Introduction:

“Emotions organize much of a child’s experience and behavior and are central to most relationships.” [1, p. 315]. They vary in nature, intensity and duration. Emotion regulation process interferes with the quality, intensity, duration and dynamics of forthcoming emotions [2]. Thus, the ability to regulate one’s emotions is considered such a crucial achievement to be reached during childhood, with many implications for child’s development, in particular, psychological adjustment and socioemotional competence [3,4]. Emotion regulation comprises a set of behaviors, skills and strategies, whether intrinsic or extrinsic, that allow regulating, inhibiting and enhancing emotional experience and expressions to meet social and overall adaptation demands and achieve personal goals [3, 5]. Thus, emotional regulation patterns became dysfunctional when they are linked to cognitive strategies that avoid the eliciting of certain emotions or/and inhibits the expression and modulation of emotions [6]. Deficits in emotional regulation are often linked to child psychopathology and mental health problems [4].

This is a clinical case of a 10 years old boy who shows difficulty in regulating and moderating his own emotions to adapt to social demands, which is now affecting his well-being. Thoroughgoing this paper, we will also, describe the assessment, case formulation, as well as, the therapeutic intervention approach and the therapeutic tools and strategies used.    

Henry’s History

Henry is a 10-year-old boy, who appears to be an older child of 12 years old, since he is very tall for his age and have a rich and elaborate social speech. He is the only child and lives with his parents.

His parents brought him to therapy because they were concerned about Henry’s difficulties in controlling emotions across diverse situations, dealing with frustration, and to relate with his peers. In the session, his mother stated “he behaves by now better for his age”. She also described Henry as sensitive, dependent (mainly on her) and, sometimes, stubborn child.

In terms of developmental milestones, it stands out difficulties in walking and significant delay in acquisition of language. Because of these difficulties, he attended a child development center where he had speech therapy, occupational therapy and was accompanied by psychologist. Around age 4, he ceased the need for such support, since his initial difficulties disappeared.

Regarding Henry’s education background, during his first years of primary school he had to change school, due to integration problems in the class, partly caused by his difficulty in defending himself from aggressive classmates, according to his mother. Now, he is finishing the fourth year of primary school. Over the years, he has had very good grades except in the area of physical education discipline. He enjoys learning and shows a great curiosity about the world and things. He plays clarinet and loves airplanes. He said that, in the future, he wants to be an aeronautic engineer.

Psychological Assessment

Prior to embark on the course of the therapeutic intervention, we conducted a comprehensive psychological evaluation of Henry’s functioning, in order to better understand the behaviors described by his parents. The assessment process included semi-structured interviews with the child and his parents, clinical observations, behavior scales and formal psychological tests.

In relation to behavioral domain, we accent the presence of substantial social problems, based on high scores of social scale obtained on the child behavior checklist for ages 4-18 (CBCL 4-18) [7].

In terms of cognition functioning, results on Coloured Progressive Raven Matrices test (CPM) [8], a measure test of general intelligence and abstract reasoning, shows that Henry has an intellectual capacity very superior than average, compared with children of his age.

In socioemotional domain, and based on the analysis of Family Test, a test that asses children’s perception of family relationships [9], Henry seems to perceive his family in a positive manner as being supportive and warm. Nonetheless, he describes his father as being too strict in terms of rules and establishment of limits at home. Besides this, he projects himself as an older child. Our hypothesis is that, this might be related to the expectations that others have of him (especially his parents). He prefers to be older, though, he told that he prefers not having to assume as much responsibilities as his parents do, which seems to show an ambivalent pattern of grow.

