DIFFICULTY REGULATING EMOTION PREDICTS DEPRESSION AND ANXIETY IN CHINESE ADOLESCENTS: MINDFULNESS MODERATES
A Thesis submitted to the faculty of San Francisco State University AS In partial fulfillment of the requirements for the Degree
p S 'fc H . S5H- Master of Arts In
Psychology: Developmental Psychology
by
Alexandra Elizabeth Sherman
San Francisco, California
January 2018 CERTIFICATION OF APPROVAL
I certify that I have read Difficulty Regulating Emotion Predicts Depression and Anxiety in Chinese Adolescents: Mindfulness Moderates by Alexandra Elizabeth Sherman, and that in my opinion this work meets the criteria for approving a thesis submitted in partial fulfillment of the requirement for the degree Master of Arts in Psychology:
Developmental Psychology at San Francisco State University.
UaL k H. Paik Ph.D. Associate Professor
9- Sarah Holley Ph.D. Assistant Professor DIFFICULTY REGULATING EMOTION PREDICTS DEPRESSION AND ANXIETY IN CHINESE ADOLESCENTS: MINDFULNESS MODERATES
Alexandra Elizabeth Sherman San Franeiseo, California 2018
Adolescence is a time of vast transition, both in social settings and by the means of biological restructuring initiated by the onset of puberty. Thus, it may not be surprising that adolescence is often a time in which symptoms of depression and anxiety first arise, in part stemming from difficulty regulating emotion. Mindfulness is a promising protective factor against symptomatology for Chinese adolescents considering its cultural and religious relevance. However, research on mindfulness in Chinese youth in scarce. In this study, I examined the effect of emotion regulation difficulty on depression and anxiety symptomatology in Chinese adolescents (ages 10 to 17) and I explored the extent that dispositional mindfulness may serve as a potential buffer to this association. It was found that (I) difficulty regulating emotion was positively associated with depression and anxiety, (2) mindfulness was negatively associated with depression and anxiety, and (3) mindfulness buffered the effect of difficulty regulating emotion on psychological symptomatology. Specifically, for those with high levels of difficulty regulating emotions, the presence of high levels of mindfulness was associated with lower levels of depression and anxiety symptomatology as compared to those with low levels of mindfulness. The present study supports the notion that emotion regulation difficulty is detrimental to mental health, and suggests that mindfulness may play an important mitigating role in this association. The broader implication of mindfulness as a tool for adolescent mental health across the world is discussed. In the future, examination of the specific modes of emotion regulation difficulties, and whether they differentially predict rates of depression and anxiety, would be worthwhile.
ipresentation of the content of this thesis.
Date TABLE OF CONTENTS
List of Tables...... v
List of Figures...... vi
Introduction...... 1
Psychological distress in adolescence...... 2
Difficulty with emotion regulation and psychological distress...... 5
Mindfulness...... 7
Present study...... 11
Method...... 12
Participants...... 12
Procedure...... 13
Measures...... 14
Results...... 17
Hierarchical moderated regression of depression...... 17
Hierarchical moderated regression of anxiety...... 19
Discussion...... 21
References...... 28
IV LIST OF TABLES
Table Page
1. Sample demographic information...... 47 2. Sample means...... 48 3. Exploratory data analysis in the form of zero order correlations...... 49 4. Summary of hierarchical regression analysis for variables predicting adolescents’ reported depression...... 50 5. Summary of hierarchical regression analysis for variables predicting adolescents’ reported anxiety...... 51 LIST OF FIGURES
Figure Page
1. Simple slope analysis for the significant interaction between difficulty regulating emotion and mindfulness in predicting depression symptomatology for Chinese adolescents...... 52 2. Simple slope analysis for the significant interaction between difficulty regulating emotion and mindfulness in predicting anxiety symptomatology for Chinese adolescents...... 53 1
Adolescence is a time of vast transition, both in external social and academic settings, and by the means of internal hormonal changes and neural restructuring that are initiated by the onset of puberty (Gross, 2013; Guyer, Silk, & Nelson, 2016). With dynamic changes spanning cognitive, physical, and social domains, it is not surprising that adolescence is often a time in which symptoms of depression and anxiety first arise
(Brown et al., 2008; Gross, 2013; Guyer et al„ 2016; McRae, 2016; Neil & Christensen,
2009; Teesson et al., 2014; Zisook et al., 2007). Thus, it is important to further examine factors associated with psychological distress and ways in which we can provide adolescents with the relevant and necessary tools to mitigate the potential for negative developmental trajectories and major emotional disorders (Seligman & Csikszentmihalyi,
2000).
For instance, symptoms of depression and anxiety have been found, in part, to stem from difficulty regulating one’s emotion (Aldao, Nolen-Hoeksema, & Schweizer,
2010; Campbell-Sills & Barlow, 2007; Gross & Munoz, 1995). This is a phenomenon that can result from the inability to manage one's reaction to, or experience of, emotion
(Nolen-Hoeksema, Wisco, & Lyubomirsky 2008). Conversely, mindfulness, the act of bringing one’s awareness to the present moment without labeling or judging experience, has emerged as a factor that can be very protective to mental health (Kabat-Zinn, 1990;
Kobau et al., 2011). The present study examined the role of dispositional mindfulness as a potential buffer to the association between difficulties with emotion regulation and the psychological symptomatology of depression and anxiety in Chinese adolescents. While 2
previous research has demonstrated the capacity for mindfulness to act as a buffer to risk in samples of American adolescent populations (Kuyken et al., 2013; Metz et al., 2013;
Raes, Griffith, Van der Gucht, & Williams, 2014: Zhou, Liu, Niu, Sun, & Fan, 2017), less is known about whether these findings are applicable to Chinese adolescents. Yet, with Chinese adolescents ranking 6th highest on emotional and behavioral disorders out of 31 countries assessed across the world, this population clearly deserves further study
(Rescorla et al., 2007).
