Given the clear role of emotion regulation as a foundational process that, when developing optimally, contributes to healthy development, but when gone awry, introduces risk for a variety of psychological disorders, it is a critical target for many psychosocial prevention and intervention approaches. For young children, whose ongoing development in a variety of domains makes their general emotion knowledge and skills more limited than older adolescents and adults, prevention and intervention programs often start with the building of basic emotion knowledge, such as acquiring and practicing an emotion vocabulary and developing an understanding of nonverbal emotion cues (e.g., facial expressions). Given that emotion regulation capacities develop over the course of childhood and adolescence, aspects of caregiver–child coregulation are incorporated into many of the evidence-based prevention and intervention programs for youth.
Enhancing Emotion Regulation Across the Family System
Although caregiver–child coregulation is undoubtedly important, it is notable that other family subsystems, not to mention the entire family unit, are not systematically targeted by most youth prevention and intervention programs. This is at odds with the research (reviewed above) indicating the importance of emotion regulation within other family dyads (e.g., co-caregivers, siblings), and larger family systems (i.e., triads and beyond) on children’s emotional well-being. Whole family approaches
do have a long history in psychosocial prevention and intervention; family therapy approaches (e.g., structural family therapy, strategic family therapy) have long focused on the multiple streams of interaction among and within the multiple family subsystems that make up whole family units. Yet, the focal target of treatment of most traditional family approaches is not emotion regulation specifically, but rather other family structures (e.g., hierarchies, boundaries) or processes (e.g., storytelling, problem-solving; (Tadros,
2019).
This section will discuss ways in which we might bridge across these previously parallel paths of intervention by explicitly targeting emotional processes at multiple levels of a family system beyond the caregiver–child dyad (including the coparent system, the sibling relationship, triads and beyond) via psychoeducation, skill-building, and in vivo family emotion regulation practice. Psychoeducation, which is a core component of most prevention and intervention programs, serves to help individuals understand the nature of their presenting difficulty. Frequently, newly learned information is then applied within the context of skill-building activities that help families attain their treatment goals, and often these skills are practiced in sessions. We include a discussion of some of the innovative work that has already begun to make progress toward this goal.
Coparent Subsystem
Psychoeducation and skill-building on family emotion regulation may be done with any configuration of family members, and does not necessarily require all members to be present in order to have an impact on the entire system. For example, enhancing emotional coregulation among caregivers can have a significant impact on child well-being, as improving relationships between caregivers may lead to more coordinated coparenting, modeling of healthy coregulation, and a more positive family emotional climate.
In general, caregivers may benefit from a more explicit understanding of how emotion dysregulation can reverberate throughout the entire family system, including how their expression and management of their own emotions can impact other family members (i.e., children, other caregivers in the family). Psychoeducation regarding emotional coregulation as a family-level process may be especially important in families with young children, as it is not uncommon for caregivers of infants and toddlers to underestimate how attuned young children are to their environments. Infants as young as 9 months old spend more time looking at adults expressing anger than those expressing positive or no (i.e., neutral) emotion (Moore,
2009; Repacholi & Meltzoff,
2007). Yet, in our clinical experience we have found that caregivers have a tendency to dismiss the impact of very early life events on their child, saying “They were just a baby, they didn’t know what was going on.” Even in infancy, exposure to ongoing parental conflict can have generalized and long term effects: 6-month-olds exposed to a high level of interparental conflict or domestic violence (respectively) showed poorer physiological regulation during a mother-infant interaction (Moore,
2010), and heightened sensitivity in response to anger expressed by an unfamiliar adult (DeJonghe et al.,
2005). Sensitizing caregivers to how attuned even very young children are to their interpersonal environments may encourage them to view the establishment of a healthy emotional climate in the family as foundational to their child’s development. There are a few types of preventive interventions that engage the coparenting system without the child present, but with the ultimate goal of promoting child development. These programs are generally positioned around family events that are likely to elicit stress and conflict, such as the transition to parenthood and parental separation (e.g., Feinberg & Kan,
2008; McHale, Updegraff, et al.,
2012; McHale, Waller, et al.,
2012), but, surprisingly, they generally do not explicitly focus on how caregivers coregulate
one another’s emotions.
