FSW - Self-regulation models for health behavior and Psychopathology - Ou

Cate, R. ten

Garnefski, N.

Koopman, H.M.

Kraaij, V.

Leiden University Scholary Publications

Brief report: Cognitive emotion regulation strategies andpsychological adjustments in adolescents with a chronic disease.Garnefski, N.; Koopman, H.M.; Kraaij, V.; Cate, R. tenCitationGarnefski, N., Koopman, H. M., Kraaij, V., & Cate, R. ten. (2009). Brief report: Cognitiveemotion regulation strategies and psychological adjustments in adolescents with achronic disease. Journal Of Adolescence, 32, 449-454. Retrieved fromhttps://hdl.handle.net/1887/15140 Version: Not Applicable (or Unknown)License: Leiden University Non-exclusive licenseDownloaded from: https://hdl.handle.net/1887/15140 Note: To cite this publication please use the final published version (if applicable).Journal of Adolescence 32 (2009) 449e454www.elsevier.com/locate/jadoBrief report: Cognitive emotion regulation strategiesand psychological adjustment in adolescentswith a chronic diseaseNadia Garnefski a,*, Hendrik Koopman b, Vivian Kraaij b, Rebecca ten Cate ca Department of Psychology, Division of Clinical, Health and Neuropsychology, University of Leiden,P.O. Box 9555, 2300 RB Leiden, The Netherlandsb Division of Medical Psychology, Leiden University Medical Center, Leiden, The Netherlandsc Department of Pediatrics, Leiden University Medical Center, Leiden, The NetherlandsAbstractObjective of the study was to examine how cognitive emotion regulation strategies were related to psy-chological maladjustment in adolescents with a chronic disease. The sample consisted of adolescents witha diagnosis of Juvenile Idiopathic Arthritis (JIA). A self-report questionnaire was used to assess Internal-izing problems and Quality of Life. The specific cognitive emotion regulation strategies that were used inresponse to the disease were measured by the Cognitive Emotion Regulation Questionnaire (CERQ). Cor-relations and Multiple regression analyses showed that Rumination and Catastrophizing were the most im-portant ‘predictors’ of psychological maladjustment in adolescents with JIA, suggesting that they should beconsidered as maladaptive cognitive emotion regulation strategies in response to a chronic disease such asJIA. Challenging these maladaptive cognitive emotion regulation strategies may therefore play an impor-tant role in intervention strategies. 2008 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rightsreserved.Keywords: Adolescents; Cognitive emotion regulation; Coping; Psychological adjustment; Depression; Anxiety; Qualityof Life; Chronic disease; Chronic arthritis* Corresponding author. Tel.: þ31 71 5273774; fax: þ31 71 5274678.E-mail address: garnefski@fsw.leidenuniv.nl (N. Garnefski).0140-1971/$30.002008TheAssociation forProfessionals in Services forAdolescents. PublishedbyElsevierLtd.All rights reserved.doi:10.1016/j.adolescence.2008.01.003450 N. Garnefski et al. / Journal of Adolescence 32 (2009) 449e454It has been shown that adolescents with a chronic disease have increased risks to experienceinternalizing symptoms, overall adjustment problems and a lower Quality of Life (Boekaerts &Röder, 1999; Lebovidge, Lavigne, Donenberg, & Miller, 2003). One of the most common chronicdiseases of children and adolescents is Juvenile Idiopathic Arthritis (JIA). Adolescents with JIAoften have to face a broad range of difficulties associated with their disease. These include depen-dency upon their families, isolation from their peers and a wide range of physical problems (e.g.,muscle and joint pain, swelling and impaired function of affected limbs, eye problems, skeletal ab-normalities, and infections). Having a chronic disease such as juvenile chronic arthritis can there-fore be considered as an additional stressor that might compound the daily stressors thatadolescents must cope with at their developmental stage of life.Despite similar health problems, some adolescents may develop more psychological prob-lems than others (Sandstrom & Schanberg, 2004). There is increasing evidence that (ongoing)psychological distress in response to a life stressor may be associated with the cognitive emo-tion regulation strategies that someone uses to deal with that stressor (e.g., Garnefski & Kraaij,2006). Cognitive emotion regulation strategies can be defined as the conscious, mental strate-gies individuals use to cope with the intake of emotionally arousing information (Garnefski,Kraaij, & Spinhoven, 2001). Whereas responses to stress such as Self-blame, Ruminationand Catastrophizing, generally speaking, have been shown to be related to reporting ofmore emotional