rejection-related cues
from one activity, rule, or interest, even when the
Kantor, Woodard, & Lipsitt, 2011). Children with
ASD may be at greater risk to focus on negative or focus is not distressing and there is no negative affect
irrelevant cues (Embregts & van Nieuwenhuijzen, (Ozonoff Strayer, McMahon, & Filloux, 1994), sug
2009), and although they are often detail oriented gesting that perseveration is related to overall difficul
ties with cognitive control. This speaks to broader
(O'Riordan, Plaisted, Driver, & Baron-Cohen, 2001),
they may miss the most contextual and central infor impairments in attention as potential risk factors and
mation required to counter their emotional states causes for rumination in individuals with ASD, rather
than the emotional experience being the cause. (Mazef-
(Farrugia & Hudson, 2006). According to parent
report, children with ASD are often less able to focus sky, Oswald, et al., 2012; Mazefsky, Pelphrey, et al.,
and shift their attention on emotionally relevant stimuli 2012) suggest that motivationaUy significant topics,
such as intense interests, may lead to dampened cogni
compared to peers, indicating that their attentional
biases may be highly rigid (Bailey, Hatton, Mesibov, tive flexibility and to impaired ability to disengage
attention and that this reduced ability can lead to emo
Ament, & Skinner, 2000; Hepburn & Stone, 2006;
tion regulation problems. This broader cause of rumi
Janes, 2001; Konstantareas & Stewart, 2006; Landry &
nation in individuals with ASD highlights the need for
Bryson, 2004). Rumination is a related maladaptive
attentional strategy, defined as "a pattern of responding interventions to address cognitive flexibility and atten
to distress in which an individual passively and persev- tional difficulties beyond emotion regulation to assist
individuals with ASD in emotion regulation tasks. Such
eratively thinks about his or her upsetting symptoms
and the causes and consequences of those symptoms, attentional deployment is a hallmark of mindfulness-
while failing to initiate the active problem solving that based interventions, which aim to bring attention to
emotions in a nonjudgmental way, promoting accep
might alter the cause of that distress" (McLaughlin &
tance and a move away from both suppression and
Nolen-Hoeksema, 2011, p. 186). Rumination includes
excessive worry and brooding, which can lead to emo rumination (de Bruin, Zijlstra, & Bogels, 2014). In
tional distress in children and youth with ASD (Rieife adults with ASD, mindfulness-based cognitive therapy
et al., 2011). As children with ASD are predisposed to has been successfully used to reduce rumination, anxi

perseverate, they are at risk of rumination, and inter ety, and depression (Spek et al., 2013). In young chil
ventions are required to improve their abilities to shift dren with ASD, particular interventions have focused
their focus toward positive topics when needed. on improving joint attention between mother and
It is important to note that the mechanisms underly child, and this improvement in joint attention has led
to improvements in emotion regulation (Gulsrud, Jahr-
ing rumination in children with and without ASD may
differ. Problems with attention in individuals with omi, & Kasari, 2010).
ASD extend beyond a problematic focus on emotion Even if we cannot control the situation or our
attention to it, our emotional reactions can be modified
ally laden stimuli or situations, or with coping with dis
through our thoughts about the situation and our
tress, and may instead be caused by broader deficits in
executive functions, including response inhibition, capacity to cope with it, known as cognitive change
working memory, cognitive flexibility (set-shifting), (Figure 1; Gross & Thompson, 2007). Reappraisal typ
planning, and fluency (Ozonofl & Strayer, 1997; ically involves using evidence to alter the valence or
Pennington & Ozonoff, 1996). It is well known that intensity of the experience (Trosper et al., 2009).
children with ASD have difficulties shifting attention Developing reasonable interpretations of a distressing
situation (i.e., reappraisal), rather than directly attempt
ing to change it, can lessen its emotional impact (Aldao
et al., 2010). Reappraisal also occurs through the inter
pretations of the meanings we place on the emotions
themselves (Gross & Thompson, 2007). Like all emo
tion regulation strategies, reappraisal is a developmental
process, which only fully emerges at approximately age