Psychological Distress in Adolesccnce
Adolescence is often referred to as a “window of risk” in which teens are “...in a chronic state of threatened homeostasis” (Dorn & Chrousos, 1993; Somerville & Casey,
2010). In China, this state of upheaval seems to bare particularly severe consequences, with the rate of adolescents reporting psychological distress steadily on the rise (Tepper et al., 2008; Zheng, Rijsdijk, Pingault, McMahon, & Unger, 2016). China's rapidly changing infrastructure has been linked to an increase in psychological distress that has strained both the physical and mental health of the population (Liu, Ma, Kurita, & Tang,
1999). Indeed, the prevalence of depression and anxiety symptomatology affecting
Chinese adolescents is now deemed a major public health concern (Zheng et al., 2016).
While signs of depression are relatively uncommon among children, the risk of developing symptomatology steadily begins to escalate in the early teens (Kessler et al.,
2005). In the Hunan Province, 22% of adolescents report depression symptomatology, a rate that increases to the staggering height of 50% in other populous cities like Hong 3
Kong (Hong et al., 2009; Sun, Hui, & Watkins, 2006; Yang et al., 2010). Considering anxiety, approximately 30.2% of Chinese adolescents are reported to display symptoms
(Leung et al., 2008). Overall, the current global prevalence of anxiety disorders is 7.3% based on cumulative results from 87 studies across 44 different countries (Guo et al.,
2016). The current prevalence in China, on the other hand, ranges from 21.86% to
31.59%. Further studies have compared rates of psychological distress across cultures and have found that Chinese adolescents, in particular, report higher rates of anxiety than teens in other countries like Germany, and report higher rates of depression than teens in such countries as America and Canada (Essau, Leung, Conradt, Cheng, & Wong, 2008;
Zgambo, Kalembo, Guoping, & Honghong, 2012). Considering these cultural divergences, the need for more research concerning psychological distress in this population becomes abundantly clear.
Unfortunately, due to stigma and inadequate knowledge and understanding surrounding psychopathology in China, very few individuals receive the treatment they require (Deva & D’Souza, 2012). Nearly 50-70% of Chinese youth that exhibit symptoms of psychological disorders fail to receive adequate care (China Health Information
Profile, 2010). Moreover, there are only around 15,000 psychiatrists to serve the Chinese populous of 1.2 billion, meaning there is one psychiatrist per 80,000 Chinese citizens
(Meshvara, 2002). Compare this with the ratio in the United States of around one psychiatrist per 8,350 people (World Health Organization, 2014) and the need for further study of symptoms of psychopathology continues to stand out. 4
Studying the experience of depression and anxiety in this age group is further important due to the extensive destructive consequences associated with psychological distress, such as decreased academic performance, peer rejection, aggression, and a diminished ability to effectively express emotion (Grover, Ginsburg, & Ialongo, 2007;
Hughes, Lourea-Waddell, Kendall, 2008; Mathews, Koehn, Abtahi, & Kerns, 2016).
These symptoms often evolve into chronic or episodic conditions that impact achievement, relationships, and overall health (Neil & Christensen, 2009). In addition, experiencing high levels of depression and anxiety are often comorbid with each other and with other serious conditions like substance abuse and a heightened risk of cardiovascular disease (Angold, Costello, & Erkanli, 1999; Kober, 2014; Suls & Bunde,
2005). Symptoms of depression and anxiety are also strongly linked with an increased likelihood of suicide across cultures, which is a leading cause of death for adolescents and whose rate is rising in this age group faster than in any other (Chen, Lee, Wong, &
Kaur, 2005; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Between 100,000 and
200,000 youth commit suicide annually, with perhaps 40 times as many attempts (Chen et al., 2005). At least 90% of these individuals have one or more psychological conditions at the time of death, the most common being depressive symptomatology (Gould,
Greenberg, Velting, & Shaffer, 2003). In China, these results are even more staggering.
China’s suicide rate is believed to be three times the global average, and considering this rate in respect to China’s population size, China is subsequently responsible for more than 40% of all suicides worldwide (Hesketh, Ding, & Jenkins, 2002). Given that 5
approximately half of all mental disorders first arise during adolescence (Kessler et al.,
2005). this age group holds particular promise for studying these symptoms, and the factors that both strengthen and reduce them, in the hopes of preventing such catastrophic consequences later in life.
Difficulty with Emotion Regulation and Psychological Distress
Research has resoundingly concluded that emotion regulation plays an important role in the development of depression and anxiety symptomatology (Berenbaum,
Raghavan, Le, Vernon, & Gomez, 2003; Greenberg, 2002; Kring & Bachorowski, 1999;
Mennin, Holoway, Fresco, Moore, & Heimberg, 2007). Emotion regulation is defined as the set of skills necessary for assessing and altering one’s emotions and emotional reactions to adaptively interact with one's environment (Campbell-Sills & Barlow, 2007;
Cole, Martin, & Dennis, 2004; Gratz & Roemer, 2004; Li, Xu, & Chen, 2015).