Caring for children is an emotional and often stressful endeavor (Bradley et al.,
2013; Hajal et al.,
2019), and families in which there are multiple caregivers (whether a parent, a non-parental relative, or non-relative caregiver) may benefit from being able to lean on the support of their co-caregiver when needed. This is important for all families, but especially families in which a caregiver is ill. As one example, it is well established that parental depression has a negative impact on children’s socioemotional adjustment; the relation between parental depression and children’s adjustment appears to operate through a variety of factors, including the depressed caregivers’ parenting practices, lack of engagement, and displays of negative emotion (Goodman et al.,
2011,
2020; Lovejoy et al.,
2000). However, research suggests that sensitive caregiving from a non-depressed caregiver can buffer the negative impact of maternal depression on overall family functioning (Vakrat et al.,
2018a) and child socioemotional adjustment (Vakrat et al.,
2018b), even in families where there are multiple risk factors (e.g., teen mothers who are depressed; (Lewin et al.,
2015). Furthermore, longitudinal research suggests that the buffering effect is long-lasting, including from perinatal maternal depression to 12-month child development (Goodman et al.,
2014), and maternal depression during infancy to kindergartner internalizing symptoms (Mezulis et al.,
2004). Observational research with infants suggests that the buffering effect of father involvement operates not only through warm or sensitive fathering, but also through its association with increased family cohesion during triadic interactions with the infant and reduced maternal distress (Feldman,
2007). Thus, families in which a caregiver is depressed may benefit not only from individual treatment for the depressed caregiver, but also coparent or family-level regulation that aims to shore up the capacities of the non-depressed caregiver, whether as a support to their partner, their children, or both. Partner-assisted therapies for perinatal depression (in which the depressed caregiver’s partner is involved in at least one session) have been developed, and initial studies suggest promise for this approach, although there are not yet enough data to test whether adding a patient’s partner adds incrementally to established individual therapy approaches (Sockol,
2018). Future clinical research in this area should assess multiple aspects of family functioning, including perceived quality of the coparenting relationship and child adjustment.
Basic family science research suggests several other areas that could be fruitful for intervention developers to consider integrating into their approaches. Many dyadic interventions focus on reciprocal interactions between a young child and a single caregiver (e.g., Dozier et al.,
2002; Lieberman et al.,
2000; Luby et al.,
2018). Yet, there is evidence (McHale & Fivaz-Depeursinge,
1999; McHale et al.,
2008) for the emergence of “triangular capacities” in infants as young as 3 months wherein they are able to competently coordinate their attention and the exchange of affect in the context of triadic interactions (i.e., infant interacting with two caregivers). A next step for intervention could be to integrate provider coaching of caregivers during whole family interactions in addition to dyadic interactions.
Additionally, many behavioral parent training approaches involve creating a “parenting plan,” or, advance planning of adaptive strategies that caregivers can use in response to children’s behaviors. Although originally stemming from a heavily behavioral perspective, some contemporary programs integrate discussion of parents’ and children’s emotions into the creation of parenting plans. One potential area for future work is for intervention approaches to create a similar plan for coregulation during coparenting. This might include advance discussion about how best to coordinate efforts to provide coregulation to a distressed child and ensuring they are not working at cross purposes. For example, if one caregiver is attempting to distract a dysregulated child, it would be important for the other caregiver to follow their lead rather than trying to re-focus the child on a discussion of why they are upset. A caregiver might also reinforce the existence of a secure family base by overtly narrating and praising the other caregiver’s efforts to provide coregulation for the child (“I bet that hug from Grandma is helping you feel better!”). Caregivers might also work together to navigate emotionally charged family interactions by allowing one another to “tap out,” stepping in to soothe a distressed child when the other caregiver needs a break. This kind of coordination can be difficult to execute when family interactions are highly dysregulated, so it might be beneficial for caregivers to communicate and plan in calmer moments about how they might work together as a team in those more dysregulated moments.
The value of intentional discussions about how to approach coregulation as coparents also extends to communication that can happen after emotionally charged family interactions. Emotion regulation in family systems is a dynamic process (Butler,
2011; Calkins,
2010), in which dysregulated interactions can continue to echo through the family even long after specific interactions have ended. By periodically debriefing outside of the heat of the moment, coparents can reflect on both their own and other family members’ experiences of the interactions. Taking time to process and deconstruct emotionally challenging interactions with their child may strengthen the coparenting dyad by allowing them to clarify miscommunications, discuss differing perspectives on how to manage a highly distressed child, and allow them to plan for any different strategies they might want to try in the future, all of which may lessen the negative residue of such moments. Moreover, as children mature, they can be included (when appropriate) in these post-dysregulation discussions to further reinforce the norm that emotional experiences can be openly discussed and navigated as a family.