problems, responses such as Positive Reappraisal have been shown to be re-lated to fewer problems in adolescents (Garnefski, Boon, & Kraaij, 2003; Garnefski & Kraaij,2006; Garnefski et al., 2001; Garnefski, Legerstee, Kraaij, van den Kommer, & Teerds, 2002;Jermann, Van der Linden, d’Acremont, & Zermatten, 2006; Martin & Dahlen, 2005). Thus far,however, there has been no study of the relationship between cognitive emotion regulationstrategies and psychological adjustment in a sample of adolescents with a specific chronic dis-ease such as JIA.The present study will focus on the relationship between cognitive emotion regulation strate-gies, Internalizing problems and Quality of Life in adolescents with Juvenile Idiopathic Arthritis(JIA). By studying which cognitive emotion regulation strategies are related to adjustment prob-lems in adolescents with JIA, important clues might be found for a more targeted tailoring ofintervention (Garnefski et al., 2001).MethodSample and procedureThe sample consisted of 53 adolescents with a diagnosis of Juvenile Idiopathic Arthritis, rangingin age between 12 and 18 years with a mean age of 14 years and 3 months (SD¼ 1.83), and 30.2%(N¼ 16) being male. Participants were recruited from the outpatient pediatric JIA clinic of LeidenUniversity Medical Center (LUMC) in the Netherlands. Before their visit to the physician in-formed consent was obtained. The adolescents completed the questionnaires at the hospital imme-diately after the adolescent visited the physician. About 90% of the adolescents who were invited toparticipate actually agreed to participate in the study. Completing the questionnaires took between20 and 30 min and took place in the presence of a researcher. Confidentiality was guaranteed. Per-mission for the study was obtained from the Medical Ethical Committee from the LUMC.451N. Garnefski et al. / Journal of Adolescence 32 (2009) 449e454MeasurementsCognitive emotion regulation strategiesThe cognitive emotion regulation strategies that adolescents used in response to their JIA weremeasured by the Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski, Kraaij, &Spinhoven, 2002). The CERQ is a 36-item questionnaire, consisting of the following nine concep-tually different subscales, each consisting of four items measured on a 5-point Likert scale andeach referring to what someone thinks after the experience of a stressful life event (here: havingJIA): Self-blame, Other-blame, Acceptance, Planning, Positive Refocusing, Rumination, PositiveReappraisal, Putting into Perspective, and Catastrophizing. The following instruction was given:‘‘You are in the hospital because of your illness. There are more adolescents who have this par-ticular illness and every one copes with it in his or her own way. The following questions concernyour thoughts about having this illness’’. Research has shown that the subscales have good inter-nal consistencies, with alphas ranging from 0.67 to 0.81 (Garnefski et al., 2001, 2002). In the pres-ent study, the subscales had good internal consistencies, with alphas ranging from 0.60 to 0.80,1except for the subscale Other-blame (0.32), which was therefore excluded from further analyses inthe present study. Correlations among CERQ subscales ranged from 0.02 (Acceptance and Self-blame) to 0.55 (Rumination and Catastrophizing).Internalizing problemsInternalizing problems were measured by the Depression and Anxiety subscales of the SCL-90,respectively consisting of 15 and 10 items measured on a 5-point Likert scale (Symptom CheckList: Derogatis, 1977; Dutch translation and adaptation by Arrindell & Ettema, 1986). Previousstudies have reported alpha-coefficients ranging from 0.82 to 0.93 for Depression and from 0.71 to0.91 for Anxiety. In addition, both subscales have been found to show strong convergent validitywith other conceptually related scales (Arrindell & Ettema, 1986). As the Depression and Anxietysubscales were highly correlated (r¼ 0.70), the two scales were combined into one total score. Re-liability of the total scale was 0.89.Health-related Quality of LifeThe quality of daily functioning of the adolescents was measured by the DUX-25 (Conolly &Johnson, 1999; Kolsteren, Koopman, Schalekamp, & Mearin, 2001). The DUX-25 assesses theaffective evaluation of physical, emotional, social and home aspects of daily life functioning ofchildren and adolescents. The DUX-25 consists of 25 items. A total Quality of Life score was cal-culated by summing all items. Previous studies have shown that alpha reliability of the total scalewas 0.90 and that testeretest correlations were good (Kolsteren et al., 2001). In the present