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N4, D E C E MB E R 2014 338

10 years (as cited in Chambers et al., 2009; Ochsner & that can most help youth with ASD. Children with
Gross, 2005). Prior to this age, more concrete levels of ASD are at great risk of employing maladaptive cogni
reappraisal continue to be effective, such as using posi tive change strategies, including "all-or-nothing" and
tive statements to offset negative ones, and it is these
catastrophic thinking, which can impact their interpre 1998), and youth with ASD are often susceptible to
tations of emotion-eliciting situations (Attwood, 2004; missing such cues (Loveland, Pearson, Tunali-Kotoski,
Fujii et al., 2013). They have been shown to be capa Ortegon, & Gibbs, 2001). As such, an important part
ble of developing cognitive change strategies, including of intervention is to help youth to understand the
social situation and how best to express their feelings
coping statements and thinking in more neutral or
positive ways about distressing situations, to counteract (Friedberg & McClure, 2002; Williams, Gray, & Ton-
these cognitive distortions (Beaumont & Sofronoif, ge, 2012). Teaching behavioral self-management strate
2008; Reaven et al., 2012; Sofronoif et al., 2005). gies to children with ASD is a common aspect of
applied behavior analysis and can include diflierentially
Response Modulation reinforcing prosocial ways of expressing emotions (Lee,
Response modulation (Figure 1) involves the physio Simpson, & Shogren, 2007).
As avoidance is to situation selection, escape-related
logical and behavioral ways of regulating emotion after
it is felt. For example, relaxation strategies are meant to behaviors are to response modulation, implemented
lessen physiological arousal, resulting in a calmer emo once a person experiences a distressing emotion in an
tional state (Weersing, Rozenman, Maher-Bridge, & effort to reduce the intensity. When objectively dan

Campo, 2012). Children with ASD are less able to gerous situations exist, escape is an important adaptive
sooth and are more sensitive to negative stimuli than strategy of responding to an emotional signal. How
matched peers (Janes, 2001; Konstantareas & Stewart, ever, individuals with emotional difliiculties often aim
to escape situations that they interpret as threatening or
2006; Landry & Bryson, 2004). They may also exhibit
an overall higher rate of physiological arousal (Bal undesirable, and by doing so, serve to maintain the
et al., 2010; Hirstein, Iversen, & Ramachandran, 2001; contingency linking the negative emotion to the situa
tion (Trosper et al., 2009). As such, response modula
Kylliainen & Hietanen, 2006). If used appropriately,
relaxation strategies, such as progressive muscle relaxa tion is thought to influence one's situation selection

tion, can help children with ASD to experience a neg (Gross & Thompson, 2007). Such emotion-driven
ative emotion at a suitable level, while staying in the behaviors take many forms, including withdrawal,
situation to benefit from exposure (Mullins & Chris aggression, or flight (Barlow et al., 2004), and children
with ASD are well known to react to negative emo
tian, 2001; Sofronoff et al., 2005, 2007).
tions with behaviors that serve escape functions (Jahr-
Response modulation also involves how emotions
are behaviorally expressed. Trosper et al. (2009) note omi et al., 2012). They also struggle more to tolerate
that emotional expression lies on a continuum from experiencing negative affect compared to peers (Gold
stein & Schwebach, 2004; Loveland & Tunali-Kotoski,
inhibition, to appropriate expression, to exaggeration
of emotional response. Children with emotional 1997). There is a robust literature in applied behavior
disorders are known to show both an under- and analysis indicating how differential reinforcement can
overcontrol of emotional expression, by inhibiting address behaviors that serve escape functions (e.g.,
emotional expression and by expressing it in noncon- Hagopian, Wilson, & Wilder, 2001; Harper, Iwata, &
structive, excessive ways (Zeman et al., 2002). The Camp, 2013). Helping children with ASD endure neg
ative afliect in an acceptable way, without attempting
appropriate expression of emotion is influenced by
how it is modeled by others and the larger social con to escape, is a critical component of helping them
text (Gross & Thompson, 2007; Zeman & Shipman, manage their emotions (Singh et al., 2011).