Individuals may desire to regulate emotion to change the intensity of an emotion, the duration of an emotion, or the quality of an emotional response (Gross, 2015). For example, when experiencing sadness, one might recognize this feeling and wish to decrease its severity in order to move on with daily life or to simply feel better internally
(Gross, 2015). Successful emotion regulation is associated with healthy relationships, academic success, and work performance (Brackett & Salovey, 2004; John & Gross,
2004). It is also thought to act as both a buffer to psychological distress and as a stimulus for sympathy and prosocial behavior (Eisenberg, 2000). 6
Difficulty with emotion regulation, on the other hand, is a chief component in the overwhelming majority of psychological disorders (American Psychiatric Association,
2000). In addition to being able to change the intensity, the duration, or the quality of an emotion, there are various other components of successful emotion regulation that may be faulty or absent and can lead to eventual difficulties (Gratz & Roemer, 2004). First, issues may arise if one is unable to flexibly use a wide range of emotion regulation strategies according to the present situation or the demands of the goal in mind (Gratz &
Roemer, 2004). For example, a person with social anxiety may shift toward solely relying on avoiding social environments, a habit that prevents them from implementing other, more effective strategies (Gross, 2015). The avoidance, in turn, reinforces the anxiety and can lead to long-term consequences. Furthermore, issues may arise if one is unable to accept the emotion that is being experienced. For instance, one may attempt to employ expressive suppression, which is defined as the attempt to inhibit the emotion that is being currently felt (Gross, 2015). Suppression can appear to be an effective way to avoid experiencing negative emotions at the outset, but research demonstrates that it actually increases the salience of the suppressed thought or emotion and heightens both emotional and physiological arousal (Wegner, Broome, & Blumberg, 1997; Wegner & Erber, 1992).
This in turn results in difficulty regulating the emotion and creates a hypersensitivity to depressive and anxious symptoms (Wegner & Zanakos, 1994; Wenzlaff & Wegner,
2000). 7
Yet, there are some aspects of these findings that are not universal and point to the need for further exploration of difficulty regulating emotion across cultures (Matsuinoto,
Yoo. & Fontaine, 2008). While European Americans rate high-arousal positive emotion as more valuable, East Asians strive for low-arousal states of emotion like calmness
(Tsai, 2007). This may necessitate more frequent use of suppression in order to maintain social order (Matsumoto, Yoo, & Nakagawa, 2008). In Western cultures, using suppression is associated with the aforementioned consequences (John & Gross, 2004).
However, employing suppression does not have the same ramifications for those in
Eastern cultures, instead aiding individuals in complying with norms and not interfering with interpersonal relationships (Matsumoto et al., 2008). While suppression does not have immediate consequences for Chinese individuals compared with European
Americans, maladaptive strategies like rumination and catastrophizing are still linked to predicting vulnerability to depression in samples of Chinese adolescents (Li et al., 2015).
These cultural deviations bring further attention to the need for the study of emotion regulation difficulties in China. Furthermore, they remind us that it is essential to consider the context of culture and the value of cross-cultural research when attempting to uncover universal positive traits, like mindfulness, that may help to prevent symptomology and the deficits associated with emotion regulation difficulty.
Mindfulness
Within the positive psychology framework, dispositional mindfulness is a positive trait that can be cultivated and act as a buffer for psychological symptomatology (Kobau 8
et al., 2011). Mindfulness is conceptualized as a state of attention; bringing one’s awareness to the present moment without attempting to label, judge, or attach to stimuli
(Kabat-Zinn, 1990; Treanor, 2011). Inherent to mindfulness is an unbroken and immediate attention toward physical sensations, cognitive perceptions, and affective states (Grossman, Niemann, Schmidt, & Walach, 2004). This concept originally stems from the teaching of sal i, a form of cognitive training rooted within Buddhist philosophy dating back as far as 2,550 years ago (Keng, Smoski, & Robins, 2011). In the Buddhist spiritual doctrine, mindfulness lends itself to a shift in how one responds to internal and external experiences, allowing for purposeful reflection rather than reflexive and automatic patterns of thoughts or actions (Sanger & Dorjee, 2015). It is both a technique to cultivate and a general way of existing (Shapiro, de Sousa, & Jazaieri, 2006). While mindfulness has been relevant in Eastern traditions as a spiritual practice for thousands of years, in more recent years, mindfulness has been studied as a scientific construct and has been linked with decreases in both emotion regulation difficulty and symptoms of psychopathology (Kabat-Zinn, 1990; Keng et al., 2011).
