children

Article
The Role of Emotion Regulation and Executive Functioning in
the Intervention Outcome of Children with Emotional and
Behavioural Problems †
Blossom Fernandes 1,2 , Mark Wright 3 and Cecilia A. Essau 2, *

1 Department of Health Services Research and Policy, Faculty of Public Health and Policy,
London School of Hygiene and Tropical Medicine, London WC1H 9SH, UK
2 School of Psychology, University of Roehampton, London SW15 4JD, UK
3 School of Humanities and Social Science, University of Brighton, Brighton BN1 9PX, UK
* Correspondence: [email protected]
† This is a part of Ph.D. thesis of Blossom Fernandes in University of Roehampton, London, UK.

Abstract: Emotional and behavioural problems are closely associated with impairments in regulating
emotions and in executive functions (EF). To examine this further, the aim of the present study
was to determine whether EF and emotion regulation at baseline would predict emotional and
behavioural problem scores post-intervention, and further explore the extent to which emotion
regulation mediates these outcomes. Participants were 41 primary school children who exhibited
emotional and/or behavioural problems, aged 8 to 11 years. All the children completed measures
of emotional and behavioural problems, cognitive emotion regulation, anxiety symptoms, and
performed two experimental tasks to measure working memory and response inhibition before and
after participating in a transdiagnostic Cognitive Behaviour Therapy-based programme, “Super
Skills for Life” (SSL), and at 3-months follow-up. Results revealed significant reduction in the use of
maladaptive emotion regulation strategy catastrophising and other blame following the intervention.
Additionally, EF and emotion regulation was associated with outcomes for emotional problems and
conduct problems. More specifically maladaptive emotion regulation strategy such as catastrophising
Citation: Fernandes, B.; Wright, M.; and other blame was closely related with self-reports of emotional problems, likewise other blame,
Essau, C.A. The Role of Emotion was also linked with scores of conduct problems. This study provides preliminary empirical support
Regulation and Executive for EF and emotion regulation in predicting outcomes of emotional and behavioural problems in
Functioning in the Intervention
children following intervention.
Outcome of Children with Emotional
and Behavioural Problems. Children
Keywords: emotional and behavioural problems; emotion regulation; executive function
2023, 10, 139. https://doi.org/
10.3390/children10010139

Academic Editors: Oana A. David

and Marie Danet 1. Introduction
Received: 23 November 2022 The number of children exhibiting emotional and behavioural problems is signifi-
Revised: 8 January 2023 cantly higher than previously thought. One in five children in the UK have emotional
Accepted: 8 January 2023 and behavioural problems [1] and these problems tend to emerge in children as young
Published: 11 January 2023 as six years old [2]. Emotional and behavioural problems in children have been closely
linked with difficulties in regulating emotions [3–6]. As argued by Aldao et al. [3], mal-
adaptive emotion regulation strategies, such as rumination, could be directly linked to the
development of emotional and behavioural problems. Likewise, executive function (EF)
Copyright: © 2023 by the authors.
impairments are also associated with emotional and behavioural problems [7], with Warren
Licensee MDPI, Basel, Switzerland.
and colleagues [7] claiming that depressive mood and anxiety are linked to disruptions
This article is an open access article
in maintaining task goals, and importantly, that EF impairments contribute towards the
distributed under the terms and
maintenance of emotional disorders.
conditions of the Creative Commons
EFs are cognitive processes, which allow individuals to organise, plan and set goals.
Attribution (CC BY) license (https://
These functions are supported by core underlying processes such as working memory,
creativecommons.org/licenses/by/
4.0/).
inhibition and cognitive flexibility/set shifting [8]. Specific EF processes are associated

Children 2023, 10, 139. https://doi.org/10.3390/children10010139 https://www.mdpi.com/journal/children