Sibling Subsystem
Perhaps even more than the coparent subsystem, the sibling relationship has been relatively neglected in terms of emotion-focused prevention and intervention. Given the impact that siblings have on one another’s emotion socialization (Kramer,
2014) and development of psychopathology (Buist et al.,
2013; Feinberg et al.,
2012; Kramer & Conger,
2009; Whiteman et al.,
2020), this is a significant gap. Furthermore, the quality of the sibling relationship has an impact on the larger family system; for example, one study showed that sibling agonism had an impact on parent emotional reactivity and regulation (Ravindran et al.,
2015). In some family constellations, such as when children are in foster care (Kothari et al.,
2017), or experience another type of caregiver separation (e.g., military deployment; Whiteman et al.,
2020), the sibling relationship might be the most consistent close family relationship, at least for a period of time. Thus, it may be particularly important to address enhancement of sibling relationships for children who face adversity.
A few sibling relationship interventions exist, all of which address emotions to some extent (Feinberg et al.,
2013; Kothari et al.,
2017; Updegraff et al.,
2016). For one program, The More Fun with Sisters & Brothers Program (MFWSB; Kennedy & Kramer,
2008), promoting family-level emotion regulation is central to the theory of change. MFWSB is based on the idea that emotion socialization and learning occurs partly via sibling relationships (Kramer,
2014). It posits that enhancing sibling
prosocial behaviors is just as important, if not more so, than reducing sibling conflict and rivalry (Kramer,
2010), and views building emotion regulation capacities as a key skill that can enhance sibling relationships (Kennedy & Kramer,
2008; Kramer,
2010). An individual family intervention, all family members receive psychoeducation in seven key social–emotional skills shown by research to promote positive sibling relationships (Kramer & Gottman,
1992; Kramer & Kowal,
2005), which include identifying emotions, perspective taking, regulating intense emotions, and managing conflict. Most sessions are dyadic sibling sessions that involve in vivo practice, with provider coaching, of the sibling skills; caregivers are heavily involved in “transfer of training” activities such that they can guide the generalization of these skills to the home setting. A randomized controlled trial showed that MFWSB increased sibling prosocial behavior and decreased sibling conflict. In line with the view that the quality of the sibling relationships reverberates throughout the family system, MFWSB also had a significant positive impact on parents’ emotion dysregulation (Kennedy & Kramer,
2008).
There are several challenges in building sibling interventions, which may partly explain the relatively scant attention paid to this family subsystem from an intervention perspective. First, unlike other family subsystems, in which at least one partner is an adult, the sibling relationship involves at least two children, whose developmental stages might vary widely. Current sibling interventions provide at least some age-related boundaries; for example, MFWSB is for families in which both siblings are between 4 and 8 years (Kennedy & Kramer,
2008), the multi-family group-based Siblings Are Special program (Feinberg et al.,
2013) is for 5
th graders and their younger siblings, and the individual family-based SIBS-Foster Care program (Kothari et al.,
2017) requires that the older sibling be between the ages of 11 and 15 years. These age parameters make sense given the wide variety of developmental capacities in the skill areas that these interventions focus on (e.g., perspective taking, social skills, emotion regulation) and the activities that siblings might engage in together (e.g., play for young children, versus a conversation for adolescents). However, there remains a need for programs that address other sibling constellations, not only in age ranges but also in number of siblings, biological relatedness, etc. Future intervention development work might also explore adding sibling relationship psychoeducation and skill-building components on to whole family interventions; some examples of this are described below.
Whole Family System
Depending on the developmental level of the child, psychoeducation, skill-building, and in vivo practice of family emotion regulation may be implemented at the whole family level. Due to differing capacities of children and adults to learn new information, it may be necessary to initially teach information in separate caregiver and child sessions, before reviewing and practicing skills as a family unit. Or, material may be taught to all family members at once, with providers deferring to the family member at the earliest developmental stage, possibly enlisting older children and caregivers to support the younger child’s learning. Although there has been more basic family science research conducted on coparenting and sibling dyads than triadic-plus family interactions, from the clinical science side, interventions that target the whole family system appear to be more common. Many (although not all) of the family-level interventions that address coregulation are fairly recent (i.e., within the last two decades) adaptations of individual child therapies. These approaches go beyond periodically bringing parents in for collateral sessions (e.g., to report on the child’s behavior at home, or to hear about what their child is learning in therapy) by systematically and actively integrating multiple family members into sessions. Perhaps due to that particular evolution, there has been more empirical investigation in the whole family interventions literature (as compared to coparenting or sibling interventions) of the incremental, added value of considering the whole family in treatment, above and beyond individual child treatment.