Mindfulness has previously been studied primarily in adult clinical populations, and mindfulness-based interventions have been associated with robust success in treating symptoms of anxiety and depression for over thirty years (Burke, 2010; Grossman et al.,
2004; Khoury et al., 2013). However, its application in populations of youth is still largely unbroached (Burke, 2010; Greenberg & Harris, 2012; Shapiro et al., 2015; Zelazo
& Lyons, 2012). Yet adolescents may specially benefit from mindfulness due to the 9
mixture of drastic cognitive development and increased stress from school and social environments during this period (Broderick & Metz, 2009; Kuyken et al., 2013). First, mindfulness has been found to prevent depressive symptoms by promoting a switch to greater activation in the left anterior brain regions as opposed to the right (left > right frontal brain asymmetry; Keune, Bostanov, Hautzinger, & Kotchoubey, 2013). Frontal brain asymmetry pertains to the distinct activation pattern of the two frontal brain regions
(Watford & Stafford, 2015). Left > right frontal brain activation has been associated with experience of positive emotion and recovery from negative emotion, in addition to an approach orientation that promotes adaptive emotional responding (Davidson et al., 1990;
Keune et al., 2013; Watford & Stafford, 2015). On the other hand, right > left activation is associated with avoidance, the use of maladaptive emotion regulation strategies, like rumination and suppression, and a withdrawal orientation to experience that is linked to depressive symptoms (Keune et al., 2013; Watford & Stafford, 2015). The implementation of mindfulness spurs a shift to a left > right activation pattern compared with those engaging in maladaptive emotion regulation strategies. This signifies that mindfulness is associated with a pattern of brain activity that is aligned with more adaptive experience of, and response to, emotion. By promoting this switch from the detrimental pattern of right > left activity, mindfulness allows for approach-oriented motivation and a deceased likelihood of experiencing depressive symptoms (Barnhofer,
Chittka, Nightingale, Visser, & Crane, 2010; Keune et al., 2013; Watford & Stafford,
2015). 10
Concerning anxiety, mindfulness nurtures a willingness to face challenging experiences and lessens defensiveness (Weinstein, Brown, & Ryan, 2009). This allows for the use of more adaptive coping strategies, frees the individual from negative cognitive appraisals, and lowers perceived stress (Weinstein et al., 2009). Mindfulness has also been shown to reduce anxiety by redirecting stressful thoughts of the future to being present in the moment (Bajaj & Pande, 2016; Kabat-Zinn, 2003) and has been linked with diminished effects of distress on cortisol levels (Daubenmier, Hayden,
Chang, & Epel, 2014). While mindfulness shows promise in treating depression and anxiety symptomatology in adults thus far, its full potential in youth is still largely unexplored and merits further exploration (Burke, 2010; Greenberg & Harris, 2012;
Shapiro et al., 2015).
With regard to the relationship between mindfulness and emotion regulation difficulty, mindfulness is thought to increase awareness of the emotion one is presently feeling and allows for more accurate emotion labeling (Jimenez, Niles, & Park, 2010).
Mindfulness also predicts desensitization to threatening stimuli (Arch & Craske, 2006;
Broderick, 2005; Creswell, Way, Eisenberger, & Lieberman, 2007). This desensitization helps to reduce emotional reactivity, allowing for less perceived stress in the face of threat and for more adaptive responses (Hill & Updegraff, 2012). These factors interrupt automatic and maladaptive response patterns in the face of emotions and thoughts, which in turn allows for more successful and appropriate use of emotion regulation strategies
(Lynch et al., 2006; Shapiro et al., 2006). Individuals are then able to dampen initial 11
reactions to turn toward rumination and repetitive thoughts (Feldman, Flayes, Kumar,
Greeson, & Laurenceau, 2007). Thus, mindful individuals feel less distress from attempting to control and suppress thoughts and feelings and build a sense of efficacy when it comes to emotion (Feldman et al., 2007; Roemer & Orsillo, 2009).
Present Study
This study aims to examine the associations between difficulties in emotion regulation, dispositional mindfulness, and psychological distress (i.e., depression and anxiety). The study advances what is known about the relationships between these variables by assessing them in a sample of Chinese adolescents, and by examining whether dispositional mindfulness may serve to moderate the impact of difficulties in emotion regulation on psychological symptomatology.
In line with previous research concerning a representative population of predominantly English speaking adolescents (e.g. Aldao et al., 2010), I hypothesize that
(1) higher levels of difficulty in emotion regulation will be positively associated with levels of depression and anxiety symptomatology in Chinese adolescents. I also hypothesize that (2) higher levels of dispositional mindfulness will be negatively associated with levels of depression and anxiety symptomatology. This hypothesis is also supported by previous research indicating a strong negative association between dispositional mindfulness and depression and anxiety (e.g., Keng et al., 2011; Kuyken et al., 2013; Johnson, Burke, Brinkman, & Wade, 2016). 12
Finally, 1 address the potential for dispositional mindfulness to act as a buffer to the relationship between difficulty with emotion regulation and the experience of depression and anxiety symptomatology. Mindfulness has previously demonstrated moderation capabilities regarding the consequences of negative traits and behavioral patterns on physical and mental health (Zhou et al., 2017). For example, researchers found that the presence of mindfulness interceded between the effect of psychological distress on cortisol responses and lessened the likelihood of developing symptoms of depression and anxiety due to insecure attachment styles (Daubenmier et al., 2014; Davis,
Morris, & Drake, 2016). Based on these findings, I hypothesize that (3) there will be an interaction effect such that, for individuals with high difficulty regulating emotion, those high in dispositional mindfulness will report lower levels of depression and anxiety symptomatology as compared to those low in dispositional mindfulness.
Method
Participants
Participants were 3,120 (53% female) junior and high school students from
Chengdu, China. Chengdu is the capital of the Sichuan province, located in the southwestern portion of the country, and houses a population of approximately 14 million people. Participant ages ranged from 10 to 18 years old (M= 13.14, SD = 1.22) and were students between seventh to twelfth grade within 15 public schools serving families with an average or mid-level socioeconomic status (SES). In China, the designation for junior 13
high consists of seventh to ninth grade, while high school consists of tenth to twelfth grade. Most adolescent participants fell into the junior high school category (75%) while the rest were in high school (25%). Lastly, a portion of the overall sample collected
(approximately 8%) was excluded from these analyses due to missing or incomplete data.