Children 2023, 10, 139 2 of 12

with emotional disorders such as anxiety. In a study by Toren et al. [9], children with
an anxiety disorder performed poorly on EF tasks compared with children without this
disorder [9]. Similarly, young adults with anxiety and depression had significantly lower
scores on EF tasks compared with healthy controls [10]. Specific EFs are further associated
with emotional problems and the ability to use effective emotion regulation strategies
to deal with stressful situations [11]. For example, O’Rourke et al. [11] found that EF
impairments were linked to maladaptive coping strategies (e.g., rumination), which, in
turn, was related to anxiety. With research showing maladaptive emotion regulation
linked to emotional disorders such as depression then predicting impairments in episodic
memories in adulthood [12].
Pruessner and colleagues [13] suggest that for emotion regulation strategies to be
implemented and maintained core EF functions are necessary, for example, cognitive
flexibility and control would allow for effective emotion regulation strategy selection
and application. This level of processing then requires effective working memory [13].
Hence, children and adolescents who often use maladaptive emotion regulation strategies,
also report anxiety and depression [14–16]. In contrast, research focusing on conduct
problems in children report that EF deficits may not always be present in those exhibiting
conduct problems, however, they are more likely to exhibit maladaptive emotion regulation
strategies [17,18]. For example, a study by Tajik-Parvinchi et al. [17] showed that children
with cognitive difficulties experience greater maladaptive emotion regulation, which then
predicts both emotional and behavioural problems [19].
Young people with emotional and behavioural problems tend to exhibit difficulties in
regulating emotions [3–6] and have EF impairments [20,21]. In a study involving adults,
cognitive behavioural therapy (CBT) augmented with executive skills training sessions
have led to a significant improvement in EF skills including working memory, inhibition
and set shifting tasks [22]. Mohlman [20] argues that CBT may be effective in enhancing
EFs of those with emotional disorders, suggesting that EF performance could be improved
following interventions based on principles of CBT (i.e., social competence and cognitive
restructuring). Similarly following a mindfulness based CBT programme, individuals were
found to exhibit improved EF skills and reduced difficulties with emotion regulation [23].
Huang et al. [21] reports that reduced emotional interferences reduces the cognitive load,
thereby leading to more effective EF.
For children and adolescents with emotional problems, such as anxiety and depression,
CBT is the treatment of choice [24–26] and is recommended by the National Institute for
Health and Care Excellence in England (NICE; 2011). CBT programmes, such as Super Skills
for Life programme [27], allows children to recognise anxious feelings and physiological
reactions, and clarify thoughts (e.g., unrealistic or negative attributions and expectations)
that occur during anxiety provoking situations. CBT utilises the concept of cognitive
restructuring, which may be closely associated with EF processes [28]. The ability to
amend cognitive patterns requires underlying EF processes to function effectively and then
efficiently implement emotion regulation strategies [25]. This ability to supress a dominant
response and implement an adaptive strategy is considered an important aspect of CBT [29].
Following CBT, evidence has shown a significant reduction in behavioural problems in boys
aged 6–11 years, alongside improvement in emotion regulation skills [30]. Research also
shows that CBT is effective in improving emotion regulation abilities among young people
with emotional problems; for example, children and adolescents with anxiety disorders
have been shown to have increased emotional awareness and reduction in emotional
dysregulation following CBT [31].
Using the transdiagnostic CBT-based programme Super Skills for Life (SSL), children
and adolescents with emotional problems in Mauritian residential care institutions showed
a significant increase in inhibitory control, an increase in adaptive (e.g., positive reappraisal)
and decrease in maladaptive (e.g., rumination) emotion regulation strategies; and fewer
internalising and externalising symptoms [32]. Several other studies have highlighted the
effectiveness of the SSL programme in improving emotional and behavioural problems
Children 2023, 10, 139 3 of 12

in children and adolescents [27,33–35]. These studies demonstrate that emotional prob-
lems following the SSL programme significantly reduced; moreover these effects were
maintained 12 months post intervention [33].
The aim of the present study was therefore to examine the extent to which EF per-
formance and emotion regulation at baseline would predict emotional and behavioural
problem scores at post-intervention, and to examine whether the emotion regulation strate-
gies mediate these outcomes. Specific emotion regulation strategies (e.g., other blame) have
been found to mediate the relationship between emotional and behavioural problems [35],
however studies that examine whether emotion regulation mediates the relationship be-
tween EF and emotional and problem behaviours are few, and have shown mixed results.
For example, one study reported little effect of emotion regulation on emotional problems
following CBT [36], whereas for behavioural problems, psychosocial interventions have
shown to improve emotion regulation [30]. This study therefore aimed to examine the
extent to which EF predicted emotional and behavioural problems and the emotion regu-
lation strategies that mediate these outcomes. Based on previous studies of EF [19,22,32],
firstly we expect a significant reduction in reported emotional, and behavioural problems
after the intervention. Secondly, we expect a significant increase in the use of adaptive
emotion regulation strategies, and a decrease in maladaptive emotion regulation strategies
post intervention. Finally, for EF tasks we also expect to see links to post intervention
outcomes with emotional and behavioural problems.

2. Method
2.1. Participants
Participants were 41 school children (n = 30 male pupils, n = 11 female pupils),
aged between 8 and 11 years (Mage = 9.53, SD = 1.09). The schools were state funded
schools, located in ethnically diverse neighbourhoods in Southwest London, the number
of pupils from diverse ethnic groups attending the school was above national average
(Department for Education, UK, 2017). The children were referred by their class teachers
from four primary schools in Southwest London because they exhibited emotional and
behavioural problems. Research shows that teachers can act as key informants in assisting
with identifying emotional and behavioural problems [37,38].

