[MUSIC PLAYING] We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome to Mind the Kids podcast from the Association for Child and Adolescent Mental Health, known as ACAMH. Have you ever wondered how a child's ability to manage their emotions and impulses might shape their later mental health. And what if one of the most important predictors isn't really about how clever they are, but how well regulated they are on the inside. Today's episode explores the important role that self-regulation plays in children's emotional and behavioural development, and what this can tell us about their later mental health. Hi, I'm Mark Tebbs. I'm your host for today. I spent my whole career working in mental health from frontline service delivery to director of mental health commissioning. I'm currently a Chief Executive of charity, and I'm a trustee of a mental health organisation and also a Career Coach. I'm really pleased to be hosting these podcasts. It gives me the opportunity to speak to some of the leading clinicians and academics in the forefront of children and young people's mental health. So if you're a clinician, if you're an educator, a parent, or just curious about mental health, I hope these discussions leave you with some fresh insights and practical tools to help. Don't forget to subscribe where you get your podcasts from. And also on your YouTube channel. Just search ACAMH and you'll find us across all socials. I'm delighted to be joined by Lilja Jónsdóttir from the Uppsala University, whose research looks at early inhibitory control and emotional regulation as predictors of internalising and externalising problems in childhood. We'll be discussing what those terms mean in practise, what her longitudinal study found, and why emotional regulation may be such a meaningful and important area for future research and intervention. So let's get started. Welcome, Lilja It's an absolute pleasure to be speaking to you. Thank you. Thank you for having me. Good stuff. Let's start with just some introductions. It'd be great to understand a little bit more about you, maybe what your research interests are. And there's a chance to just give a little bit of a name check of the people that you worked with on this paper. So, yeah. Over to you. Yeah. So my name is Lilja Jónsdóttir and we are recording this in April, and I'm currently a PhD student here at the Department of Psychology at Uppsala University in Sweden. And when this comes out, I will be a postdoctoral researcher in child and adolescent psychiatry here at the Department of Medical Sciences at Uppsala University. So I have been focusing on self-regulation development in my PhD and working with a supervisor named Karin Brocki. So Professor Karin Brocki, who is also one of the co-authors on this paper. And then I have my co-supervisors Matilda Frick and Andreas Frick, who are both associate professors here and in at Stockholm University. And then I have Emma Heeman as a co-author, also, who's a PhD student here with me. You're a stuff so congratulations on your new post coming up shortly. Yeah, thank you. So let's dive in and we'll talk a little bit more about your paper. So the paper is called examining early inhibitory control and emotional regulation as predictors of childhood internalising and externalising problems a longitudinal study. So what drew you into this research area? So like I said my PhD thesis is on the development of self-regulation, which is this ability to regulate our behaviours and emotions and our thoughts. So our cognition. So what I have been focusing on is different self-regulation skills, so how they relate to one another. So what influences their development and what they also predict during development. And what I thought was interesting when looking at these theories behind self-regulation development is that it is seen as hierarchical. So we have simple regulation skills that then become integrated into more complex skills. And these also affect later outcomes. And here the idea was to look at the developmental role of the simpler skill, which is inhibitory control and see how it relates to emotion regulation, which is then maybe could be seen as a more complex regulatory skill. All right. Yeah. OK. It'd be really great if you could bring that to life with an example. What would that look like in a child? So do you mean what inhibitory control would look like or what the development would look like? Yeah, just thinking about a kind of case study to help explain it to the listener. And when we talk about self-regulatory control, what does it look like for relation behaviour Yeah. I mean one classic example that I think many people know about and relate to is the Marshmallow test. So when we put something very, very tempting in front of a child and then ask them not to touch it for a while and see are they able to inhibit that automatic response of going for the thing that they want. And I think that is what we would refer to as one sort of aspect of inhibitory control, for example. OK. So it's the-- so it's the control of natural impulses. So everyone wants to grab the Marshmallow. But it's the kind of yeah I certainly would. So it's the ability to not act on that impulse. Yeah so overriding what would be the automatic thing to do in favour of something that is more maybe adaptive in the moment or more important in the moment for your goals. So I think that is a pretty good way of explaining it. OK. Good stuff. And then you mentioned a hierarchy. So what does that refer to? Yeah. So I mean when we talk about self-regulation we're often-- we're often talking about different things. So it can be this overarching ability of just being able to regulate yourself, being able to not do something that you should not do in the moment or be able to stick to your goals and things like that. But then we also have these simpler skills. We can break down self-regulation into different skills. And maybe if we refer to it during development, then we can measure very early on things like inhibitory control. So being able to stop an automatic response, just that one part of self-regulation. So I think that is the idea with the hierarchy is that we have these more simple abilities and things like working memory for example, is also an example of self-regulation. So there are many different things that feed into these more broad skills. OK. Brilliant. OK. Really clear. And then the link with outcomes, mental health issues. Could you unpack that a little bit. Yeah. So we know from previous research that there is an association between self-regulation and then later socio-emotional outcomes. So a lot of different important outcomes both within childhood and also when we come to adulthood. So these are really important to look at. And then also we know that these are associated with mental health outcomes. So both what we look at here in this study internalising and externalising problems. But also just when you look at different mental health issues we do know that self-regulation predicts these later on. OK. Brilliant. And then just like a little bit definition check. So internalising