Procedure
Participants were asked to complete a collection of online questionnaires aimed at evaluating adolescents' self-reported levels of emotion regulation difficulty, psychological distress, and dispositional mindfulness. The battery of questionnaires also included a wider range of assessment measures evaluating the domains of self-regulation, self-efficacy, self-esteem, and motivation; these are not the focus of the present study and will not be further explored in this paper. Completion of the surveys was spread over the span of two days: half on the first day and half on the second after at least 24 hours had passed. Participants completed all measures online using either a provided school computer room or a home computer, and the ordering of the surveys was randomized for each student. Total time to complete the surveys ranged from an hour to an hour and a half. The scales assessing difficulty with emotion regulation and psychological distress had been translated to Mandarin via past research. The demographic information and mindfulness measure, however, were translated from English to Mandarin and back- translated into simplified Chinese by three English-Mandarin bilingual translators. 14
Measures
Demographic questionnaire. Students were asked to provide basic demographic information concerning age, gender, and socioeconomic status (SES). Age was measured in years and gender was coded as 1 {female) and 2 {male). SES was defined as the rating given on a scale of income brackets from 1 (0-1000 yuan, about 0-162 USD) to 11 (over
10,000 yuan, about 1620 USD) concerning parental monthly income, with higher numbers indicating greater parental income. See Tables 1 and 2 for sample demographics and sample means.
Psychological distress. Adolescents completed the Depression Anxiety and
Stress Scale-Short Form (DASS-21; Lovibond & Lovibond, 1995) to measure self- reported psychological distress within the past week. Because stress is currently not a classifiable condition of significant psychological distress according to the DSM-5
(American Psychiatric Association, 2013), items for stress were excluded from the present study. Therefore, the scale used in the present study consists of 7 items for depressive symptoms (e.g., “I couldn't seem to experience any positive feeling at all”) and 7 items for symptoms of anxiety (e.g., “I was worried about situations in which I might panic and make a fool of myself’). Each subscale includes seven items with a 4- point response scale ranging from 0 {Never) to 3 {Almost Always). Responses were added together for two discrete totals for depression and anxiety symptomatology. Higher totals indicate more extensive symptomatology of depression and anxiety and thus greater psychological distress. 15
The DASS-21 has been verified as both reliable and valid in measuring depression and anxiety in non-clinical samples of adults (Antony, Bieling, Cox, Enns, &
Swinson, 1998; Henry & Crawford, 2005) and in different eultural and ethnic populations
(de Beurs, Van Dyck, Marquenie, Lange, & Blonk, 2001; Daza, Novy, Stanley, &
Averill, 2002). In addition, internal consistency (Cronbach's Alpha) is high within adolescent samples: .87 for depressive symptoms and .83 for symptoms of anxiety.
Finally, the scale demonstrates construct validity and high internal reliability (a = .95) among Chinese speaking samples (Szabo, 2010). In the present sample of Chengdu adolescents, the Cronbach's alpha was .96 for the total score and ranged from .86 to .89
for the subscales.
Difficulty with emotion regulation. Emotion regulation difficulty was measured
using the Difficulty with Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). The
DERS consists of 36 items divided into six subscales assessing the multidimensional nature of emotion regulation difficulty and are as follows. Non-acceptance of emotional
responses (e.g., “When I’m upset, I feel guilty for feeling that way”), difficulties engaging in goal-directed behavior (e.g., “When I'm upset, I have difficulty concentrating"), impulse control difficulties (e.g., “When I'm upset, I lose control over my behaviors”), lack of emotional awareness (e.g., “I pay attention to how I feel”),
limited access to emotion regulation strategies (e.g., “When I’m upset, I believe that I will remain that way for a long time”), and lack of emotional clarity (e.g., “I have no idea how I am feeling”). Responses ranged from 1 (Almost Never) to 5 {Almost Always) and 16
referred to how often the items reflected participants' lives. After the appropriate items were reverse coded, higher values indicated greater difficulty with emotion regulation.
Scores were added to create one comprehensive difficulty with emotion regulation assessment.
The DERS has demonstrated high overall internal consistency in a sample of undergraduate students (a = .93) and all six factors also met the specified guidelines (a >
.80; Gratz & Roemer, 2004). Since its creation, researchers have also verified the scale exhibits reliability in a large sample of American adolescents (alphas ranged from .76 to
.89) as well as in a sample of Chinese adolescents (alphas ranged from .88 to .96 overall and among subscales; Weinberg & Klonsky, 2009). In the present sample, the
Cronbach’s alpha was .96 for the total score and ranged from .71 to .91 for the subscales.
Mindfulness. Trait level mindfulness was assessed using the Child and
Adolescent Mindfulness Measure (CAMM; Greco, Baer, & Smith, 2011). The questionnaire consists of 10 items, all worded to be reverse coded (e.g., “I push away thoughts that I don't like”). Possible responses ranged from 0 (Never True) to 4 (Always
True) and scores were added to compute a single comprehensive score. Higher total values symbolized a higher rate of dispositional mindfulness. Internal consistency for this scale was a =.80 and loads on one factor (Greco et al., 2011). In the present sample of
Chengdu adolescents, the Cronbach's alpha was .89 for the total score. 17
Results
To examine possible extraneous influences within this population, I first conducted exploratory data analysis in the form of zero-order correlations between the variables of interest in addition to participants’ reported age, gender, and SES. While SES did not prove to be significantly correlated with the variables of interest, age was significantly associated with both difficulty regulating emotion and mindfulness (Table
3). Furthermore, when conducting independent samples t-tests to examine possible gender differences, depression appeared to be significantly different for females and males, /(3118) = -2.871, p = .004. Therefore, age and gender were controlled for in the subsequent models while SES was not.
Hierarchical Moderated Regression of Depression
First, depression symptomatology was explored across adolescents using hierarchical moderated regression within the statistical package RStudio. All assumptions for linearity, absence of outliers, lack of collinearity, and homoscedasticity were met. In addition, both the predictor and moderator variable means were centered to reduce the risk of collinearity. A multiple regression analysis was conducted to examine the influence of difficulty regulating emotion on reported depression symptomatology with the addition of mindfulness as a moderator (see Table 4). In accordance with exploratory analysis, both age and gender were controlled for in all steps. There was a significant overall effect of the model, F(5, 3114) = 94.94,/? < .001, Adjusted R2 = .131, meaning 18
that this model accounted for approximately 13.1% of the variation in depression scores.