2.2. Procedure
Following approval of ethics from the university psychology ethics committee, the
schools were approached via email. Once the school’s head teachers confirmed their
participation in the study, the SENCOs and deputy heads were then approached by the
head teacher to liaise with the researcher. As this was an opt-out study, parents were sent
letters informing them of the nature of the study and giving them the opportunity of 2
weeks to inform the teachers who selected the participants if they wish their child to be
excluded from the study.
Prior to the intervention, children completed baseline tasks and questionnaires which
were also completed immediately post intervention and at follow up 3 months later. They
were informed about their participation in the programme and the lead researcher of
this study provided instructions and supported those children who required any further
assistance with the completion of the tasks or questionnaires. The tests were conducted
during school hours. The computerised tasks were published online using the millisecond
software; the task sequence was set beginning with the dot probe task, followed by the
questionnaires which were also completed online as published on the Qualtrics website.
The whole procedure ended with testing participants on the digit span task. At the start
of the programme the children were all provided with a workbook and were informed
that they would be taught specific skills to cope with challenging and anxiety provoking
situations. In total 5 children missed one session and only 1 child missed 3 sessions due
to absence from school as a result of illness, this child was however updated with an
individual session. The flow diagram of the study can be seen in Figure 1.
 that they would be taught specific skills to cope with challenging and anxiety provoking
situations. In total 5 children missed one session and only 1 child missed 3 sessions due
to absence from school as a result of illness, this child was however updated with an in-
Children 2023, 10, 139 dividual session. The flow diagram of the study can be seen in Figure 1. 4 of 12

Figure 1. Intervention Flow.

Figure 1. Intervention Flow.
2.3. Super Skills for Life Programme
2.3. Super
TheSkills
Superfor Life for
Skills Programme
Life (SSL) [24,27] is a psychosocial programme for the prevention
of The
anxietySuper
andSkills for Life
depression in (SSL)
young[24,27]
people.isItaispsychosocial
based on fiveprogramme
core principles: for(i)
theit prevention
uses a
of anxiety and depression in young people. It is based on five core principles: (i)and
transdiagnostic approach by targeting common core risk factors such as low social skills it uses a
self-esteem; (ii) it is based on the principles of CBT to help children develop skills to cope
transdiagnostic approach by targeting common core risk factors such as low social skills
with anxiety-provoking situations; (iii) it uses video feedback with cognitive preparation to
and self-esteem; (ii) it is based on the principles of CBT to help children develop skills to
assist children with enhancing their self-perception; (iv) it relies on behavioural activation,
cope
by with anxiety-provoking
encouraging situations;
children to increase (iii) itlevels;
their activity uses video
and (v)feedback
it involveswith cognitive
teaching children prepa-
ration
skillstotoassist children
use during with
social enhancingSSL
interactions. their
was self-perception;
delivered by the(iv) leadit author
relies on
and behavioural
other
activation,
graduate by encouraging
students children
with previous to increase
experience their activity
of providing emotional levels; andto(v)
support it involves
children
teaching children in
and adolescents skills to use during
a non-clinical social
setting. The interactions. SSL was
facilitators received deliveredone-day
an intensive by the lead
author and other
workshop by thegraduate students
senior author (CAE)with previous
of SSL [27]. Allexperience of providing
the facilitators were givenemotional
a leader’s sup-
port to children
manual and adolescents
which included a detailedin a non-clinical
outline setting.
of each session The
of the facilitators received an in-
SSL.
tensive one-day workshop
2.4. Implementation of SSL by the senior author (CAE) of SSL [27]. All the facilitators were
given a leader’s manual which included a detailed outline of each session of the SSL.
SSL consists of eight sessions which were implemented twice a week, for the duration
of four weeks. Each session lasted approximately 45 min, with an average of six children
2.4.per
Implementation of SSL
group. The commencing session was an opportunity for the children to introduce
SSL consists
themselves of eight sessions
and understand whichofwere
the purpose beingimplemented twice a week,
part of the programme; this wasforfollowed
the duration
of four weeks. by
immediately Each sessionthe
requesting lasted approximately
children present a piece 45about
min, themselves
with an average of six
for a 2-min children
video
per group. The commencing session was an opportunity for the children to introduce
recording in their intervention group. The following session involved going over the videos
as a group and discussing positive features and aspects of each individual recording, and
themselves and understand the purpose of being part of the programme; this was fol-
areas of improvement were discussed from the child’s perspective. For the remaining
lowed immediately by requesting the children present a piece about themselves for a 2-
sessions, children were introduced to topics such as ‘recognising feelings’, thoughts, and
minthevideo recording
link between in their
feelings, intervention
thoughts, group. The
and behaviours. following
Midway session
through involved going
the intervention,
over the videos as a group and discussing positive features and aspects
a session was devoted solely to teaching the children relaxation techniques, by helping of each individual
recording, and areas
them identify differentof improvement were discussed
muscles and possible from
ways to relax the child’s
them. perspective.
The following sessionsFor the
remaining
were thensessions,
focused on children were
topics such introduced
as social to problem-solving
skills and topics such as steps‘recognising
during socialfeelings’,
thoughts,
conflicts.and theoflink
Most the between feelings,
sessions began withthoughts, and behaviours.
low intensity physical warm Midway through the
up to increase
intervention, a session was devoted solely to teaching the children relaxation
core and muscle temperature. Similarly, another component of the programme techniques,
involved
dedicating 5–10 min of the session to structured play; these were games which required
 increase core and muscle temperature. Similarly, another component of the programme
involved dedicating 5–10 min of the session to structured play; these were games which
required following instructions and being physically active. The programme also required
children to complete home tasks involving activities that were taught in session and which
Children 2023, 10, 139 5 of 12
can be applied to their usual setting of playground or home.