study,the reliability of the total scale was 0.92. The correlation between Health-related Quality of Lifeand Internalizing problems was 0.46.1 Alpha reliabilities in the present study were: Self-blame (0.67), Other-blame (0.32), Acceptance (0.73), Planning(0.70), Positive Refocusing (0.80), Rumination (0.73), Positive Reappraisal (0.63), Putting into Perspective (0.71), Cat-astrophizing (0.68).452 N. Garnefski et al. / Journal of Adolescence 32 (2009) 449e454ResultsMeans and standard deviations of the CERQ subscales are presented in Table 1 (2nd and 3rdcolumn). To study the bivariate relationships between CERQ scales and the two outcome mea-sures (Internalizing problems and Quality of Life), Pearson correlations were calculated. To studythe multivariate relationships, Multiple Regression Analysis was performed (MRA; method step-wise), in order to control for the mutual correlations among CERQ scales. By performing MRA,the unique relationships between CERQ scales and outcomes can be studied by correcting for theinfluence of the other variables. The results are presented in Table 1.The correlations presented in the fourth column of Table 1 show that the cognitive emotionregulation strategies of Rumination and Catastrophizing had the strongest correlations withthe total Internalizing problem score. The MRA results presented in the fifth column of Table1 show that e even after controlling for the influence of the other CERQ scales e the relationshipsof Internalizing problems with Rumination and Catastrophizing remained significant.Pearson correlations as well as MRA results concerning the relationships between CERQ scalesand total Quality of Life showed that Rumination was the most important ‘predictor’ of a lowerQuality of Life (Table 1, 6th and 7th column).Discussion and conclusionThe present study is the first to report associations between cognitive emotion regulation strat-egies and psychological adjustment in a sample of adolescents with Juvenile Idiopathic Arthritis(JIA). Although the sample was small and the power to find significant results was low, some in-teresting relationships were found. The most remarkable finding was the relationship between thetwo indicators of maladjustment and Rumination. Rumination, referring to thinking all the timeTable 1CERQ scales: descriptives, Pearson correlations and stepwise MRA results with Internalizing problems and Quality ofLife as outcomes.Descriptives Internalizing problems Quality of LifePearson MRA Pearson MRAM SD r b r bCERQ subscalesSelf-blame 5.14 1.65 0.22 0.22Acceptance 11.48 3.41 0.26 0.23Rumination 8.65 2.85 0.53*** 0.35* 0.31** 0.30*Positive Refocusing 13.16 3.89 0.09 0.18Planning 9.59 2.51 0.12 0.08Positive Reappraisal 10.44 3.31 0.24 0.06Putting into Perspective 12.83 3.38 0.14 0.14Catastrophizing 6.20 2.31 0.53*** 0.33* 0.10Explained variance R2¼ 0.36*** R2¼ 0.08****P< 0.001; *P< 0.05.453N. Garnefski et al. / Journal of Adolescence 32 (2009) 449e454about the feelings and thoughts associated with having a chronic disease was not only associatedwith the reporting of Internalizing problems, but also with a lower health-related Quality of Life.In addition, the cognitive strategy of Catastrophizing or emphasizing the terror of having JIA wasrelated to Internalizing problems, but not to a lower Quality of Life.The findings suggested that strongly Ruminating and Catastrophizing in response to havingJIA should be considered as maladaptive cognitive emotion regulation strategies. These findingsfit in with findings in general population samples where the same strategies were related to mal-adjustment (Garnefski et al., 2006; Nolen-Hoeksema, Parker, & Larson, 1994; Sullivan, Bishop, &Pivik, 1995). On the basis of the present study, the conclusion can be added that a relationshipbetween these cognitive emotion regulation strategies and Internalizing problems also holds ina specific sample of adolescents with JIA. Challenging these maladaptive cognitive emotion reg-ulation strategies may therefore play an important role in intervention strategies to be developedfor adolescents with juvenile idiopathic arthritis.In the present study, no significant associationswere found betweenmaladjustment and cognitiveemotion regulation strategies that were expected to be adaptive, such as Positive Reappraisal. It istoo early to conclude that these strategies do not have to play a role in interventions. Instead, rela-tionships between such strategies andmaladjustment should be further explored to find out whetherthis finding can be replicated or rather reflects a power issue, caused by the small sample size.A limitation was that no indicators of