More specifically in this model, difficulty regulating emotion was significantly and positively correlated with depression, b = .038, /(3114)= 12.93,/? < .001, svder — .203.
This indicates a moderate effect and shows that as difficulty regulating emotion rose, so too did reports of depression. Furthermore, mindfulness was significantly and negatively correlated with depression, b = -.100, /(3114) = -10.36,/? < .001, sriu = -.160. This signifies a smaller effect in this model and as dispositional mindfulness increased, reports of depression decreased. Concerning the control variables, age and gender both appeared to be significantly and positively associated with depression, b = .277, /(3114) = 4.09, p <
.001, stage = .057; b = .507, /(3114) = 3.08, p = .002, slender = .053, respectively.
Concerning age, an increase in depression scores seemed to be associated with older participants. In the case of gender, male participants appeared to exhibit higher reports of depression symptomatology. However, both control variables accounted for a relatively small amount of variance in this model. Lastly, there was a significant interaction, although small in effect, between difficulty with emotion regulation and mindfulness, b =
-.001, /(3114) = -3.01,/? = .003, skderxM = -.050.
This interaction was examined using simple slope analyses (see Figure 1), showing that those high in mindfulness (+1 SDs) displayed increasing reports of depression from low to high levels of difficulty regulating emotion, /(3114) = 9.60,/? <
.001. Those low in mindfulness (-1 SDs) also showed increasing reports of depression from low to high levels of difficulty regulating emotion, /(3114) = 11.90,/? < .001; 19
however, those presenting low mindfulness reported higher initial depression ratings.
Furthermore, these individuals deviated from the trend of those with high mindfulness by exhibiting a more rapid increase in symptomatology moving from low to high problems regulating emotion. This indicates that for individuals with low emotion regulation difficulties, there was a moderate main effect for depression levels between individuals reporting low and high levels of mindfulness. This main effect persisted when examining individuals with high levels of emotion regulation difficulties. However, as problems rose, those with low mindfulness reported greater levels of depression at a significantly higher rate compared to those with high mindfulness. Thus, mindfulness appears to somewhat moderate the effects of emotion regulation difficulties depression symptomatology in Chinese adolescents.
Hierarchical Moderated Regression of Anxiety
Anxiety symptomatology also was explored across adolescents using hierarchical moderated regression within the statistical package RStudio. Across all models, assumptions for linearity, absence of outliers, lack of collinearity, and homoscedasticity were met and all variable means were centered prior to analyses. A multiple regression analysis was conducted to examine the influence of difficulty regulating emotion on reported anxiety with the addition of mindfulness as a proposed moderator (see Table 5).
In accordance with exploratory analysis, both age and gender were controlled for in all steps. There was a significant overall effect of the model, F(5, 3114)= 120.16,;? < .001,
Adjusted R2 = .160. Within this moderation model, difficulty regulating emotion was 20
significantly and positively associated with anxiety, b = .038, /(3114) = 13.15,/? < .001, sroER - .203, a moderate effect meaning that as difficulty regulating emotion rose, so too did ratings of anxiety symptomatology. Conversely, mindfulness was negatively and significantly correlated with anxiety, b = -.134, /(3114) = -14.1 \ ,p < .001, sr\i= -.214.
This signifies that as dispositional mindfulness increased, ratings of anxiety decreased, again accounting for a moderate effect in this model. Age was again a significant control variable, although it accounted for a very small amount of variance in depression scores, b = .166, /(3114) = 2.48,/? = .013, skage~ .031. In this model, gender was not significant and demonstrated a miniscule effect, b = .146, /(3114) = .90, p = .370, s fgender = .016.
There was also a significant interaction between difficulty with emotion regulation and mindfulness, b = -.0005, /(3114) = -2.29, p = .022, srderxM = -.037.
Using the procedures outlined by Aiken and West (1991), the interaction was examined using simple slope analyses (see Figure 2). These analyses showed that those high in mindfulness (+1 SDs) showed increasing anxiety from low to high levels of difficulty regulating emotion, /(3114) = 10.20,/? < .001. Those low in mindfulness (-1
SDs) also showed increasing ratings of anxiety from low to high levels of difficulty regulating emotion, /(3114) = 11.70, p < .001. Yet those individuals reporting low mindfulness started out at a significantly higher level of anxiety than those reporting high mindfulness. In addition, those with low mindfulness deviated at a faster rate when going from low to high difficulty regulating emotion. This signifies that individuals reporting low difficulty started out slightly different levels of anxiety according to their degree of 21
mindfulness. However, as problems rose, those with low mindfulness reported significantly greater levels of anxiety compared to those with high mindfulness. Thus, mindfulness appears to also buffer the effects of emotion regulation difficulties on the rating of anxiety symptomatology for Chinese adolescents. Of note, this deviation is slopes appears to be less robust than when examining the role of mindfulness in moderating reports of depression symptomatology. However, there was a greater main effect between those with high and low mindfulness regarding anxiety symptomatology.