CBT is well established for the treatment of anxiety disorders in children and adolescents, with both individual child CBT and individual family-based CBT shown to be efficacious (Goger & Weersing,
2021; Higa-McMillan et al.,
2016). Individual family-based CBT (FCBT) was developed with the recognition that a high proportion of children with anxiety disorders also have parents with anxiety, that children’s anxiety can be distressing for parents, and that caregiver behaviors (e.g., modeling of anxious behaviors and maladaptive coping strategies, parental accommodation of children’s avoidance, etc.) contribute to and maintain child anxiety (Goger & Weersing,
2021). Although the degree of caregiver involvement and specific family emotion regulation topics covered vary by specific model, FCBT for anxiety generally includes caregivers in at least some sessions in which they receive psychoeducation on the impact of their own emotional responses to their children’s anxiety and their behaviors (e.g., accommodation, overprotection, modeling) that may be maintaining it, and skills training to enhance their own emotion regulation, parenting, and emotion socialization behaviors (Wood et al.,
2009). A substantial number of studies have been conducted on FCBT, and interestingly, evidence for the incremental benefit of FCBT over individual child CBT has been mixed, with several meta-analytic studies showing no benefit (Goger & Weersing,
2021; Peris et al.,
2021). It may be that FCBT is incrementally beneficial for specific populations (e.g., families in which parents have an anxiety disorder; Kendall et al.,
2008), or that for FCBT to be uniquely helpful, it must include certain parenting components (Manassis et al.,
2014). Peris and colleagues noted that the vast majority of FCBT studies include only child diagnosis and/or symptoms as an outcome measure, and surprisingly few included pre- and post-intervention assessment of the targeted family process (Peris et al.,
2021). Thus, it is possible that lack of findings for FCBT’s incremental benefit is due not to family processes
not being an important part of treatment for childhood anxiety, but rather, to current treatment approaches’ lack of efficacy in improving those family processes. Notably, FCBT for child anxiety typically focuses on parents’ individual emotion and emotion regulation and the parent–child dyad, without consistent, particular attention paid to the coparent relationship, sibling relationships, or whole family interactions. This represents a gap in this work, given evidence that partner conflict is a maintaining factor for parental anxiety (Stuart Parrigon & Kerns,
2016) as well as the impact of sibling relationships on emotion socialization (Kramer,
2014) and the development of psychopathology (Feinberg et al.,
2012). Thus, in addition to including measurement of the family processes identified as treatment targets (Peris et al.,
2021), a next step for FCBT for childhood anxiety might be to incorporate intervention components for other family subsystems.
Another example of an individual child treatment that has been adapted to engage the entire family is Family-Focused Treatment for Childhood Depression (FFT-CD), which has been tested with children aged 7–14 years as an individual family intervention. FFT-CD is unique in its emphasis on family relationships as the primary mechanism to improve depression symptoms, and works across the associations among depressed mood, emotions, and family interactions (Tompson et al.,
2020). For example, FFT-CD providers work with family members to fill out an adapted version of the commonly used “spiral” for family interactions with family interactions in mind. These “spirals” are generally used in individual CBT for depression to delineate the way thoughts, feelings, and behaviors influence one another to lead to depressed mood (e.g., feeling sad → withdraws from others → thinks “I’m all alone” → feels more sad, depressed). In FFT-CD, however, the emphasis is put on how different family members’ emotions and behaviors reverberate off of one another to make moods spiral downwards or upwards. For example, “Child: Alone in bedroom → Parents: Worry and suggest alternative activities → Child: Becomes irritable and snaps at parents → Parents: Feel frustrated and withdraw → Child: Feels guilty and sad, withdraws more” (Tompson et al.,
2020, p. 690). Over the course of the intervention, family members engage in multiple activities to improve family interaction patterns and a variety of family skills (e.g., family problem-solving). Although siblings are not systematically included in FFT-CD for every family, they are when clinically indicated (e.g., when sibling conflict is related to depressed mood; Tompson et al.,
2020). In a randomized clinical trial comparing FFT-CD to individual supportive child therapy for depression, children in the FFT-CD group had higher levels of depression response and their families reported greater knowledge of depression management techniques than those in the individual therapy group (Tompson et al.,
2017), although by the one-year follow-up assessment, children in the individual therapy group had caught up to the FFT-CD group (Asarnow et al.,
2020).