2.5. Measures
following instructions and being physically active. The programme also required children
toChildren completed
complete home a set of questionnaires
tasks involving andtaught
activities that were two experimental tasks before
in session and which can be and
after the intervention,
applied to their usualand three
setting months following
of playground or home.the end of the intervention.

2.6.2.5.
EF Measures
Tasks
Children completed a set of questionnaires and two experimental tasks before and
Digit span, a subscale of the Wechsler Intelligence Scale for Children (WISC III;
after the intervention, and three months following the end of the intervention.
Wechsler, 1991), was used to measure working memory. The forward and backward digit
span tests
2.6. were used, and the participants were required to recite a sequence of digits after
EF Tasks
the sequence wasaverbally
Digit span, subscale ofpresented.
the Wechsler Following
IntelligencetheScale
samefor principle, participants
Children (WISC III; Wech-were
then required
sler, to repeat
1991), was used tothe sequence
measure in reverse
working memory. order for the backward
The forward and backwarddigit test,
digit respec-
span
tively.
testsHigh
were scores on the
used, and thisparticipants
task indicate weregreater
requiredperformance.
to recite a sequence of digits after the
Dot Probe
sequence wasTask [39]presented.
verbally was used Following
to measure theinhibition whichparticipants
same principle, is one of the core
were under-
then
lying processes of EF [8,40]. The task required the participants to identify a non-emotional
required to repeat the sequence in reverse order for the backward digit test, respectively.
High scores on this task indicate greater performance.
probe which was a word, which can appear in one of two spatial locations. Immediately
Dot Probe Task [39] was used to measure inhibition which is one of the core underlying
prior to the probe presentation, emotional and non-emotional words appeared simulta-
processes of EF [8,40]. The task required the participants to identify a non-emotional probe
neously
whichinwastwoa separate
word, whichlocations (see Figure
can appear 2).two
in one of Thespatial
mean locations.
percentage of correct responses
Immediately prior
wastodetermined for the block
the probe presentation, of trials
emotional andfor each participant
non-emotional as a measure
words appeared of inhibition,
simultaneously
higher
in twoscores indicate
separate greater
locations (seeperformance.
Figure 2). The mean percentage of correct responses was
determined for the block of trials for each participant as a measure of inhibition, higher
scores indicate greater performance.

Figure 2. Dot Probe Task.

Figure 2. Dot Probe Task.
2.7. Questionnaires
2.7. Questionnaires
Strengths and Difficulties questionnaire (SDQ) [41] was used to measure emotional
Strengths
and and symptoms.
behavioural DifficultiesItsquestionnaire
25 items are set(SDQ) [41] was
on a 3-point used
Likert to measure
scale, emotional
ranging from 0
and behavioural symptoms. Its 25 items are set on a 3-point Likert scale, ranging from 0
(Not True) to 3 (Certainly True). This scale can be categorised into five subscales: emotional
symptoms, conduct problems, hyperactivity, peer problems and pro-social behaviour. The
(Not True) to 3 (Certainly True). This scale can be categorised into five subscales: emo-
mean scores of participants at baseline were close to average, in line with UK cut off scores.
tional symptoms, conduct problems, hyperactivity, peer problems and pro-social behav-
To get the total of the difficulties score, all the subscales except for the pro-social behaviour
iour. The mean
subscale were scores
added of
up;participants
the higher theatscores,
baselinethewere close
greater to average,For
the difficulties. in line
SDQwith
pre UK
cut intervention
off scores. To get the total of the difficulties score, all the subscales
Cronbach’s alphas in the current study ranged from 0.19 to 0.41. except for the pro-
Cognitive Emotion Regulation Questionnaire (CERQ) [14] was used to measure the
use of emotion regulation strategies. It consists of 18 items, which are rated on a 5-point
Likert scale ranging from 1 (almost never) to 5 (almost always) in response to how often
each of the following strategies are used. The items are categorised into 9 separate emotion
regulation strategies: refocus on planning, putting into perspective, acceptance, positive
 Children 2023, 10, x FOR PEER REVIEW 6 of 12