the severity of JIA symptoms were included in the study.It is advisable to include such an index of JIA symptoms in future studies, to be able to investigatewhether cognitive strategies might play mediating or moderating roles in the relationship betweenJIA (severity) and outcomes. In addition, although clear relationships have been shown betweencognitive emotion regulation strategies and psychological maladjustment, the cross-sectionalcharacter of the study does not allow drawing conclusions about causality. Still, whatever the di-rections of influence may be, it might be argued that Rumination and Catastrophizing could beimportant indicators of mental health problems in adolescents with JIA.Generalizing the findings beyond the sample would only be possibly after replicating the studywith other specific chronic disease samples and populations, while including prospective elements.If our results can be confirmed, they carry important implications for the focus and content ofintervention and prevention of mental health problems, not only in youngsters with JIA, but inall adolescents experiencing a chronic disease.AcknowledgmentsWe thank Hanneke van Essen, Jeroen Legerstee and Marianne Dijkstra for their conscientioushelp in the process of data assembly.ReferencesArrindell, W. A., & Ettema, J. H. M. (1986). SCL-90. Handleiding bij een multidimensionele psychopathologie-indicator.Lisse, The Netherlands: Swets & Zeitlinger BV. [Manual for a multidimensional psychopathology-indicator/Dutchtranslation and adaptation].Boekaerts, M., & Röder, I. (1999). Stress, coping and adjustment in children with a chronic disease: a review of theliterature. Disability and Rehabilitation, 21, 311e337.454 N. Garnefski et al. / Journal of Adolescence 32 (2009) 449e454Conolly, M. A., & Johnson, J. A. (1999). Measuring Quality of Life in paediatric patients. Pharmacoeconomics, 16,605e625.Derogatis, L. R. (1977). SCL-90: Administration, scoring and procedures manual-I for the Revised version. Baltimore:John Hopkins University School of Medicine, Clinical Psychometrics Research Unit.Garnefski, N., Boon, S., & Kraaij, V. (2003). Relationships between cognitive strategies of adolescents and depressivesymptomatology across different types of life event. Journal of Youth and Adolescence, 32, 401e408.Garnefski, N., & Kraaij, V. (2006). Relationships between cognitive emotion regulation strategies and depressive symp-toms: a comparative study of five specific samples. Personality and Individual Differences, 40, 1659e1669.Garnefski, N., Kraaij, V., & Spinhoven, Ph. (2001). Negative life events, cognitive emotion regulation and emotionalproblems. Personality and Individual Differences, 30, 1311e1327.Garnefski, N., Kraaij, V., & Spinhoven, Ph. (2002). CERQ: Manual for the use of the Cognitive Emotion RegulationQuestionnaire. Leiderdorp, the Netherlands: DATEC.Garnefski, N., Legerstee, J., Kraaij, V., van der Kommer, T., & Teerds, J. (2002). Cognitive coping strategies and symp-toms of depression and anxiety: a comparison between adolescents and adults. Journal of Adolescence, 25, 603e611.Jermann, F., Van der Linden, M., d’Acremont, M., & Zermatten, A. (2006). Cognitive Emotion Regulation Question-naire (CERQ): confirmatory factor analyses and psychometric properties of the French translation. European Jour-nal of Psychological Assessment, 22, 126e131.Kolsteren, M. M. P., Koopman, H. M., Schalekamp, G., & Mearin, M. L. (2001). Health-related Quality of Life inchildren with celiac disease. Journal of Pediatrics, 138, 593e595.Lebovidge, J. S., Lavigne, J. V., Donenberg, G. R., & Miller, M. L. (2003). Psychological adjustment of children andadolescents with chronic arthritis: a meta-analytic review. Journal of Pediatric Psychology, 28, 29e39.Martin, R. C., & Dahlen, E. R. (2005). Cognitive emotion regulation in the prediction of depression, anxiety, stress andanger. Personality and Individual Differences, 39, 1249e1260.Nolen-Hoeksema, S., Parker, L. E., & Larson, J. (1994). Ruminative coping with depressed mood following loss. Jour-nal of Personality and Social Psychology, 67, 92e104.Sandstrom, M. J., & Schanberg, L. E. (2004). Brief report: peer rejection, social behaviour and psychological adjust-ment in children with juvenile rheumatic disease. Journal of Pediatric Psychology, 29, 29e34.Sullivan, M. J. L., Bishop, S. R., & Pivik, J. (1995). The pain Catastrophizing scale: development and validation. Psy-chological Assessment, 7, 524e532.

Brief report: Cognitive emotion regulation strategies and psychological adjustments in adolescents with a chronic disease.

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