The results from Roberts Apperception Test for Children [10], a tool used to asses child’s social understanding by using a narrative storytelling format, corroborate the presence of an available support system for the child and suggests that limits are perceived by the child as being excessive or inadequate, based on the high scores obtained on support-other and limit setting scales.  Additionally, from the analysis of Roberts-2 data, we concluded that Henry has good cognitive skills and a satisfactory repertoire of internal resources. The narratives elaborated by Henry reveal imagination, variety of contend and coherent organization. Besides this, he obtained high scores in problem identification scale and, normative scores in resolution scales. These results are also congruent with CPM’s outcomes. Nevertheless, high values in reliance on others scale, points out that he may ask for help and/or depend on others to solve problems. This finding seems to be convergent with his mother perspective. For instance, his mother usually refers that in school when he gets into conflicts with his peers he stays in silence and does not defend himself, asking for adult intervention, as well as, at home when he has a nightmare or when he cannot fall asleep, during the night, he calls his parents. Besides this, she describes that Henry is “always clinging” to her.

Moreover, results from Roberts-2 suggest that Henry may have difficulties in regulating emotions, based on high scores on anxiety, depression and rejection scales, beyond normative range. The themes of his narratives are related to school, peer acceptance, fears and concerns about diseases and accidents, which involve him and his family, as well, as an anxiety towards the future.

Case formulation and Hypotheses of diagnostic

The assessment data suggests the existence of some disharmony between different areas of Henry’s development. Thus physical, cognitive and socioemotional areas differ significantly among themselves, which poses substantial challenges to Henry.

In terms of physical development, Henry has a very superior stature compared to children of his age. In turn, this contributes to Henry feeling different from his peers and, consequently, may inhibit a positive integration in the peer group. He considers that this physical feature attracts unwanted attention from his peers. Sometimes, they make fun of him because of this characteristic. Despite this fact, he told that sometimes he likes to be taller than his peers, because it can help him enforce respect from his colleagues.

Concerning cognitive domain, Henry shows good reasoning skills, ability to identify problem situations and imaginative capacity. Also, exhibit good verbal skills. More precisely, his speech reminds of an older child because he frequently uses a rich vocabulary and likes talking about “adult issues”, for example, money management, home management, social questions and career choice. All these abilities combined suggests that Henry has a good intellectual potential, as also confirmed by data from formal testing. This reflects on Henry’s ability to be well succeeded in school and manage effectively most of the academic challenges. Additionally, Henry enjoys learning and is always looking to have the best scores on tests. His parent’s educational expectations may have influenced positively Henry’s attitude towards school. Parental educational expectations on literature plays an important role in children’s success at school and are linked to student’s motivation, high scores on tests and attending college [11, 12, 13]. School, top grades, attending college and choosing a status quo profession are strongly valued by Henry’s parents. It is important to mention that Henry’s parents have higher academic qualifications.  

Yet, in socioemotional domain, Henry presents difficulty in regulating emotions, especially negative ones, such as anxiety and rejection, and to adapt and interact in social contexts, based on data from Roberts-2, clinical behavioral observation and interviews. Henry might be at risk of developing an emotional disorder. According to Thompson and Calkins [14] children at risk for, or diagnosed with a psychological disturbance usually exhibited inhibition of emotion expression and poor control over them. In particular, anxious children tend to experienced emotions in a more intense way than those non-anxious children [15], even though they may have good comprehension of emotions, because they frequently adopt maladaptive strategies such as distraction and avoidance [16].  Besides this, these children are often characterized by their mothers as being more inflexible, labile and emotionally negative [15]. This is in line with the description given by Henry’s mother in regard to her son behaviors. More concretely, she told that Henry gets frustrated easily and is a bit stubborn. 

In addition to this, Henry presents distress and high anxiety, accompanied by physical symptoms, such as tremors and muscle tension, when he faces certain situations (e.g. peer conflict; not be succeeded in something, being alone, anticipating separation of parental figures) or has negative and unhelpful thoughts about something bad might happen to him or parents, like accidents, disease, and losing a loved one. He usually tends to avoid those situations or/and talking about unpleasant emotional experiences and thoughts. Intrusive and catastrophic thoughts/worries, avoidance behavior and physiological responses shown by Henry are considered common symptoms of anxiety [16].  Furthermore, anxiety disorders are very common during the childhood [17].