Children 2023, 10, 139 6 of 12

social behaviour subscale were added up; the higher the scores, the greater the difficulties.
For SDQ pre intervention Cronbach’s alphas in the current study ranged from 0.19 to 0.41.
Cognitive Emotion Regulation Questionnaire (CERQ) [14] was used to measure the
use of
refocusing, positive emotion regulation
reappraisal, strategies. Itother
self-blame, consists of 18 items,
blame, which areand
rumination, rated on a 5-point
catastrophising.
Likert scale ranging from 1 (almost never) to 5 (almost always) in response to how often
Self-blame, other blame, rumination and catastrophising are often considered maladaptive
each of the following strategies are used. The items are categorised into 9 separate emotion
strategies, whereas
regulationrefocus onrefocus
strategies: planning, putting
on planning, intointo
putting perspective,
perspective, acceptance, positive
acceptance, positive
refocusing,
refocusing, positive positive reappraisal,
reappraisal self-blame,
are putatively other blame,
adaptive rumination,
strategies. The and catastrophiz-
internal reliability
ing. Self-blame,
scores for CERQ other blame,
pre-intervention rumination
scores in this and catastrophising
study are often considered
for each strategy ranged frommala-0.19
to 0.64. daptive strategies, whereas refocus on planning, putting into perspective, acceptance,
positive refocusing, positive reappraisal are putatively adaptive strategies. The internal
The Screen for Child Anxiety Related Emotional Disorders (SCARED) [42] was used
reliability scores for CERQ pre-intervention scores in this study for each strategy ranged
to measure symptoms
from 0.19 to of common anxiety disorders in children and adolescents. It consists
0.64.
of 38 items which The Screen
can beforcategorised
Child Anxietyinto
Related Emotional
five Disorders
subscales: (SCARED) [42] generalized
somatic/panic, was used
to measure
anxiety, separation symptoms
anxiety, of common
social phobia,anxiety disorders
and school in children
phobia. and adolescents.
Participants It con- to
are required
sists of 38 items
indicate the likelihood which can be categorised
of experiencing each symptom into five
onsubscales:
a 3-pointsomatic/panic, generalized
scale: 0 (almost never), 1
anxiety, separation anxiety, social phobia, and school phobia. Participants are required to
(sometimes), and 2 (often). Reliability scored for SCARED ranged between 0.55 to 0.80.
indicate the likelihood of experiencing each symptom on a 3-point scale: 0 (almost never),
1 (sometimes), and 2 (often). Reliability scored for SCARED ranged between 0.55 to 0.80.
3. Results
3. Results
3.1. Preliminary Analysis
3.1. Preliminary
The mean Analysis
of SDQ, SCARED, CERQ and EF variables for the children at pre- and
post-intervention,Theand
meanatof3-month
SDQ, SCARED, CERQ and
follow-up are EF variablesin
reported forTable
the children at pre- and
1. A series post-
of one-way
intervention,
repeated measures and at
analysis of 3-month
variancefollow-up
(ANOVA) are were
reported in Table 1.toAexamine
conducted series of one-way re-
the difference
peated measures analysis of variance (ANOVA) were conducted to examine the difference
in outcome variables at pre- and post-intervention and at follow-up.
in outcome variables at pre- and post-intervention and at follow-up.

Table 1. MeanTable 1. Mean differences

differences in SDQ, SCARED,
in SDQ, SCARED, and CERQ
and CERQ pre-pre-
vs. vs.
postpost SSLintervention.
SSL intervention.