Discussion
The present study sought to explore the relationships between difficulty regulating emotion, the ensuing symptomatology of depression and anxiety, and the potential moderating effect of mindfulness. First, I found support for my initial hypothesis that difficulty with emotion regulation would be positively associated with depression and anxiety symptomatology, with greater problems regulating emotion predicting higher reports of depression and anxiety symptomatology. It appears that the negative outcomes associated with difficulty regulating emotion also apply to Chinese adolescents. This is not surprising, as previous research has shown that the biological and social network changes associated with an individual’s evolution into adolescence present an opportunity for susceptibility to emotion regulation challenges (Gross, 2013). Our results are unique, however, in pointing out that despite cultural differences concerning the successful processing of emotion (Matsumoto et al., 2008). the consequences associated with difficulty regulating emotion may be similar between U.S. and Chinese adolescents. 22
Successful emotion regulation can be defined as the awareness and acceptance of emotion, the ability to alter behavior with the intention of modifying emotion, and the ability to use these strategies in the proper context to effectively alter emotion (Gratz &
Roemer, 2004). When an individual encounters a complication while trying to implement one or more of these components, negative consequences ensue (Gross, 2013). For example, difficulty regulating emotion is associated with a range of mental disorders, particularly in models of major depressive disorder and generalized anxiety disorder
(Aldao et al., 2010). In fact, emotion regulation difficulties are now recognized as a transdiagnostic risk factor for the onset of depression and anxiety symptomatology prior to the emergence of diagnosable disorders (Johnson et al., 2016). Furthermore, depression and anxiety disorders are now considered the principal deterrent to child and adolescent health on a global scale (Stockings et al., 2015). The World Health
Organization (2008) has even gone as far as to label efforts to prevent these disorders as a public health priority.
Chinese adolescents are especially in need of preventative care concerning emotion regulation difficulty, with recent large scale modernization and social upheaval prompting unprecedented social and academic stress (Yang et al., 2010). Indeed, researchers have found that psychological distress has become a pervasive influence on physical and mental health across all aspects of daily life for some Chinese individuals
(Liu et al., 1999). In certain populous cities in the region, an estimated 11% suffer from depression symptomatology, while 13% of youth exhibit anxiety symptomatology (Lam, 23
2016). Furthermore, according to parent ratings across 31 countries, Hong Kong children exhibit the 6th highest emotional and behavioral problem scores (Lam, 2016). The present study provides a unique insight into the risk factors linked with depression and anxiety symptomatology in this population and warrants further exploration as to how best we can prevent emotional disorders and the ensuing lifelong challenges associated with their development. In the future, I would like to explore which specific categories of emotion regulation difficulties may differentially lead to higher or lower rates of depression and anxiety symptomatology for adolescents.
My second hypothesis was also corroborated, indicating in this sample that mindfulness negatively predicts depression and anxiety symptomatology, such that greater levels of dispositional mindfulness predict lower ratings of depression and anxiety. Mindfulness may act upon depression and anxiety symptomatology by decreasing long-held reflexes to become defensive and increasing the likelihood of successfully adapting to threatening or harmful situations (Weinstein et al., 2009).
Spending too much time concerned with past or future stressors opens the door to becoming inordinately rooted in this type of thinking and is linked with depression and anxiety (Zhou et al., 2017). Mindfulness, on the other hand, is thought to break an individual from becoming overwhelmed by negative feelings and thoughts by instead promoting attention to the present moment (Zhou et al., 2017). Mindful individuals are thus able to limit the perception of, and consequences from, potential failures to the present context instead of allowing the possibility of failure to limit them from 24
approaching novel experiences in the future (Hanley, Palejwala, Hanley, Canto, &
Garland, 2015).
The confirmation of mindfulness as a negative predictor of depression and anxiety symptomatology in this population may not be surprising considering both previous research regarding the effectiveness of mindfulness in treating adults and the cultural and religious background of mindfulness in China (Johnson et al., 2016; Manuello, Vercelli,
Nani, Costa, & Cauda, 2016). Mindfulness-based interventions have been associated with robust treatment effects for over thirty years in the treatment of depression and anxiety in adults (Johnson et al., 2016). Yet research concerning the effectiveness of mindfulness in youth populations remains underdeveloped despite the suggestion that adolescents may particularly benefit from school-based mindfulness programs due to the convergence of academic and social pressures during this time (Johnson et al., 2016; Schonert-Reichl &
Roeser, 2016). In China, however, mindfulness has long been integral in the Buddhist tradition and is held as a key part of its doctrine, integrated into a wide range of spiritual practices and an overall ethical lifestyle aimed at attaining liberation from suffering
(Keng et al., 2011; Manuello et al., 2016). Nevertheless, little empirical research has been conducted concerning mindfulness in Chinese youth (Lam, 2016), pointing to a stark necessity to further examine the potential positive influence of mindfulness in abating depression and anxiety in Chinese adolescents.
Lastly, I found support concerning my third hypothesis that mindfulness would act as a moderator to the relationship between emotion regulation difficulty and 25
depression and anxiety, such that those adolescents with high levels of emotion regulation difficulty, yet high dispositional mindfulness, would report lower levels of depression and anxiety when compared to those adolescents with high levels of emotion regulation difficulty and low dispositional mindfulness. Our results corroborate previous findings that mindfulness is able to moderate negative influences on physical and mental health (Jimenez et al., 2010; Zhou et al., 2017). While there is much debate surrounding the mechanisms through which mindfulness works, most of the field agrees upon it encompassing the non-judgment and acceptance of emotion (Aldao et al., 2010).
Dispositional mindfulness allows individuals to better tolerate uncomfortable emotions and sensations and to allocate less time to recovering from negative emotion (Kabat-
Zinn, 1990). These attributes are particularly useful in hampering the negative consequences of emotion regulation difficulties on depression and anxiety in adolescents
(Sanger & Dorjee, 2015). Depression is particularly linked with reduced positive affect and a lack of emotional awareness, understanding, and acceptance (Jimenez et al., 2010).