Taking this into account, we first ponder that Henry’s behaviors could be better explained by the presence of a separation anxiety disorder (SAD). Henry presented some common feature of SAD as frequent worry about losing parental figures or about possible harm happens  to them, such as accidents, injury and death, as well as intense anxiety and fear of or reluctance about being alone at home or without major attachment figures, according to Diagnostic and Statistical Manual of Mental Disorders DSM-IV-R (i.e., DSM-IV-TR) [18]. However, this symptomatology does not seem to severely disturb Henry’s functioning in daily life or causes him excessively distress that extending for long periods of time. Henry feels confortable at school and attending extra-curricular activities, without his parent’s presence.

Excluding the hypothesis of SAD, we also considered that some behaviors presented by Henry such as irrational and uncontrollable worry could be associated to generalized anxiety disorder (GAD). Uncontrollable worry is assumed as core feature of GAD [18].  Despite he frequently expresses concerns and worries about diverse themes, such as losing a parent, diseases, accidents, and injury and future, they do not meet yet the criteria of time duration (at least six months) neither severity, proposed by DSM-IV-R.

Therefore, we argued that Henry’s symptomatology and behaviors may be in borderline zone, between normal and pathological anxiety. Although some anxiety, fears and worries are part of normal development of child [19], in this case, it seems that Henry is experiencing more intensely, as well as, showing difficulty managing them appropriately.

Henry’s tendency to worrying too much may be linked to his capacity to reasoning, abstracting and establishing deductive associations. As stated by [20] Vasey, Crnic and Carter (1994) to be concerned and worried, a child must be able to anticipate and predict future events. Worry and more complex worry are a characteristic of older children up to 8, given their cognitive level of development achieved [21]. 

Yet, Henry difficulties in regulating emotions may be, at some extent, influenced by how his parents address emotions. According to [22, 23, 34] parents who encourage the expression of emotion and coach their children regarding their emotions have children more capable of regulating them. Henry’s parents seem not to encourage freely expression and discussion of negative emotions (such as sadness and anger) with the child.  This might inhibit Henry ability to identify, express and cope with negative emotional states.

Regarding social problems expressed by Henry (e.g. peer integration and withdraw) these may be correlated with his difficulty in managing emotions. Successful social interaction implies that children must be capable of identifying and understanding their own emotions and others and also modify their emotional responses to the demands of the specific social context. Thus, requires that children have a good repertoire of strategies to manage their emotional experience [23, 36] .  It is important to note that Henry does not like to play sports, which is not a plus point to favor his integration with peers during the breaks at school. Also, he likes to talk about specific interests and issues (“adult issues”), which are not usually considered interestingly for other children of the same age, creating a barrier between him and others.

We consider that Henry might be at risk of developing an emotional disorder, since he already shows some anxiety symptomatology. Thus, the therapeutic intervention could address this symptomology, preventing these to become more intense, severe and crystalized over the time.  Hence, anxiety disorders in childhood tend to persist during the adulthood [17, 37].

Therapeutic Intervention 

The intervention grounded mostly in the principles of emotion-focused cognitive-behavioral therapy focused (ECBT) and its components (e.g., emotion psychoeducation, reframing emotions, cognitive restructuring, relaxation exposure) to address Henry’s emotional-related difficulties.  The cognitive behavioral therapy (CBT) focuses on how individuals mediate the information processing. Children’s interpretations about his/her experiences shape his emotional experiences [24].

The emotional component was our main focus, since Henry shows significant difficulty in regulating his emotions. Emotional competent is assumed to play an important role in children social adaptation and emotional adjustment [6, 25]. In addition to this, empirical work suggests that therapy must address not only dysfunctional cognitions and behaviors, but also problems related to emotion regulation [2]. Therefore, therapeutic intervention should focused on building a repertoire of emotional skills, beyond anxiety management. Research shows that 1/3 of anxious children after intervention still show considerable levels of anxiety [23]. Integration of emotional component in therapy may enhance the results of cognitive behavioral therapy protocols. Therefore, children, who have received an ECBT approach, show improvement in their ability to identify emotions, discuss emotional experiences and understand emotion regulation strategies [23].  Also, this therapeutic approach seemed to be compatible with some of Henry unique personal characteristics, such as abstract and reasoning ability and excellent verbal regulation skills, as well as, his stage of development.