A D E V E L O P ME NTA L CONTEXTUAL FRAMEWORK OF E M O T I O N

REGULATION

Emotion regulation is described as an individual-


TRA NSDI ACNO ST IC CASE CONCEPTUALIZATION W E IS S context transactional process (Figure 1, Level 1;
Gross & Thompson, 2007) embedded within an
ecological framework of multiple systems of influence

339

(Bronfenbrenner, 1986, 1992). That is, the develop ily, school, and larger community (often described as
ment and continued use of emotion regulation require
"developmental assets"; Benson, 2006; Lerner, 2005).
an alignment among a child's internal capabilities and The comprehensive model of positive youth develop
the provision of ecological resources found in the fam
ment (or thriving) articulated by Lerner and colleagues particular context, faded as the child begins to demon
strate more competence in handling the context, and is
provides an ideal example of how an ongoing process
of emotion regulation requires particular child charac done in a way that the child gains more understanding
teristics and external supports (Geldhof, Weiner, Agans, and responsibility for emotion regulation. For instance,

Mueller, & Lerner, 2014). We are influenced by, and adaptive situation selection for children involves the
influence, our ecological assets, which include "the developmentally appropriate provision of guidance
from parents, who need to assist in choosing the appro
presence, quantity, and accessibility of human, material,
and social resources in the environment" (Lerner, priate contexts (e.g., children may not want to go to
the dentist, but parents rightly override that situation
2005, p. 40).
There are indeed key individuals who are instru selection choice). As well, through shared attention and
mental in promoting successful emotion regulation in engagement in emotion-eliciting situations, parents
youth with and without ASD. Parents play a critical help their children to attend adaptively to modulate
role supporting all children in selecting appropriate their distress (Raver, 1996).
Parental emotional scaffolding has been associated
situations, scaffolding skills and the development of
with emotion regulation in children with and without
confidence, and modeling appropriate regulation strate
gies (Gross & Thompson, 2007). Scafliblding is defined ASD, although the research is still sparse. Mothers of
as a process where a more experienced individual (e.g., children with and without ASD are able to synchronize
their behaviors to their children's attention and behav
parent) provides assistance to the child in a way that
ior (Siller & Sigman, 2002; Watson, 1998), and moth
helps him or her develop within a zone of proximal
ers of children with ASD are able to adapt their
development (Harrop & Green, 2012; Vygotsky, 1978)
and involves three overarching components: contin scafliblding to their children's individual levels of need,
both of which are critical for successful scaffolding
gency, fading, and transfer of responsibility (van de Pol,
Volman, & Beishuizen, 2010). A number of parent (Kasari, Sigman, Mundy, & Yimiya, 1988; Konstanta-
strategies, which appear to target specific emotion reg reas, Zajdeman, Homatidis, & McCabe, 1988). Parents
ulation domains as discussed above, can be used to are often integral parts of behavioral intervention pro
scaffold (Reiss, unpublished manuscript): distraction grams for children with ASD, and there is substantial
evidence that providing parents with the skills to
(altering attentional deployment), reassurance (as a
safety signal; situation modification), encouragement/ implement pivotal response training (a form of applied
behavior analysis) can assist in teaching children with
praise (response modulation), guidance/problem solving
ASD self-management skiUs (Koegel & Kern Koegel,
(situation modification), following/elaborating (elabo
rating on a child's distress), or direction/control (ver 2006; Schreibman & Koegel, 1996). When scaffolding
is present, children with developmental disabilities
bally or physically directing a child's attentional
show greater improvements in social skills, including
deployment or situation selection; Calkins & Johnson,
1998; Eisenberg & Fabes, 1994; Grolnick, Kurowski, aspects of emotional regulation (Baker, Penning, Crnic,
& McMenamy, 1998; Rubin, Hastings, Chen, Stewart, Baker, & Blacher, 2007), and more recently, Gulsrud
& McNichol, 1998). In the context of emotion regula et al. (2010) demonstrated that children with ASD and
their parents "co-regulate" emotions during distressing
tion, a parent's behavior "scafliblds" a child's emotion
events. In this latter study, 34 motherchild dyads par
regulation development if it is tailored to the develop
mental level and degree of needs of the child in a ticipated in a joint attention intervention, and the
authors studied children's emotion regulation through
behavioral observation across all intervention sessions.
The authors found that mothers (and children) were
more likely to use emotion regulation strategies during
periods of distress compared to periods without distress
and that child comfort strategies (physical self-comfort
and comfort seeking) were correlated with maternal

