Emotion regulation and the COVID-19 pandemic: a practical guide to rehabilitating children and adolescents

The coronavirus disease 2019 (COVID-19) pandemic has resulted in a global mental health crisis, contributing to the appearance of psychiatric symptoms and the worsening of existing mental health conditions among children and adolescents. Social distancing measures, school closures, elevated stress in the home environment, economic recession, and increased screen time may have impacted the development of youth and contributed to a worsening of their emotion regulation (ER) skills.¹ Thus, there is a growing need for evidence-based practices and strategies to guide clinicians in dealing with emerging demands.

Although life is slowly returning to normal, it is important to carefully consider last year’s toll on mental health and its possible short- and long-term ramifications; evidence has been accumulating about long-term COVID-19 symptoms in youth, such as fatigue and brain fog. In addition, increasing social anxiety, which has been fueled by the large amount of time in home schooling and away from peers, is one of the burdens that have been overwhelming families, schools, and clinicians alike.²

ER strategies enable individuals to reason with and about emotions, regulating their intensity and frequency. These strategies affect one’s awareness of and ability to express emotions, as well as to handle interpersonal relationships wisely. Young people with higher levels of psychological distress show heightened difficulties in reading non-verbal cues, which translates into difficulties in understanding the emotions of oneself and others, leading into social, functional, and academic difficulties.

Thus, appraising a patient’s ER skills is an essential part of a comprehensive mental health assessment. ER skills provide individuals with the means to better understand and communicate feelings and needs, improving their overall functioning. ER strategies can be taught by psychiatrists and psychotherapists as supplementary tools or as an extension of their regular practices. By teaching ER skills to affected youth and their caregivers, practitioners will be able to help patients decrease conflict and tension at home, as well as reduce social anxiety and improve emotional well-being at school.

Some skills mentioned below are easy to apply, while others require special certifications, for which we recommend referral to specialized psychotherapists. Clinicians could use the following descriptions to determine which strategies best suit their clinical practice and patient needs.

The main goal of acceptance and commitment therapy (ACT) is to help patients live a fulfilling and value-oriented life. By learning skills to deal with feelings and emotions in a way that involves more observation and less judgment, patients can engage in actions that are consonant with their values, increasing psychological well-being.³ The techniques of ACT decrease experiential avoidance behaviors (used to solve psychological pain, with active avoidance of confused feelings and thinking) and improving psychological flexibility and acceptance towards emerging thoughts and feelings. In ACT, cognitive defusion is a method for separating language and thought, leading one to experiencing one’s own thoughts and beliefs as literally true. This method aims to repair lost contact with the present, belief in negative stories about oneself, and rigid living and thinking.

Dialectical Behavior Therapy (DBT) teaches mindfulness, distress tolerance, ER, and interpersonal effectiveness.⁴ Its protocols include a set of skills for emotional problem solving. Some exercises that could benefit youth struggling with the current global scenario include the “wise mind” and “what” skills for mindfulness training, the “how intensely to ask or say no” and the DEAR MAN skill for interpersonal effectiveness, and the “check the facts and opposite action” for ER. These skills could help effectively incorporate ER in youth suffering from mental health disorders. Lessons on skill training can be found in the Guilford Press book DBT skills in schools.⁴ DBT training includes describing emotions, problem solving, tolerating distress, coping with crises, self-soothing, being mindful of current emotions, and communicating effectively.

Another evidence-based a set of practices that can enhance emotional regulation and well-being is Marc Brackett’s RULER.⁵ RULER is an acronym for the five skills needed for social-emotional learning: recognizing emotions in oneself and others, understanding the causes and consequences of emotions, labeling emotions with a diverse and accurate vocabulary, expressing emotions constructively across contexts, and regulating emotions effectively. Teaching affected youth how to manage these five skills will help them better understand and deal with their own and others’ emotions and feelings.

Learning these skills could improve the well-being of affected children and adolescents, reducing their tension and anxiety at school and home and improving effective communication with caregivers, peers, and teachers. Although their importance is not exclusive to the COVID-19 pandemic, the current circumstances have heightened the burden in this population, creating an ideal scenario for ER training. Since most of the general population has been vaccinated and children and adolescents are returning to school, ER skills will continue to be essential to combat the increased social anxiety involved in the new normal.² Thus, our hope is that incorporating such strategies in clinical practice will not only help patients at the near-end of COVID-19 pandemic, but to improve their subsequent emotional and functional well-being as well.

Acknowledgments

TCK was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES; grant 88887.461435/2019-00) during the preparation of this manuscript. LSR was supported by CAPES (grant 88887.475730/2020-00) during the preparation of this manuscript. BL was supported by the Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP; grants 17/07089-8, 2018/11963-8, and 2020/05087-0) during the preparation of this manuscript. These funding agencies had no role in writing the manuscript or in the decision to submit it for publication.

References

• ¹
  Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatr. 2020;174:819-20.
• ²
  Courtney D, Watson P, Battaglia M, Mulsant BH, Szatmari P. COVID-19 impacts on child and youth anxiety and depression: challenges and opportunities. Can J Psychiatry. 2020;65:688-91.
• ³
  Swain J, Hancock K, Dixon A, Bowman J. Acceptance and commitment therapy for children: a systematic review of intervention studies. J Contextual Behav Sci. 2015;4:73-85.
• ⁴
  Mazza JJ, Dexter-Mazza ET, Miller AL, Rathus JH, Murphy HE, Linehan MM. DBT^® skills in schools: Skills training for emotional problem solving for adolescents (DBT STEPS-A). The Guilford practical intervention in the schools series. New York: Guilford Press; 2016.
• ⁵
  Brackett MA, Rivers SE. Transforming students’ lives with social and emotional learning. In: Pekrun R, Linnenbrink-Garcia L, editors. International handbook of emotions in education. New York: Taylor & Francis; 2014. p. 368-88.

Publication Dates

• Publication in this collection
  06 Dec 2021
• Date of issue
  May-Jun 2022

History

• Received
  13 Sept 2021
• Accepted
  13 Sept 2021