Setting therapeutic goals

The therapeutic goals were formulated, based on Henry’s problems and key competencies to be promoted throughout therapy, in order to reassure his well-being and healthy development. The therapeutic aims were: a) establish a therapeutic alliance and involvement in therapy; b) promote the identification, recognition and understating of his own emotional experience and learn to recognize the emotions expressed by others; c) develop a repertoire of strategies for self-regulating emotions; d) promote more adaptive ways of reframing cognitive and emotional experiences; e) promote the development of social skills and cognitive problem solving and f) promote autonomy.

Course of the Therapeutic Intervention

In this part, we present the therapeutic work that we have been conducting with Henry in the first six therapy sessions, organized according to the goals set for therapy, and the guidelines for next sessions.

Establish a therapeutic alliance and involvement in therapy. As stated by [24]  efforts to create a pleasant therapeutic atmosphere and motivation for therapy are crucial for children to be able to enjoy being at therapy and for their further participation in the process. Unlike what happen with most cases with adults, children usually not seek for help, but are their parents or others authority figures that sent them to therapy.

Thus, in order to foster Henry’s engagement in the sessions, we worked on increasing his understanding about his problem and the reasons that led his parents to bring him to therapy. We also defined the goals for therapy. Henry asked for help in being more social (“I want to become a little less anti-social, because my dad says, sometimes, I am like an anti-social kid”).

In addition to this, at the end of each session, we always performed a ludic activity, chosen by Henry. These moments in therapy were important, which allowed strengthening the therapeutic alliance with the child and explore his inner feelings, which he tends to hide or avoid talking about it in therapy. According to [25, 26] through ludic play children can more easily express their emotions.

Promote the identification, recognition and understanding of his owns and others emotional experience.  For these purpose, we performed different ludic activities with Henry, in the sessions, such as the clock of emotions, the dictionary of emotions and the identification of emotions in the body. 

The clock of emotions has been used at the beginning of each session. We had chosen this activity to help Henry name and express more easily his emotions at the moment, by adjusting the pointers of clock.  In this clock the place for the hours are replaced by different emotions/feelings, such as pride, guilt, sadness, happy, nervous, calm, angry, ashamed, sadness, among others. We also used this activity to explain the nature of emotions and its variation over the time by moving the pointers in the clock.

Yet, the construction of a dictionary of emotions in therapy, involved writing a list of emotions and feelings by the child. Firstly, he wrote the emotions/feelings he already knew as angry, sadness, happiness, fear, and guilt and then he added others, with our help.  This activity allowed Henry to gain more vocabulary related to emotions/feelings, which can assist him to better respond in social interactions.

Through the activity “emotions in the body” we addressed, mainly, how emotions could be expressed in the human body. For that, we asked Henry to identify in which parts of the human drawing figure manifests certain emotions like angry, fear, happiness, sadness and guilt. Naming emotions in the body helps children to develop some sense of control over emotions and the possibility to change them [2, 27, 28].  In this activity, Henry was able to identify some of physical reactions linked to emotions (e.g., butterflies in stomach signal of anxiety), revealing that he have some knowledge about the way emotions make us feel.  As literature mentioned, anxious children may have knowledge about emotions, yet they have difficulty selecting adaptive strategies to manage them [20]. In addition to this, Henry has also identified emotions in the head of human drawing, saying, “Emotions are in the mind”. Given that, we used his expression to explore and explain the link between emotions and thoughts. According to [2] it is important that children understand that negative thinking patterns may elicits negative emotions, for example sadness, anger, shame, guilt, fear, anxiety and avoidance. Moreover, in this activity, we asked the child to think about situations where he had experienced the emotions identified in human body.  This is a significant aspect, because if children learn to be aware of what emotions they can feel in certain situations, they can prepare themselves to cope with those emotions [2].