Pre- Post- 3-Month Follow

Pre-Intervention Post-Intervention 3-Month
Intervention Follow Up
Intervention Up F F Ƞ2
Mean (SD) Mean (SD) Mean (SD) Mean Mean(SD)
(SD) Mean (SD)
SDQ SDQ
Emotional problems 4.24 (2.37) Emotional 3.08
problems
(2.77) 4.24 (2.37) 3.08
3.10 (2.77)
(2.16) 3.10 (2.16)
2.45 2.45 0.08
0.08
Conduct problems 3.37 (2.68) Conduct problems
3.11 (2.20) 3.37 (2.68) 3.11
2.90 (2.20)
(1.81) 2.90 (1.81)
0.30 0.30 0.01
0.01
Hyperactivity 4.48 (2.32) Hyperactivity
4.14 (2.14) 4.48 (2.32) 4.14
4.48 (2.14)
(2.13) 4.48 (2.13)
0.77 0.77 0.01
0.01
Peer problems 3.25 (2.37) Peer problems
2.80 (1.94) 3.25 (2.37) 2.80
2.67 (1.94)
(1.65) 2.67 (1.65)
0.74 0.74 0.01
0.01
SCARED SCARED
Panic disorder 6.56 (4.72) Panic disorder
6.14 (5.99) 6.56 (4.72) 6.14
4.40 (5.99)
(4.46) 4.40 (4.46)
1.02 1.02 0.03
0.03
Generalised anxiety Generalised anxiety
5.92 (3.50) 5.51 (4.56) 5.92 (3.50) 5.51
5.25 (4.56)
(4.01) 5.25 (4.01)
0.21 0.21 0.01
0.01
disorder disorder
Social Anxiety 6.04 (3.63) Social Anxiety
5.64 (3.85) 6.04 (3.63) 5.64
5.10 (3.85)
(3.80) 5.10 (3.80)
0.83 0.83 0.02
Separation anxiety 6.44 (3.70) Separation5.68
anxiety
(4.32) 6.44 (3.70) 5.68
5.00 (4.32)
(4.10) 5.00 (4.10)
0.64 0.64 0.01
School avoidance 1.53 (1.46) School avoidance
1.81 (1.77) 1.53 (1.46) 1.81
1.45 (1.77)
(1.35) 1.45 (1.35)
0.44 0.44 0.01
CERQ CERQ
Self-blame 5.37 (1.80) Self-blame
4.52 (1.95) 5.37 (1.80) 4.52
5.57 (1.95)
(2.11) 5.57 (2.11)
2.62 2.62 0.05
Rumination 5.97 (2.21) Rumination
5.18 (2.65) 5.97 (2.21) 5.18
4.86 (2.65)
(1.93) 4.86 (1.93)
1.91 1.91 0.04
Catastrophising 5.84 (2.23) Catastrophising
5.66 (2.62) 5.84 (2.23) 5.66
3.95 (2.62)
(1.69) 3.95 (1.69)
4.10 ** 4.10 ** 0.08
Other blame 5.05 (2.36) Other blame
4.31 (1.98) 5.05 (2.36) 4.31
3.76 (1.98)
(1.37) 3.76 (1.37)
2.96 * 2.96 * 0.06
Acceptance 5.65 (2.32) Acceptance
5.09 (1.80) 5.65 (2.32) 5.09
5.67 (1.80)
(2.08) 5.67 (2.08)
0.81 0.81 0.02
Positive refocusing 5.38 (2.42) Positive refocusing
4.85 (2.30) 5.38 (2.42) 4.85
4.23 (2.30)
(2.02) 4.23 (2.02)
1.74 1.74 0.04
Planning 4.86 (2.22) Planning
4.42 (2.26) 4.86 (2.22) 4.42
4.61 (2.26)
(2.15) 4.61 (2.15)
0.72 0.72 0.01
Putting into perspective 5.84 (2.23) 5.65 (2.62) 3.95 (1.68) 5.08 ** 0.10
Positive reappraisal 5.81 (1.90) 5.02 (2.33) 5.19 (2.16) 0.26 0.01
Note. ** p < 0.01; * p < 0.05; SDQ = Strengths and Difficulties Questionnaire; SCARED = Screen for Child Anxiety
Related Emotional Disorders; CERQ = Cognitive Emotion Regulation Questionnaires.

The ANOVA results showed a significant effect of time on maladaptive emotion regu-
lation strategies catastrophising and other blame (Table 1). Post-hoc analysis of Bonferroni
further showed significant differences at follow-up for catastrophising (p < 0.001) and
other blame (p < 0.05). No significant main effect of time was found for adaptive emo-
tion regulation strategies acceptance, planning, positive reappraisal, positive refocusing
and rumination.
For measures of EF, there was a significant effect of time on performance for forward
digit span task (Table 2). These effects were not observed for backward digit span task.
 from 0.19 to 0.64.
The Screen for Child Anxiety Related Emotional Disorders (SCARED) [42] was used
to measure symptoms of common anxiety disorders in children and adolescents. It con-
sists of 38 items which can be categorised into five subscales: somatic/panic, generalized
anxiety, separation anxiety, social phobia, and school phobia. Participants are required to
indicate the likelihood of experiencing each symptom on a 3-point scale: 0 (almost never),
Children 2023, 10, 139 7 of 12
1 (sometimes), and 2 (often). Reliability scored for SCARED ranged between 0.55 to 0.80.

3. Results
There was3.1. Preliminary in
a reduction Analysis
reports of self-blame, emotional and conduct problem scores
(based on SDQ) The mean
and of SDQ,
anxiety SCARED,
scores CERQ
(based onand EF variables
SCARED), for the children
however, these at pre- and post-
reductions were
intervention,
not significant; and anand at 3-month
increase follow-up are reported
in performance in Table 1. A
on the inhibitory series of
control one-way
task, re-
dot probe
peated measures analysis of variance (ANOVA) were conducted to examine the difference
(p = 0.06) was noted.
in outcome variables at pre- and post-intervention and at follow-up.

Table 2. Mean differences

Table for EF tasks
1. Mean differences pre-SCARED,
in SDQ, vs. postand
SSL intervention.
CERQ pre- vs. post SSL intervention.