and externalising behaviours. So we focused in this particular study on two dimensions of behavioural and social and emotional problems that we call internalising and externalising problems. And internalising problems, they refer to these inwardly directed problems like worrying and sadness and social withdrawal. And then we have externalising problems which refer to more outwardly directed problems, and that can be impulsivity, defiance, and aggression, for example. OK, brilliant. So this might be quite a difficult question, but if we were like meeting a group of young people today. So is there anything in how they manage emotions or impulses that might enter their future mental health problems. So I think that if we look at emotion regulation, for example, if we have a child that has a lot of problems in recovering from being emotionally upset. So if we think of a child that is very angry or maybe very fearful and has issues with recovering from those emotions without a lot of support, then that could be something to look out for. So we can think of it as also difficulty with calming down independently, or also difficulty with calming down with assistance. And I think that also the opposite pattern of being very flat or showing very restricted emotional responses, that could also be relevant. But I think in this paper we looked at maybe more of these emotional problems I would say. OK. Brilliant. So how did you go about the study. Tell us a little bit about your methodology. Oh yeah. So this study comes from-- it's part of a longitudinal project that has been going on for quite a long time here in Uppsala. So this study is called the effect project. And we've been following children from infancy here in Uppsala. And these children are currently, I think in their early teenage years. And for this paper we had 94 typically developing children. So this is a community sample. And their families were followed. So both the children and their parents. And the sample is, of course, could be said to be relatively socioeconomically advantaged, which is really important to keep in mind also when interpreting this study. But when the children were four years old, they did a task called the day night stroop task. So that is how we measured inhibitory control. And this is a pretty well-established task. So the children are shown pictures. So for example, they're shown a picture of a sun and they're asked to say opposite of what they see. So they see a sun and they should say night. And then they're shown a picture of a moon and they should say day. And then we ask them to do this repeatedly, and we count how many times they get this right, basically. So that's how we measured inhibitory control. OK. And then we went on to measure emotion regulation when the children were six years old. And that was done through parent reports. So a questionnaire called the emotion questionnaire, which is a validated Swedish measure. And we focus on regulatory abilities. So questions like it's easy for others to calm the child down or this child has difficulties calming themselves down. And then at 9 to 10 years, we assessed these social and emotional and behavioural problems, internalising and externalising problems, using the strengths and difficulties questionnaire. So we asked the parents to indicate their agreement with things like whether the child is often unhappy, depressed, or tearful. Whether they're restless, overactive, or fight with other children and things like that. OK. Brilliant. So the task at four. So, like, what's that-- what's that measuring. Could you just explain that again to me? I didn't quite get it. Yeah so it is measuring inhibitory control. So basically it's the ability to suppress this more automatic response. So when you see a picture of a sun, you would maybe as a child associate that with saying it's day. And then you would see a picture of a moon and you would associate that with saying it's night. But when we asked them to play the opposite game, so we asked them to say night when they see a sun and day when they see a moon, and to try to do this repeatedly when we show them the pictures. OK. Brilliant. OK, so there's this test of inhibitory control at four and then a parental self-assessment and then a measurement of behavioural challenges at nine. And what were the headlines findings? So we have two maybe most important findings that are maybe putting us-- pulling us in somewhat different directions. So we have first, when we looked at this inhibitory control that we measured using the day night task. It did not predict emotion regulation and it did not predict internalising or externalising problems. So we found no effect there. So the mediation model where we thought maybe there would be mediation. So inhibitory control would somehow predict internalising and externalising problems through its effects on emotion regulation. But we didn't find anything in terms of that. But we did find that general emotion regulation at six predicted both internalising and externalising problems 3 to 4 years later. So that's the main findings. OK. So you didn't find the link with the inhibitory control, but you did find the link with the emotional regulation? Yes, exactly. OK. How are you interpreting those findings? Yeah. So I mean, what we see here is that if we just look at the emotion regulation findings, we see that children who were better at regulating emotions at six they showed fewer problems-- fewer internalising and externalising problems at 9 to 10 years. But inhibitory control, I mean, we did measure inhibitory control very early. So it might be that it was difficult to find that association. We did predict some-- we did expect some sort of predictive signal. But it could be the fact that there's this long interval that perhaps the inhibitory control maybe if we would find a sample with more issues with inhibitory control, that maybe we would find this association. Could also be that because we use this task, even though it is pretty well established, it could be that it didn't really capture inhibitory control reliably enough to detect these longitudinal association. So I mean, it also could-- there are very many different reasons why this happened. Really. Yeah. Yeah, sure. Were there any aspects of those results that you found particularly surprising that you didn't expect? I would say that not finding this association between inhibitory control and emotion regulation, and then also later mental health outcomes was maybe the most surprising fact. I think we would, based on prior research, we would have expected to find those associations. So that was surprising. Yeah. I was just going to ask that as well. Kind of like was-- were the findings inconsistent with other findings in the area? Yeah. I would say so. I mean, we went into this basically looking at previous research that said that inhibitory control was, I would say, consistently related to externalising problems. And then there was some mixed findings in terms of internalising problems. So we did expect to find these associations. And we also did expect theoretically to find something