Develop a repertoire of strategies for self-regulating emotions. For this end, we used a board game, called “Gostarzinho” (translating into English means approximately “Liking”), that addresses specifically the area of affectivity. In this game, the child has to perform various tasks, for instance solve problem-situations presented, role-plays, identify and represent emotions through mimic, among others. This activity provides a good therapeutic pathway for working on adaptive emotional coping strategies in a more appealing way. According to [27] play allows mental space for introspection, learning, problem solving, coping and mastery. We also chose this activity since Henry likes to play board games. At the beginning of the game, Henry showed a great enthusiasm, but as the time passed, he started to get bored and turn off the task.  He commented that he felt a little annoyed when doing some of those tasks. This, in it self, was very therapeutic because through this game, we could identify and work on some resistances exhibited by Henry in addressing emotional issues.

We also resorted to books, as therapeutic tools, to work on the development of emotional repertoire skills. Bibliotherapy is more than reading books, involves reflection about what we are reading.  Through bibliotherapy, children can improve their assertiveness, empathy toward others, self-confidence, as well as, their ability to reflect and solve problems (Lucas & Soares, 2013). In therapy we used, for example O grande livro das emoções; in english, “The greatest book of emotions”) [29]. This book comprises twenty stories and some of them address specific emotions and feelings such as fear, anger, sadness, guilt, among others. Through some of these stories, we reflected with Henry, about the emotions expressed by characters of the story, why they felt in that way in certain situations, and what are the strategies they have used to cope with their emotions. As a supplement we asked Henry to write about other possible strategies that those characters could have used to manage effectively their emotions and problems.

Building specific strategies to cope with emotion of fear. During the sessions, it was given a special emphasis to the emotion of fear and we invested on developing specific strategies to assist Henry´s dealing with fear. We started by psycho educating him about the nature of fear and anxiety and their role in our daily life. Then, we tried to understand which situations trigger anxiety or fear on Henry. For this purpose we did an activity, which consisted in identifying the most and less fear situations, among different situations presented. He identified the following as most fearful situations: being alone, something bad happen to his parents, getting dark, boating, diseases and death. From this activity, we constructed a hierarchy of fears and develop a supervised exposure plan for subsequent sessions.

Furthermore, we trained, in session, some relaxation techniques, such as progressive muscle relaxation and diaphragmatic breathing, as proposed by CBT approach [2]. Relaxation training helps children to be more aware and control over their physical responses to anxiety [2]. We also set these as homework tasks and recommend that Henry use them when he felt anxious or tense.

Guidelines for future next sessions. Although, throughout the therapeutic process, Henry had shown a greater ease in identifying emotions in himself and in others, through verbal responses and non verbal responses; less inhibition in talking about emotions (e.g., takes the initiative to share some of his emotional experiences, without having to be his mother telling him to do so) and has shown a decreased in anxiety when addressing unpleasant experiences  (e.g., reducing tremors, distraction, cognitive avoidance), it is still important to consolidate and enlarge these changes in further sessions. Additionally, we need to continue assisting him in building a good repertoire of strategies for self-regulation of emotions, in order to be more autonomous in managing his own emotions and, consequently, adapting to situations. To this end, it may be useful to resort strategies as cognitive restructuring, reframing emotional experiences, refocusing attention and problem solving, among others, as suggested by [2].

Through cognitive restructuring, it is possible to rework the negative thinking patterns of the child, interchanging those by other more adaptive patterns of thought. This is important because by changing the thought patterns, emotions altered too [2]. Combined with this strategy, empowering Henry to reframe emotionally stressful experiences in a more adaptive and positive way are crucial, as anxious children tend to interpret negative or neutral events as stressful [2].  In addition to this, we intended to teach Henry to refocus his attention from negative and stressful situations to positive or neutral emotions stimuli. This strategy seems to be helpful for anxious children when they are attempting to regulate negative emotional states [2]. 

Moreover, problem-solving training in future sessions constitute a valuable complement to the therapeutic process, as it allows the child to identify emotional challenging situations and find solutions to them [2]. 