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N4, DE C E M B E R 2014 340

active (prompting/helping, redirection of attention, and


externalizing behaviors, suggesting that mothers are
providing physical comfort) and vocal strategies (vocal more likely to employ scaffolding in the presence of
comfort and reassurance). O f interest, maternal scaf
challenging behavior. Perhaps most important, over the
folding was positively related to children's levels of
course of the 24-session joint engagement intervention, (Jahromi et al., 2013). Unfortunately, individuals with
mothers demonstrated more emotional scaffolding, ASD are more likely to have relationships with atypical
commensurate with children demonstrating improved social agents in their environment (e.g., educational
emotional regulation. assistants, therapists, and other specialized support staff;
Recent advances in the treatment of anxiety disor Bauminger & Kasari, 2000; Daniel & Billingsley, 2010;
ders in youth with ASD underscore how parents play a Humphrey & Symes, 2010; Mesibov & Shea, 1996) as
role in the development and treatment of their chil well as negative typical relationships (e.g., peers and
dren's anxiety disorders (Reaven, 2011; Wood et al., teachers), and these relationships can have a profound
2009). Reaven and Hepburn (2006; see also Reaven, impact on the cognitive schemata children form about
2011) describe the critical role parents play in the themselves, others, and the future, greatly impacting
maintenance of anxiety in youth with ASD, and these their social-emotional characteristics (Bauminger,
influences can be applied to emotion regulation more 2007). It is important to consider the various ways that
broadly. Parents of youth with ASD are more likely to peers can be involved in supporting children's develop
ment in the five discussed components of emotion reg
experience parenting stress and parental anxiety com
ulation. For instance, there is emerging evidence that
pared to parents of typically developing youth, and
such states may predispose parents to tolerate children's peer supports (such as peer "buddies") can be used as a
maladaptive emotion regulation strategies (e.g., avoid part of cognitive-behavioral interventions for anxiety in
ance), preventing the development of adaptive coping. youth with ASD to provide ecologically valid opportu
In turn, the failure to develop a repertoire of adaptive nities for social and emotional development (White
et al., 2013; Wood et al., 2009). Typically developing
strategies leads to less perceived competence and the
perpetuation of maladaptive strategies in challenging peers have also been used to teach complex social
situations. Parent-involved cognitive behavior therapy behaviors to children with ASD through pivotal
leads to greater changes in anxiety for children with response training (Pierce & Schreibman, 2013), high
ASD compared to child-only CBT or to waitlist con lighting how peers may be instrumental in teaching
trols (Puleo & Kendall, 2011; Sofronoff et al., 2005), individuals with ASD complex socioemotional skiUs,

lending support to the need to involve parents in chil including those involved in emotion regulation.
dren's emotion regulation treatment.
C ONC L USI ON
Peers and authority figures (i.e., teachers) also play
critical roles in influencing the growth and implemen A disorder-specific approach to treating emotional
tation of emotion regulation (Jahromi, Bryce, & Swan- problems may miss the main underlying maladaptive
son, 2013). In typically developing children, self- processes that can lead to problems with anxiety,
regulation is correlated with emotional and behavioral depression, or anger, which are often found to be
engagement in school (Denham et al., 2003; Valiente, co-occurring in youth with ASD. A transdiagnostic
framework has been effectively employed to treat emo
Lemery-Chalfant, & Castro, 2007; Valiente, Lemery-
tion regulation impairments in typically developing
Chalfant, Swanson, & Reiser, 2008) and with prosocial
peer engagement and peer acceptance (Valiente, Swan- youth with anxiety and depression (Ehrenreich-May &
son, & Lemery-Chalfant, 2012). More recently, Bilek, 2012), and the components of this model have
emotional regulation has been correlated with prosocial direct relevance to maladaptive processes often found
in youth with ASD. Assessing maladaptive situation
peer engagement in preschool children with ASD
selection, situation modification, attentional deploy
ment, cognitive change, and response modulation in
youth with ASD may prove to be a useful method of
formulating individual treatment plans to address
TRA NSDI AGN OST IC CASE CONCEPTUALIZATION W E IS S emotional problems at a transdiagnostic level. Further
research is needed to empirically test how a transdi
agnostic intervention can address the processes of

341

regulation and assist youth with ASD to cope with I wish to thank Dr. Irene D rmic, Dr. J. Gayle Beck, and
anger, anxiety, and depression. the manuscript reviewers for their helpful com ments on
earlier drafts of this article. This research was supported by
ACKNOWLEDGMENTS
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(Canadian Institutes of Health R esearch
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#2 84 20 8 in partnership w ith NeuroDevNet, Sinneave Fam
Barlow, D. H., Allen, L. B., & Choate, M. L. (2004). Toward
ily Foundation, C ASD A, Autism Speaks Canada, and Health
a unified treatment for emotional disorders. Behavior
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accepted January 3, 2014.

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