Mindfulness acts to prevent emotion regulation difficulty by enhancing successful emotion regulation, promoting positive affect which in turn improves one’s ability to repair adverse physiological effects from depressive symptomatology (Jimenez et al.,
2010). Furthermore, mindfulness strengthens prefrontal cortex development in adolescents, enabling them to tap into brain regions that promote the ability to recalibrate when feeling overly intense negative emotions, like anxiety (Sanger & Dorjee, 2015). 26
Clearly, despite the lack of studies conducted examining mindfulness in Chinese adolescents, further research surrounding these benefits is pressing.
In light of the results communicated in this study, it is important to also make note of several considerations. In relation to the significant moderation effect, it is possible that mindfulness may not actually be moderating the relationship between difficulty regulating emotion and its prediction of depression and anxiety symptomatology.
Because these models examined dispositional mindfulness, in lieu of actually manipulating levels of mindfulness, it is possible some other variable is responsible for the moderation effect and that mindfulness is simply a proxy. In addition, while significant, this moderation proved to be less powerful than the initial main effects of emotion regulation difficulties and mindfulness, separately, on reports of depression and anxiety. While this phenomenon may deter from my initial hypothesis, it also points to the benefits of implementing training programs in both mindfulness and successful emotion regulation training. Finally, because difficulty regulating emotion was a self- report measure and not manipulated, the directionality of its relationship with anxiety and depression cannot be determined with absolute confidence in this context. This also holds true considering the directionality of mindfulness in predicting anxiety.
Yet even with these implications in mind, this study also encompasses various strengths. First, with the presence of such a large sample size, all models of prediction and moderation are presumed to have adequate power to differentiate accurate relationships among predictors and their respective outcomes. Additionally, as sample 27
size increases, the variation within the reports of constructs begins to approach more realistic population parameters. In the future, research should aim to explore these differences in strength of predictors more closely. Examination of the specific modes of emotion regulation difficulties and whether they differentially predict rates of anxiety and depression would be worthwhile. In addition, it would be beneficial to collect comparable samples from various other cultures to determine whether these relationships in the prediction of depression and anxiety symptomatology in adolescents replicate across cultures. Finally, it would also be advantageous to explore behavioral measures of both mindfulness and difficulty regulating emotion to determine more accurate model fit when predicting anxiety and depression symptomatology in adolescents. The manifestation of anxiety and depression symptomatology in adolescence bears with it a host of disadvantages for overall health and positive development. Studying the detrimental influence of difficulty with emotion regulation further, in addition to the power of mindfulness in buffering its effects, has broad implications for adolescent mental health across the world. 28
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Table 1
Sample Demographic Information
Variable Total Participants (n) 3120 Female 1653 Male 1467 Age (years) M 13.14 SD 1.22 SES M 6.40 SD 2.91 Note. SES = socioeconomic status. Reports of SES ranged in brackets from 1 to 11 with higher numbers indicating higher brackets of parental income. 48
Table 2
Sample Means
Variable M SD Anxiety 5.11 4.75 Depression 4.15 4.67 Emotion Regulation Difficulty 99.34 27.48 Mindfulness 40.27 8.57 Note. n = 3120. 49
Table 3
Exploratory Data Analysis in the Form o f Zero Order Correlations
Variable Depression Anxiety DER Mindfulness
Depression - ---
Anxiety g72*** --- 2Q]*** 309*** DER -- Mindfulness 275*** -.335*** - 314*** - Age .093 .070 048** -.068*** SES -.075 -.070 -.015 -.007 Note, n - 3120. DER = difficulty with emotion regulation. SES = socioeconomic status. * p < .05. ** p < .01. *** p < .001. 50
Table 4 Summary o f Hierarchical Regression Analyses for Variables Predicting Adolescents ’ Reported Depression
Variable h SE h P sr Adj. R2 AR2 DER .038 .003 929*** .203 093*** .038 Mindfulness -.100 .010 -.188*** -.160 0g4*** .047 Age .277 .068 0^9*** .057 Gender .507 .165 .052** .053 DER x Mindfulness -.001 .0002 -.056** -.050 j 31 *** Note, n = 3120. DER = difficulty with emotion regulation; sr = semi-partial correlation. * p < .05. ** p < .01. *** p < .001 51
Table 5 Summary o f Hierarchical Regression Analyses for Variables Predicting Adolescents ’ Reported Anxiety
Variable h SE h P sr Adj. R2 AR2 DER .038 .003 230*** .203 098*** .062 Mindfulness -.134 .010 -.252*** -.214 1]4* ** .046 Age .166 .067 .041* .031 Gender .146 .162 .015 .016 DER x Mindfulness -.0005 .0002 -.040* -.037 .160*** Note, n = 3120. DER = difficulty with emotion regulation; sr = semi-partial correlation. * p< .05. ** p < .01. *** p < .001. regulating emotion and mindfulness in predicting depression symptomatology for for symptomatology depression adolescents. predicting Chinese in mindfulness and emotion regulating I. Figure Depression Symptomatology Simple slope analysis for the significant interaction between difficulty difficulty between interaction significant the for analysis slope Simple ifclyRgltn Emotion Regulating Difficulty Moderator A A o iduns - SO) (-1 Mindfulness Low 9 ih iduns + SD) (+1 Mindfulness High
52 53
6
Figure 2. Simple slope analysis for the significant interaction between difficulty regulating emotion and mindfulness in predicting anxiety symptomatology for Chinese adolescents