Another approach that is centered around emotion regulation at the family level is Families Over-Coming Under Stress (FOCUS), a preventive intervention for individual families that have experienced a traumatic event or other significant adversity. FOCUS was designed with the whole family system, as well as multiple subsystems, in mind, so it is one of the few interventions that addresses family-level emotion regulation within all of the systems discussed in the current paper (caregiver–child, co-caregiver, sibling, and whole family systems). FOCUS for Families (Saltzman et al.,
2011) may be used with families of children aged 5–18 years, while FOCUS for Early Childhood (Mogil et al.,
2015) is specifically designed around the needs of preschool-aged children. Over the course of caregiver-only, child-only, and whole family sessions, caregivers and children are taught that a traumatic event – even when experienced by a single family member – reverberates throughout the entire family system. Families are taught to identify trauma reminders not only within themselves, but also to communicate about reminders among family members, and make a plan for coping with them together. For example, a family might identify that a fireworks display, while exciting for some family members, is a trauma reminder for a parent who experienced a combat deployment. The parent would share where they are on a feelings thermometer when the fireworks start, and children might be asked to describe how they can tell that their parent is feeling different from them (e.g., tense body, snaps, doesn’t want to be with the rest of the family). The family then develops a plan together for how to cope with the reminder; for example, they might develop a plan for coregulation, such that the non-deployed parent takes children to see the fireworks so that the children can still enjoy them, while the previously deployed partner is able to “tap out” and engage in healthy emotion regulation strategies to cope with the triggering event.
Consistent with many trauma-informed interventions, another central component of FOCUS is narrative work. However, unlike other interventions, the narrative component in FOCUS is not used for exposure, but rather, as a tool for emotional communication among family members (Saltzman et al.,
2013). For families with school-aged or adolescent children, family members create individual visual narratives over the course of multiple parent-only, child-only, and whole family sessions; ultimately, the individual narratives are integrated into a family narrative. Each family member indicates on a timeline where they were on the feelings thermometer during significant events. A provider facilitates family members sharing their thoughts and feelings during each event, helping to identify and correct miscommunications or misunderstandings that may have occurred at times of major distress, and identify family strengths and resources that helped them cope. For families with preschool-aged children who are too young to create their own narratives, FOCUS-Early Childhood focuses on other, more developmentally appropriate techniques to enhance communication, including enhancing caregiver reflective functioning and play (Mogil et al.,
2015). After creating their own narratives, caregivers are guided to put themselves in the minds of their child, and create a narrative from their child’s perspective. Caregivers revisit the major family events that they included on their own timelines, and imagine the emotions and thoughts that their child might have been experiencing during those times. This exercise is designed to enhance parents’ perspective taking and reflective functioning “muscle,” which should improve parent–child communication no matter the child’s developmental level. Play is conceptualized as a central mechanism through which children tell their stories, so significant time is spent teaching parents about the importance of play as well as key skills to enhance play, such as praise and reflection. Importantly, to enhance emotional communication with young children, parents are provided with psychoeducation about emotion socialization, and taught emotion coaching skills. Caregivers receive in vivo coaching of play and emotion coaching techniques during family sessions that are attended by the child and all participating caregivers.
Although the ultimate goal of the FOCUS narrative is to create a
family narrative, there is intentionality in building that narrative incrementally. Caregivers first build their individual narratives in adult-only sessions; this allows opportunity for caregivers to reflect on how their own emotional experiences impacted the family system, and, importantly, in multiple caregiver families it highlights the importance of caregiver coregulation (including among more than two caregivers, when relevant; Garcia et al.,
2017). For families with more than one child, the child-only sessions offer the opportunity for children to learn emotional content alongside their sibling, providing an opportunity to enhance sibling coregulation. FOCUS has not been tested against individual trauma treatments for children or adults, so the incremental value of family-level intervention for trauma/adversity above and beyond individual treatment is unknown. However, a randomized controlled trial of FOCUS-Early Childhood with military and veteran families indicated that those randomized to the intervention condition showed greater improvement on a variety of outcomes in comparison with families randomized to a web-based parenting education curriculum, including parental mental health symptoms (depression, anxiety, PTSD), child emotional and behavioral difficulties, family functioning (parent-reported), parenting behavior (observed and parent-reported), and children’s engagement with their parents (observed), which were found at 12-month follow-up (Mogil et al.,
2021). These RCT findings were supportive of earlier program evaluation data from a large-scale implementation of FOCUS (
N = 2615 families), which indicated improvements in a variety of parent and child mental health symptoms, child prosocial behavior, and family functioning (Lester et al.,
2016).
Importantly, movement toward a more family-centered approach in promoting the development of children’s regulatory capacities does not necessarily involve re-imagining entire intervention programs and starting from scratch. Rather, there are ways in which current intervention approaches may be modified in terms of specific psychoeducation, skill-building, and therapeutic activities in order to engage the larger family system.