Pre- Pre- Post- Post- 3-Month

3-Month Follow
Intervention
Intervention Intervention
Intervention Follow Up Up F F Ƞ2
Mean (SD)Mean (SD) Mean (SD)
Mean (SD) Mean (SD)
Mean (SD)
SDQ
Forward digit span 8.85 (2.50) 9.17 (1.98) 9.88 (2.14) 6.28 ** 0.21
Emotional problems 4.24 (2.37) 3.08 (2.77) 3.10 (2.16) 2.45 0.08
Backward digit span 3.47 (1.43) 4.10 (2.19) 4.12 (1.88) 2.78 0.11
Dot probeConduct
task problems 3.37 (2.68)
66.30 (22.24) 3.11 (2.20)
69.78 (18.53) 2.90 (1.81)1.45 0.30
95.53 (97.52) 0.01
0.07
Hyperactivity 4.48 (2.32) 4.14 (2.14) 4.48 (2.13) 0.77 0.01
Note. ** p < 0.01; EF = executive functions.
Peer problems 3.25 (2.37) 2.80 (1.94) 2.67 (1.65) 0.74 0.01
SCARED
3.2. Predictors Panic
and Mediators
disorder
of Treatment
6.56 (4.72)
Outcomes6.14 (5.99) 4.40 (4.46) 1.02 0.03
Generalised
Regression analysisanxiety
was carried out to examine the extent to which EF and emotion
5.92 (3.50) 5.51 (4.56) 5.25 (4.01) 0.21 0.01
disorder
regulation strategies at baseline would predict emotional and behavioural problem scores at
SocialThe
post-intervention. Anxiety 6.04 (3.63)
results showed 5.64 emotion
that EF and (3.85) 5.10 (3.80)strategies
regulation 0.83 predicted
0.02
outcomes forSeparation
emotional anxiety
problems6.44 (3.70)
(F (8, 5.68p (4.32)
27) = 2.35, < 0.05, R2 =5.00 (4.10)
0.46) and conduct0.64 problems
0.01
School avoidance 2 1.53 (1.46) 1.81 (1.77) 1.45 (1.35)
(F (8, 28) = 2.48, p < 0.05, R = 0.47). EF and emotion regulation strategies also predicted 0.44 0.01
CERQ
hyperactivity (F (4, 27) = 2.89, p < 0.05, R2 = 0.41), suggesting that EF and maladaptive
Self-blame 5.37 (1.80) 4.52 (1.95) 5.57 (2.11) 2.62 0.05
emotion regulation strategies at pre-intervention significantly predicted emotional and
Rumination 5.97 (2.21) 5.18 (2.65) 4.86 (1.93) 1.91 0.04
behavioural problems following5.84
Catastrophising
the (2.23)
intervention.5.66 (2.62) 3.95 (1.69) 4.10 ** 0.08
EF and emotion regulation 5.05
Other blame strategies
(2.36) at pre-intervention
4.31 (1.98) was
3.76 found to
(1.37) significantly
2.96 * 0.06
predict emotional problems, conduct
Acceptance problems 5.09
5.65 (2.32) and(1.80)
hyperactivity
5.67post
(2.08)intervention; thus, a
0.81 0.02
Positiveanalysis
further mediation refocusingwas conducted
5.38 (2.42) (Baron 4.85 (2.30)
and Kenny,4.23 (2.02)
1986) 1.74 whether
to examine 0.04
the links between Planning
EF and emotional4.86 (2.22)
problems,4.42 (2.26) problems,
conduct 4.61 (2.15) 0.72 0.01 are
and hyperactivity
mediated through emotion regulation strategies. These results showed that there was a
significant indirect effect of EF on emotional problems through the maladaptive emotion
regulation strategies of catastrophising and other blame (Table 3). There was also an indirect
effect of EF on conduct problems through the maladaptive emotion regulation strategy
other blame (Table 4). No further indirect effects were observed.

Table 3. Results of mediation analysis summary of maladaptive emotion regulation strategies,

inhibition, working memory pre-intervention predicting emotional problems. (N = 41).

Inhibition (Dot Probe) Working Memory (Digit Span)

Variable b SE t b SE t
Catastrophising −0.39 0.21 −1.80 −0.49 0.19 −2.53 *
Other blame 0.63 0.19 3.21 * 0.64 0.17 3.73 **
Rumination 0.15 0.19 0.81 0.15 0.17 0.89
Self-blame 0.23 0.23 1.01 0.19 0.20 0.93
R2 0.34 0.44
F 2.70 * 3.98 *
Note. ** p < 0.001, * p < 0.05.
Children 2023, 10, 139 8 of 12

Table 4. Results of mediation analysis summary of emotion regulation strategies, inhibition, working
memory pre-intervention predicting conduct problems. (N = 41).

Inhibition (Dot Probe) Working Memory (Digit Span)

Variable b SE t b SE t
Catastrophising 0.11 0.20 0.52 0.26 0.19 −1.34
Other blame 0.42 0.18 2.41 * 0.38 0.17 2.17 *
Rumination −0.25 0.19 −1.28 −0.26 0.19 −1.34
Self-blame −0.12 23 −0.50 −0.14 0.28 2.14
R2 0.58 0.63
F 2.89 * 3.45 *
Note. * p < 0.05.