between inhibitory control and emotion regulation, because those are theoretically very much related. So it was quite surprising. Yeah. OK. So what's the research telling us. How are you interpreting this? Yeah. So, I mean, we did-- in this study, we were able to include both internalising and externalising problems in the same model, which is not always done. So usually we see research that is only predicting internalising or only predicting externalising. So here we could look at both of those at the same time. So what we did see that is that emotion regulation is this sort of maybe a transdiagnostic developmental factor. So it's relevant to both internalising and externalising trajectories. OK. So focusing on that then, so what would that mean like, just thinking about for practitioners maybe in a nursery or a school, what were the key signs that people should look for in those day to day kind of behaviours of children? Yeah. So I mean, it does tell us that emotion regulation around this age, so six years at school entry. It's a meaningful signal to look at. And if we see children that consistently struggle to regulate across multiple emotional contexts. So if we see children that have a hard time managing their emotions, who have a hard time calming down, this is something that we might need to look at. But of course, this is a modest sampled study and it's also a community sample. So we need to maybe be careful about what we say based on this one study alone. But I think it definitely does tell us that it is a meaningful signal to attend to. Sure. And then maybe thinking about this study with the kind of body of evidence that there is. Is there an emerging evidence base around the most effective support or interventions for strengthening those skills? How might that look within a care system? Yeah. So there is-- I would say that this research is especially for children and youth hasn't come very, very far. We do have some studies that are showing some very promising results in terms of just intervention for emotion regulation in general being a positive influence on mental health. So we do have these different methods. I think these interventions that exist right now are often based on methods from cognitive behavioural therapy, like emotion recognition and coping, regulation skills. And then we have mindfulness-based methods or acceptance methods or accepting difficult emotions and working with them. But I think that one aspect that is very important to look at is what we call co-regulation, which is very important throughout childhood. So that is this ability of parents or teachers even to help support children in regulating emotions. So that means warmth and acceptance of the child's emotions and also directed coaching on how to deal with them. But we do have-- we need more research on targeted interventions, I would say. There is some evidence that it does help. I was actually thinking about that as you were speaking and I'm curious about what the next steps might be in this research field, especially in relation to that global rise in mental health issues. What do you think this research could potentially lead? Yeah, I mean, I think the fact that when we find something like this, like a transdiagnostic predictive role of a factor like emotion regulation here in later mental health. I think it's really interesting that we find it in this community sample. So this is not a clinically recruited sample. So it makes-- it makes a case for these universal approaches for intervention. So helping basically everyone trying to make sure that everyone gets these interventions or at least some education around emotion regulation. But those would need to be thought through very well. Because we know that for example, if we think about school based approaches, if we were to take an entire school and teach them emotion regulation or use mindfulness and things like, that doesn't always work. And some of them actually can have negative effects on some children. But I do think that based on the previous research on caregivers being so important for children's emotion regulation, we might want to invest in parenting support, high quality early education, teacher training, and also reducing stressors in family lives that affect their functioning. Have you got any further research lined up, either yourself with the colleagues you're working with or through the University that explores these issues in more depth? I would say that not me in particular, but I do work with Emma Heeman, who one of the co-authors on this paper. And she's been working a lot on emotion regulation and the effects of emotion regulation on different outcomes. And also on for example, the influence of the home environment on children's emotion regulation skills. We don't have any research right now here on emotion regulation interventions, but I think that would be a very interesting direction to take this. Yeah brilliant. We're coming to the end of the podcast. I'm just wondering whether there's a take home message for our listeners. Yeah. I mean, I think that it's very important to think about what we can do to help children with their emotion regulation. Because it's not just this social skill that children have. It appears to be a very meaningful factor in whether they go on to develop behavioural and emotional difficulties. So we should be mindful of watching that and being able to try to support that. And I would also say that these results maybe tell us that we should invest in conditions that allow them to develop these skills. So helping with-- helping families be able to support their children. And also from a research perspective, which is a little bit more technical, the fact that we didn't find anything that we had null effects there with inhibitory controlled, development is really, really complex. So often when we think about these minor things that are supposed to predict something much later, this can be very difficult to measure and very difficult to find. So I think it's also very important to publish null results so that we know what's going on in the field and that we know how to proceed. Lilja, it's been lovely speaking to you. I really enjoyed the conversation. Oh you too. Thank you. It was great to speak to you, Lilja. Some really fascinating insights. It was really useful to hear how emotional regulation in early childhood might be such an important piece of the mental health puzzle and how it could shape how we think about support in schools, homes, and also in services. And I guess there's a final reflection from me. It was also a reminder of how important it is to publish all kinds of findings. So including ones that don't show strong effects, so we can build that honest and realistic picture of what's actually happening in children's development. So once again, don't forget to subscribe wherever you get your podcasts from. Please subscribe to the YouTube channel, search ACAMH and you'll find us across social media. Join me next week and I'll be speaking to Melody Altschuler as we discuss her research on positive developmental cascades. [MUSIC PLAYING]