Additionally we aim to focus on developing social skills, including empathy, assertiveness, conflict resolution, adjusting non-verbal responses, initiating conversation, among others.  We began to foster emotion regulation skills first, since this competence is crucial to allow interpersonal relatedness, personal assertiveness, and sympathy towards others and prosocial initiative [30].

Enhancing Henry’s social competence is fundamental, since children must be able to handle a range of challenging social situations in everyday life (Spence, 2003). This will be promoted mainly through role-plays, social problem solving, feedback, modeling and self-talk, as suggest by [31].

Furthermore, we will work with Henry in implementing these strategies, as well as, competences learned, in sessions, in the real life contexts by setting homework tasks and behavioral tryouts in the therapeutic setting.

Finally, we also intend to involve parents more in the intervention process. It is vital that parents support and motivate their son to perform the tasks proposed in therapy. We will also work with parents to reinforce the gains made by Henry across therapeutic process. Besides this, we aimed to encourage parents to cultivate an openly discussion about emotions and feelings in family context, guiding also the child in identifying strategies to manage challenging situations. By developing socioemotional competence, we will also foster Henry´s autonomy.

Conclusion

Through this paper, we presented a clinical case of a boy, who is experiencing difficulties in managing and modulating his emotions, aimed at reflecting on therapeutic approach and its tools and strategies that may be useful for addressing this issues in therapy context. We followed an emotion-focused cognitive behaviour approach, integrating the emotional component in the therapy work. An emotional component can be beneficial and a complement to cognitive strategies and solving problems skills in the therapy sessions, as referred by [4]. In fact, many problems experienced by youth are due to their unregulated emotions, such as intense anxiety, powerful anger and deep sadness, and not only caused by their disruptive thoughts or challenging situations .  Therefore, therapeutic intervention should not only emphasis the modification of the maladaptive thinking patterns and/or behaviors to external events, but also includes the regulations of emotions [4].

Thus, it is very important to assist child in recognizing, understating his/her emotions on her and on others, as well as to regulate and moderate his/her emotional states [4]. Thus, how can we educate children for emotions? Adults play a critical role in coaching children through affective and emotions path [2]. Therapists and other educators, such as parents and teachers, should encourage children to freely express and share their emotions, both positive and negative ones, to discuss emotions openly, and to analyze healthy ways to manage emotions without suppressing, avoid or deny their existence [4, 32].  Additionally, adults should share their emotions; theirs struggles in regulating emotions and provide examples of strategies they have used to cope with challenging emotions. In addition to this, it is vital to support children reframing their emotional experiences into a more adaptive and positive manner [2]. Thus, helps children to cope with unpleasant experiences. 

To open doors for the expression of emotions, among children and adults, it is imperative to provide a positive, supportive and warmth atmosphere, where the children can feel comfortable to share their inner feelings and emotions and be themselves, without being afraid to be judged or rejected. In therapy, in particular, the use of various strategies and dynamic and creative tools (e.g. games, books, among others activities), aiming to educate about emotions and work on development of emotion regulation skills, helps to have access to children’s inner world and, lower their personal barriers.

Besides this, validate and normalize children’s emotions are fundamental aspects that assist children at integrating their emotional experiences and its meanings. Emotions are organizers of inner experiences [33], a part of their experience, as well as, influence the child psychological adjustment. Emotional competence boosts key competencies, as self-control, assertiveness, solving problem, relatedness in relationship, empathy towards others  [30, 35, 38], which are essential to raise healthy children and, consequently, in the future, adults more capable to adapt and fit in demanding world.

Finally, in this particular case, through the development of socioemotional competence, Henry is progressively discovering himself in a new perspective; learn to feel and to relate differently with his self and others, with his emotions and with the world.  His inner world, unknown and disorganized earlier, begin to gain a direction, an order and organization.  As Henry develops news skills for managing his emotions, he gets a greater sense of control over challenging emotions, contributing to feel more confident to face social challenges and daily demands. Indeed, he looks now “bigger” than before, neither in height nor in cognitive domain, but in his capacity to manage and regulate his emotions.