4. Discussion
The objective of the present study was to examine the impact of EF and emotion regu-
lation on emotional and behavioural problem scores following a CBT based intervention
among children in a typical school setting, as well as examining the extent to which emotion
regulation mediate these outcomes.
Our first hypothesis that scores of emotional and behavioural problems would be
reduced was supported. As reported by previous findings [24,27,33], participation in SSL
led to reduction in emotional problems. In Essau et al.’s study [22], significant reductions in
problem behaviours are found six months after the intervention. Similarly, these reductions
could be observed 12 months after the intervention [43].
In line with the findings of Ramdhonee-Dowlot et al. [29], our second hypothesis
that maladaptive emotion regulation strategies would be reduced was supported in that
the maladaptive emotion regulation strategies of catastrophising and other blame were
significantly reduced at follow-up assessment. Alongside this, our findings showed that
emotion regulation significantly predicted emotional problems, providing further support
to the argument that specific emotion regulation strategies are prominently and habitually
employed in children with anxiety and depression [44]. More specifically these results show
that the emotion regulation strategy other blame at pre-intervention is linked to conduct
problems; supporting previous research that report conduct problems are consistently
linked with poor emotion regulation [18]. However, there were no significant increases in
the use of adaptive emotion regulation strategies, as was expected; this can be explained to
some extent, by the mixed findings in literature where adaptive emotion regulation may
not always increase following intervention [45]. Even though emotion regulation can be
affected following intervention, this change is often dependent on the disorder and age
of participants, especially as there are shift in patterns of emotion regulation use during
development [40].
Our final hypothesis that EF at baseline would be associated with post intervention
outcomes were also supported. Our results support the effect of emotion regulation and
EF at pre intervention in predicting outcomes of emotional and behavioural problems
post intervention [46]. Baseline EF is associated with emotional problems, but also predict
responsiveness to treatment, emphasising the importance of EF in treatment outcomes [46].
Moreover, participating in SSL led to a significant improvement in EF (working memory
and inhibition) in that the scores of forward digit span increased post-intervention and
at follow-up. These results are similar to the findings reported among children [32] and
adults [22,23]. The significant changes observed in EF skills in this study might have
contributed to the successful control of emotional problems and maladaptive emotion
regulation, as EF is mediated by the prefrontal cortex [47]; abnormalities and variation in
this region is likely associated with emotional problems such as anxiety [7,48].
Children 2023, 10, 139 9 of 12

5. Strengths and Limitations

A major advantage of the present study was the use of a transdiagnostic CBT-based
intervention (SSL) that targets the key risk factors (i.e., EF and emotion regulation) associ-
ated with emotional and behavioural problems. The intervention was delivered in a school
setting, which may benefit families who otherwise face barriers accessing appropriate
services for their child or fear of their child being stigmatised [49]. Furthermore, unlike
numerous studies in intervention research, this study used both self-report questionnaires
and task-based indicators of outcomes; these tasks included digit span and dot probe task
to measure working memory and inhibition.
There are however, methodological limitations which need to be considered when
interpreting our findings. The low Cronbach’s alpha scores may have impacted the effect
sizes observed; thus, the results should be interpreted with caution. The repeated use of
the same task could also have influenced some level of improvement in the participants,
therefore future studies could focus on the sequence of tasks to reduce learning effects.
Additionally, the absence of a control group could have inflated our findings [50]. Further-
more, a short follow-up period (3 months) and a small sample size could have also affected
the results. Finally, the participants were referred by their teachers as having emotional
and behavioural problems and subsequently may have affected the generalisability of
these results to a clinical population. Children who are identified as having emotional
and behavioural problems by their teachers, have been found to be at a higher risk of
behavioural problems [51].

6. Conclusions
This is the first study to our knowledge to further investigate the mediating effect of
emotion regulation and the durability of EF in maintaining positive outcomes for children
with emotional and behavioural problems. It would be informative to include a control
group to test the effects of practice on the EF tasks. However, from this SSL intervention
participants may have been able to derive increased benefits (i.e., enhanced engagement
in daily activities, improved functioning in novel situations). Future trials are needed to
identify and compare the role of emotion regulation in different groups. Further studies
would also benefit from a vast array of EF tasks measuring both cognitive flexibility and
affective decision making. These limitations notwithstanding, children who participated in
this SSL programme showed a reduction in the maladaptive emotion regulation strategies
other blame and catastrophising. Taken together, these results suggest that the outcomes
following SSL intervention may be associated with reduction in difficulties in EF and
maladaptive emotion regulation of strategy use for children exhibiting behavioural and
emotional problems in the classroom. These factors should be considered in interventions
aimed at children’s mental health following the coronavirus pandemic lockdown measures.

Author Contributions: Conceptualization, B.F. and C.A.E.; Methodology, B.F. and C.A.E.; Formal
Analysis, B.F.; Data Curation, B.F.; Writing—Original Draft Preparation, B.F.; Writing—Review &
Editing, M.W. and C.A.E.; Supervision, M.W. and C.A.E.; Project Administration, B.F. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Ethical approval was acquired from Roehampton University
in 2016 (Reference number: PSYC 15/188).
Informed Consent Statement: Informed consent was obtained from parents and verbal consent was
given by the participating children in this study.
Data Availability Statement: The data presented in this study are available on request from the
corresponding author.
Children 2023, 10, 139 10 of 12

Acknowledgments: The authors are grateful to all the children who participated in the study,
including the schools and teachers for their support.
Conflicts of Interest: The authors declare no conflict of interest.

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